SURGERY – APPENDIX

○​ Common bacteria: Escherichia coli, Bacteroides fragilis

EMBRYOLOGY, ANATOMY, & HISTOLOGY
(perforated appendicitis).
○​ Appendix: role in gut-associated lymphoid tissue (GALT) and intestinal ○​ Appendicitis can resolve spontaneously.
flora. ○​ Nonperforated and perforated appendicitis are considered
○​ Appendectomy: potential link to increased Clostridium difficile infections and distinct diseases.
some cancers (unproven).
○​ Early appendectomy: proposed protective effect against ulcerative colitis (IgA
release, Th2 response).
○​ Development: midgut origin (8 weeks gestation), cecum fixation in right lower
quadrant.
○​ Structure: true diverticulum of cecum, all histological layers of colon.
○​ Size: 6-9 cm average length.
○​ Blood supply: appendicular artery (posterior cecal branch of the ileocolic
artery).
○​ Innervation: superior mesenteric plexus (T10-L1), vagus nerves.
○​ Location:
■​ Usually found at the posteromedial wall of the cecum, just below the
ileocecal valve (of Bauhin) 1.5 to 2.5 cm below the terminal part of the
ileum
■​ Location of the Appendiceal Tip
●​ Intraperitoneal: Retrocecal (most common)
●​ Pelvic
●​ Paracecal and post-ileal
●​ Paracecal and pre-ileal
CLINICAL FINDINGS
●​ Sub-cecal
●​ Left lower quadrant (situs inversus or very long appendix) ●​ History:
■​ intraperitoneal, typically retrocecal, but can be pelvic (30%) or ○​ Murphy Triad: (in sequence)
retroperitoneal (7%). ■​ Pain: usually starts with periumbilical and diffuse pain that
eventually localizes to the right lower quadrant.
●​ Right lower quadrant pain is one of the most
sensