Appendex
In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal) appendix; also vermix) is a
blind-ended tube connected to the cecum (or caecum), from which it develops embryologically. The cecum is a
pouchlike structure of the colon. The appendix is located near the junction of the small intestine and the large
intestine.
The term "vermiform" comes from Latin and means "worm-shaped".
Size and location
The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the appendix is usually
between 7 and 8 mm. The longest appendix ever removed measured 26 cm from a patient in Zagreb, Croatia.[1]
The appendix is located in the right lower quadrant of the abdomen, or, more specifically, the right iliac fossa.[2]
Its position within the abdomen corresponds to a point on the surface known as McBurney's point (see below).
While the base of the appendix is at a fairly constant location, 2 cm below the ileocecal valve,[2] the location of
the tip of the appendix can vary from being retrocecal (74%)[2] to being in the pelvis to being extraperitoneal. In
rare individuals with situs inversus, the appendix may be located in the lower left side.
Vestigiality
Vermiform appendix
The most common explanation for the appendix's existence in humans is that it's a vestigial structure which has
lost its original function. In The Story of Evolution, Joseph McCabe argued:
The vermiform appendage—in which some recent medical writers have vainly endeavoured to find a utility—is
the shrunken remainder of a large and normal intestine of a remote ancestor. This interpretation would stand
even if it were found to have a certain use in the human body. Vestigial organs are sometimes pressed into a
secondary use when their original function has been lost.[3]
One potential ancestral purpose put forth by Charles Darwin[4] was that the appendix was used for digesting
leaves as primates. It may be a vestigial organ, evolutionary baggage, of ancient humans that has degraded
down to nearly nothing over the course of evolution. Evidence can be seen in herbivorous animals such as the
koala. The cecum of the koala is very long, enabling it to host bacteria specific for cellulose breakdown. Human
ancestors may have also relied upon this system and lived on a diet rich in foliage. As people began to eat more
easily digested foods, they became less reliant on cellulose-rich plants for energy. The cecum became less
necessary for digestion and mutations that previously had been deleterious were no longer selected against.
These alleles became more frequent and the cecum continued to shrink. After thousands of years, the once-
necessary cecum has degraded to what we see today, with the appendix.[4] On the other hand, evolutionary
theorists have suggested that natural selection selects for larger appendices because smaller and thinner
appendices would be more susceptible to inflammation and disease.[5]
The cecum is a pouch-like structure of the colon and the appendix is near the junction of the small intestine and
the large intestine and has abundant infection-fighting lymphoid cells, which suggests it plays a role in the
immune system. The most common diseases of the appendix (in humans) are appendicitis and carcinoid tumors.
Appendix cancer accounts for about 1 in 200 of all gastrointestinal malignancies. Appendicitis is a condition
where the the appendix becomes inflamed and in almost all cases it is removed either by laparotomy or
laparoscopy; left untreated, the appendix will rupture, leading to peritonitis, then shock, and, if continued
untreated, death. The appendix is routinely removed without any notable ill effects or side effects and the
scientists stress that even though the appendix seems to have a function, people should still have them removed
when they are inflamed because leaving it untreated could be fatal.
Dr. Bill Parker, a professor of surgery and one of the scientists responsible for establishing its status as a useful
organ, says the function of the appendix seems related to the massive amount of bacteria that populates the
human digestive system and where it is located just below the normal one-way flow of food and germs in the
large intestine, helps support that theory. The study appears in the online edition of the Journal of Theoretical
Biology.
Possible secondary functions
Immune function
New studies propose that the appendix may harbor and protect bacteria that are beneficial in the function of the
human colon.[6]
Loren G. Martin, a professor of physiology at Oklahoma State University, argues that the appendix has a
function in fetuses and adults.[7] Endocrine cells have been found in the appendix of 11-week-old fetuses that
contribute to "biological control (homeostatic) mechanisms." In adults, Martin argues that the appendix acts as a
lymphatic organ. The appendix is experimentally verified as being rich in infection-fighting lymphoid cells,
suggesting that it might play a role in the immune system. Zahid[8] suggests that it plays a role in both
manufacturing hormones in fetal development as well as functioning to "train" the immune system, exposing
the body to antigens so that it can produce antibodies. He notes that doctors in the last decade have stopped
removing the appendix during other surgical procedures as a routine precaution, because it can be successfully
transplanted into the urinary tract to rebuild a sphincter muscle and reconstruct a functional bladder.
Maintaining gut flora
Possible function of the human vermiform appendix as a "se house" for beneficial bacteria in the recovery from
diarrhea.
Although it was long accepted that the immune tissue, called gut associated lymphoid tissue, surrounding the
appendix and elsewhere in the gut carries out a number of important functions, explanations were lacking for
the distinctive shape of the appendix and its apparent lack of importance as judged by an absence of side-effects
following appendectomy.[9] William Parker, Randy Bollinger, and colleagues at Duke University proposed that
the appendix serves as a haven for useful bacteria when illness flushes those bacteria from the rest of the
intestines.[6][10] This proposal is based on a new understanding of how the immune system supports the growth of
beneficial intestinal bacteria,[11][12] in combination with many well-known features of the appendix, including its
architecture and its association with copious amounts of immune tissue. Such a function is expected to be useful
in a culture lacking modern sanitation and healthcare practice, where diarrhea may be prevalent.[10] Current
epidemiological data[13] show that diarrhea is one of the leading causes of death in developing countries,
indicating that as diarrhea flushes out the helpful bacteria the appendix helps recovery by providing a "safe
house" for the bacteria.[10]
Appendicitis
inflamed and enlarged appendix,sliced lengthwise.
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical
emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy.
Untreated, mortality is high, mainly because of peritonitis and shock.[1] Reginald Fitz first described acute and
chronic appendicitis in 1886,[2] and it has been recognized as one of the most common causes of severe acute
abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling
appendicitis".
The term "pseudoappendicitis" is used to describe a condition mimicking appendicitis.[3] It can be associated
with Yersinia enterocolitica.[4]
Location of the appendix in the digestive system
Signs & Symptoms
For the most part symptoms related to disturbed function of bowels. Pain first, vomiting next and fever last has
been described as classic presentation of acute appendicitis. Pain starts mid abdomen, and except in children
below 3 years, tends to localize in right iliac fossa in a few hours. This pain can be elicited through various
signs. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to
gentle pressure (palpation). Also, there is severe pain on suddenly releasing a deep pressure in lower abdomen
rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant
may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the
pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies
entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital
rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area
(McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on
palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent
surgical intervention.
Rovsing's sign
Continuous deep palpation starting from the left iliac fossa upwards (anti clockwise along the colon) may cause
pain in the right iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing pressure
around the appendix. This is the Rovsing's sign.[5] Laughing too hard can result in great pain when dealing with
appendicitis.
Psoas sign
Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with the patient extending the
hip due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas
muscles themselves. Straightening out the leg causes the pain because it stretches the muscles, and flexing the
hip into the "fetal position" relieves the pain.
Obturator sign
If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by
flexing and internal rotation of the hip. This maneuver will cause pain in the hypogastrium.
Dunphy's sign
Increased pain in the right lower quadrant with coughing.[6]
Volkovich-Kocher (Kosher)'s sign
During anamnesis, the appearance of pain in the epigastric region or around the stomach at the beginning of
disease with a subsequent shift to the right iliac region.
Sitkovskiy (Rosenstein)'s sign
Increased pain in the right iliac region as patient lies on his/her left side.
Bartomier-Michelson's sign
Increased pain on palpation at the right iliac region as patient lies on his/her left side compared to when patient
was on supine position.
Aure-Rozanova's sign
Increase pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg's sign) -
typical in retroceacal position of the appendix.[7]
Blumberg sign
Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix
followed by sudden release of the pressure causes the severe pain on the site indicating positive Blumberg's sign
and peritonitis.[8]
Causes
On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of
the appendix lumen (the inside space of a tubular structure).[9][10] Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the
appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. Rarely,
spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and
then necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix
(suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis,
which may lead to septicemia and eventually death.
Among the causative agents, such as foreign bodies, trauma, intestinal worms, lymphadenitis, and calcified
deposits known as appendicoliths,[11] the occurrence of an obstructing fecalith has attracted attention. The
prevalence of fecaliths in patients with appendicitis is significantly higher in developed than in developing
countries[12], and an appendiceal fecalith is commonly associated with complicated appendicitis[13]. Also, fecal
stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per
week in patients with acute appendicitis compared with healthy controls[14]. The occurrence of a fecalith in the
appendix seems to be attributed to a right sided fecal retention reservoir in the colon and a prolonged transit
time[15]. From epidemiological data it has been stated that diverticular disease and adenomatous polyps were
unknown and colon cancer exceedingly rare in communities exempt for appendicitis[16][17]. Also, acute
appendicitis has been shown to occur antecedent to cancer in the colon and rectum[18]. Several studies offer
evidence that a low fiber intake is involved in the pathogenesis of appendicitis[19] [20][21]. This is in accordance
with the occurrence of a right sided fecal reservoir and the fact that dietary fiber reduces transit time[22].
Diagnosis
Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of
neutrophilic white blood cells. Histories fall into two categories, typical and atypical. Typical appendicitis
usually includes abdominal pain beginning in the region of the umbilicus for several hours, associated with
anorexia, nausea or vomiting. The pain then "settles" into the right lower quadrant, where tenderness develops.
Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial
symptom. Atypical histories often require imaging with ultrasound and/or CT scanning.[23] A pregnancy test is
vital in all women of child bearing age, as ectopic pregnancies and appendicitis present with similar symptoms.
The consequences of missing an ectopic pregnancy are serious, and potentially life threatening. Furthermore the
general principles of approaching abdominal pain in women (in so much that it is different from the approach in
men) should be appreciated.
Blood Test Most patients suspected of having appendicitis would be asked to do a blood test. 50% of the time,
the blood test may be normal, so it is not fool proof in diagnosing appendicitis.
Two form of blood tests are commonly done: FBC (Full blood count) or CBC (Complete blood count), is an
inexpensive and commonly requested blood test. It involves measuring the blood for its richness in red blood
cells as well as the number of the various white blood cell constituents in it. The number of white cells in the
blood is a usually less than 10,000 cells per cubic millimeter. An abnormal rise in the number of white blood
cells in the blood is a crude indicator of infection or inflammation going on in the body. Such rise is not specific
to appendicitis alone. If it is abnormally elevated, with a good history and examination findings pointing
towards appendicitis, the likelihood of having the disease is higher. In pregnancy, there may be a normal
elevation of white blood cells, without any infection present.
CRP is an acronym for Cryo-Reactive Proteins. It is an acute phase response protein produced by the liver in
response to any infection or inflammatory process in the body. Again, like the FBC, it is not a specific test. It is
another crude marker of infection or inflammation. Inflammation at ANY site can lead to the CRP to rise. A
significant rise in CRP with corresponding signs and symptoms of appendicitis is a useful indicator in the
diagnosis of [Link] is said that if CRP continues to be normal after 72 hours of the onset of pain, it is
likely that the appendicitis will resolve on its own without intervention. A worsening CRP with good history is
a sure signal fire of impending perforation or rupture and abscess formation
Urine Test: Urine test in appendicitis is usually normal. It may however show blood if the appendix is rubbing
on the bladder, causing irritation A urine test or urinalysis is compulsory in women, to rule out pregnancy in
appendicitis, as well to help ensure that the abdominal pain felt and thought to be acute appendicitis is not in
fact, due to ectopic pregnancy.
X – Ray In 10% of patients with appendicitis, plain abdominal x-ray may demonstrate hard formed feces in the
lumen of the appendix (Fecolith). It is agreed that the finding of Fecolith in the appendix on X – ray alone is a
reason to operate to remove the appendix, because of the potential to cause worsening symptoms. In this
respect, a plain abdominal X-ray may be useful in the diagnosis of appendicitis, though plain abdominal x- ray
is no longer requested routinely in suspected cases of appendicitis. An abdominal X – ray may be done with a
barium enema contrast to diagnose appendicitis. Barium enema is whitish toothpaste like material that is passed
up into the rectum to act as a contrast. It will usually fill the whole of the large bowel. In normal appendix, the
lumen will be present and the barium fills it up and is seen when the x-ray film is shot. In appendicitis, the
lumen of the appendix will not be visible on the barium film.
Ultrasound
Ultrasound image of an acute appendicitis
Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children and shows
free fluid collection in right iliac fossa along with a visible appendix without blood flow in color Doppler. In some cases
(15% approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the
presence of appendicitis. This is especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically
difficult. Despite these limitations, in experienced hands sonographic imaging can often distinguish between appendicitis
and other diseases with very similar symptoms such as inflammation of lymph nodes near the appendix or pain
originating from other pelvic organs such as the ovaries or fallopian tubes.
Computed tomography
A cat scan demonstrating acute appendicitis (note the appendix has a diameter of 17.1mm and there is surrounding fat
stranding.)
A fecalith marked by the arrow which has resulted in acute appendicitis.
In places where it is readily available, CT scan has become frequently used, especially in adults whose
diagnosis is not obvious on history and physical. Concerns about radiation, however, tend to limit use of CT in
pregnant women and children. A properly performed CT scan with modern equipment has a detection rate
(sensitivity) of over 95% and a similar specificity. Signs of appendicitis on CT scan include lack of oral contrast
(oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in cross sectional
diameter), and appendiceal wall enhancement with IV contrast (IV dye). The inflammation caused by
appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a
mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is
not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children,
both of whom tend to lack significant fat within the abdomen. The utility of CT scanning is made clear,
however, by the impact it has had on negative appendectomy rates. For example, use of CT for diagnosis of
appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery from 20% in the
pre-CT era to only 3% according to data from the Massachusetts General Hospital.
Ultrasound and CT compared
According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, CT scan is more
accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a sensitivity of
94%, specificity of 95%, a positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of
0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 86%, a specificity of 81%, a positive
likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27).[24]
Alvarado score
A number of clinical and laboratory based scoring systems have been devised to assist diagnosis. The most
widely used is Alvarado score.
Symptoms
Migratory right iliac fossa pain 1 point
Anorexia 1 point
Nausea and vomiting 1 point
Signs
Right iliac fossa tenderness 2 points
Rebound tenderness 1 point
Fever 1 point
Laboratory
Leucocytosis 2 points
Shift to left (segmented neutrophils) 1 point
Total score 10 points
A score below 5 is strongly against a diagnosis of appendicitis[25], while a score of 7 or more is strongly
predictive of acute appendicitis. In patients with an equivocal score of 5-6, CT scan is used in the USA to
further reduce the rate of negative appendicectomy.
Other Data
Tzanakis Scoring. Tzanakis and colleagues, in 2005 published a simplified system, now called the Tzanakis
scoring system for appendicitis, to aid the diagnosis of appendicitis. It incorporates the presence 4 variables
made up of specific signs and symptoms (presence of right lower abdominal tenderness = 4points and rebound
tenderness = 3), laboratory findings (presence of white blood cells greater than 12,000 in the blood = 2) as well
as ultrasound findings (presence of positive ultrasound scan findings of appendicitis = 6), to which scores are
allocated, in the computing of a scoring to predict the presence of appendicitis. A total score of 15 is the
maximum that can be scored. Where a patient scores 8 or more points, there is greater than 96 percent chance
that appendicitis exists.
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of appendiceal rupture
among patients with acute appendicitis according to a cohort study.[26] MMP-1 was higher in gangrenous
(p<0.05) and perforated appendicitis (p<0.01) compared with controls. MMP-9 was most abundantly expressed
in inflamed appendix and reached a tenfold higher expression in all groups with appendicitis compared with
controls (p<0.001).
Differential diagnosis
In children:
Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, Henoch-Schönlein purpura, lobar
pneumonia, urinary tract infection (abdominal pain in the absence of other symptoms can occur in children with
UTI), new-onset Crohn's disease or ulcerative colitis, pancreatitis, and abdominal trauma from child abuse; distal
intestinal obstruction syndrome in children with cystic fibrosis; typhlitis in children with leukemia; in girls:
menarche, dysmenorrhea, severe menstrual cramps, Mittelschmerz, pelvic inflammatory disease, ectopic
pregnancy
In adults:
regional enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectus sheath hematoma; in men: testicular
torsion, new-onset Crohn's disease or ulcerative colitis; in women: pelvic inflammatory disease, ectopic
pregnancy, endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz (the passing of an egg in the ovaries
approximately two weeks before an expected menstruation cycle)
In elderly:
diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.
Management
Largely surgical, any conservative management is done at the threshold of operation theater as the acutely
inflamed appendix is liable to rupture during such treatment.
Inflamed appendix removal by open surgery
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for surgery. An intravenous
drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metronidazole may
be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and
postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess
with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six
hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.
Once the decision to perform an appendectomy has been made, the preparation procedure takes more or less one
to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be
considered when performing an appendectomy. With all surgeries there are certain risks that must be evaluated
before performing the procedures. However, the risks are different depending on the state of the appendix. If the
appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the
complication rate rises to almost 59%.[27] The most usual complications that can occur are pneumonia, hernia of
the incision, thrombophlebitis, bleeding or adhesions. Recent evidence indicates that a delay in obtaining
surgery after admission results in no measurable difference in patient outcomes [28]
The surgeon will also explain how long the recovery process should take. Abdomen hair is usually removed in
order to avoid complications that may appear regarding the incision. In most of the cases patients experience
nausea or vomiting which requires specific medication before surgery. Antibiotics along with pain medication
may also be administrated prior to appendectomies.
Pain management
Pain from appendicitis can be severe. Strong pain medications (i.e., narcotic pain medications) are
recommended for pain management prior to surgery. Morphine is generally the standard of care in adults and
children in the treatment of pain from appendicitis prior to surgery.
In the past (and in some medical textbooks that are still published today), it has been commonly accepted that
pain medication not be given until the surgeon has the chance to evaluate the patient, so as to not "corrupt" the
findings of the physical examination. This line of practice, combined with the fact that surgeons may sometimes
take hours to come to evaluate the patient, especially if he or she is in the middle of surgery or has to drive in
from home, often leads to a situation that is ethically questionable at best. More recently, due to better
understanding of the importance of pain control in patients, it has been shown that the physical examination is
actually not that dramatically disturbed when pain medication is given prior to medical evaluation. Individual
hospitals and clinics have adapted to this new approach of pain management of appendicitis by developing a
compromise of allowing the surgeon a maximum time to arrive for evaluation, such as 20 to 30 minutes, before
active pain management is initiated. Many surgeons also advocate this new approach of providing pain
management immediately rather than only after surgical evaluation.
Surgery
Laparoscopic appendectomy
The surgical procedure for the removal of the appendix is called an appendicectomy (also known as an appendectomy).
Often now the operation can be performed via a laparoscopic approach, or via three small incisions with a camera to
visualize the area of interest in the abdomen. If the findings reveal suppurative appendicitis with complications such as
rupture, abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy incision if
required most often centers on the area of maximum tenderness, McBurney's point, in the right lower quadrant. A
transverse or a gridiron diagonal incision is used most commonly.
In March 2008, an Indian woman had her appendix removed via her vagina, in a medical first by the NOTES
(Natural Orifice Transluminal Endoscopic Surgery) method in Coimbatore, India.[29]
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic and open procedures,
laparoscopic procedures seem to have various advantages over the open procedure. Wound infections were less
likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio (OR) 0.45; confidence
interval (CI) 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to
4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1
after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 millimeter visual
analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and
sport occurred earlier after laparoscopic procedures than after open procedures. While the operation costs of
laparoscopic procedures were significantly higher, the costs outside hospital were reduced. Young female,
obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups.[30]
There is debate whether emergency appendicectomy (within 6 hours of admission) reduces the risk of
perforation or complication versus urgent appendicectomy (greater than 6 hours after admission). According to
a retrospective case review study [31] no significant differences in perforation rate among the two groups were
noted (P=.397). Various complications (abscess formation, re-admission) showed no significant differences
(P=0.667, 0.999). According to this study, beginning antibiotic therapy and delaying appendicectomy from the
middle of the night to the next day does not significantly increase the risk of perforation or other complications.
This finding is important not simply for the convenience of the surgeons and staff involved but for the fact that
there have been other studies that have shown that surgeries taking place during the night, when people may be
more tired and there are fewer staff available, have higher rates of surgical complications.
Findings at the time of surgery are less severe in typical appendicitis. With atypical histories, perforation is
more common and findings suggest perforation occurs at the beginning of symptoms. These observations may
fit a theory that acute (typical) appendicitis and suppurative (atypical) appendicitis are two distinct disease
processes. (1)
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in complicated cases.
Laparotomy explained
Laparotomy is the traditional type of surgery used for treating appendicitis. This procedure consists in the
removal of the infected appendix through a single larger incision in the lower right area of the abdomen.[32] The
incision in a laparotomy is usually 2-3 inches long. This type of surgery is used also for visualizing and
examining structures inside the abdominal cavity and it is called exploratory laparotomy.
During a traditional appendectomy procedure, the patient is placed under general anesthesia in order to keep
his/her muscles completely relaxed and to keep the patient unconscious. The incision is two to three inches long
and it is made in the right lower abdomen, several inches above the hip bone.[33] Once the incision opens the
abdomen cavity and the appendix is identified, the surgeon removes the infected tissue and cuts the appendix
from the surrounding tissue. After the surgeon inspects carefully and closely the infected area and there are no
signs that surrounding tissues are damaged or infected, he will start closing the incision. This means sewing the
muscles and using surgical staples or stitches to close the skin up. In order to prevent infections the incision is
covered with a sterile bandage. The entire procedure does not last longer than an hour if complications do not
occur.
Laparoscopic surgery
The newer method to treat appendicitis is the laparoscopic surgery. This surgical procedure consists of making
three to four incisions in the abdomen, each 0.25 inches to 0.5 inches long. This type of appendectomy is made
by inserting a special surgical tool called laparoscope into one of the incisions. The laparoscope is connected to
a monitor outside the patient's body and it is designed to help the surgeon to inspect the infected area in the
abdomen. The other two incisions are made for the specific removal of the appendix by using surgical
instruments. Laparoscopic surgery also requires general anesthesia and it can last up to two hours. The latest
methods are NOTES appendectomy pioneered in Coimbatore ,India where there is no incision on the external
skin[34] and SILS( Single incision laparoscopic Surgery)where a single 2.5 cm incision is made to perform the
surgery.
After surgery
The stitches the day after having his appendix removed by surgery.
Hospital lengths of stay typically range from a few hours to a few days, but can be a few weeks if complications
occur. The recovery process may vary depending on the severity of the condition, if the appendix had ruptured
or not before surgery. Appendix surgery recovery is generally a lot faster if the appendix did not rupture.[35] It is
important that patients respect their doctor's advice and limit their physical activity so the tissues can heal faster.
Recovery after an appendectomy may not require diet changes or a lifestyle change.
After surgery occurs, the patient will be transferred to an intensive-care unit so his or her vital signs can be
closely monitored in order to avoid complications. Pain medication may also be administrated if necessary.
After patients are completely awake, they are moved into a hospital room to recover. Most individuals will be
offered clear liquids the day after the surgery and then progress to a regular diet when the intestines start to
function properly. It is highly recommended that patients sit up on the edge of the bed and walk short distances
for several times a day. Moving is mandatory and pain medication may be given if necessary. Full recovery
from appendectomies takes about 4 to 6 weeks but it can prolong to up to 8 weeks if the appendix had ruptured.
Prognosis
Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is
delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other
circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young
children (around 10 years old), the recovery takes three weeks.
The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy
evaluation and treatment. The patient may have to undergo a medical evacuation. Appendectomies have
occasionally been performed in emergency conditions (i.e., outside of a proper hospital), when a timely medical
evaluation was impossible.
Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If
appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should
be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative
appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either
condition, prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks
usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is
untreated. Another entity known as appendicular lump is talked about quite often. It happens when appendix is
not removed early during infection and omentum and intestine get adherent to it forming a palpable lump.
During this period, operation is risky unless there is pus formation evident by fever and toxicity or by USG.
Medical management treats the condition.
An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant
appendiceal stump left after a prior incomplete appendectomy.[36]
Disability-adjusted life year for appendicitis per 100,000 inhabitants in 2004.[37]
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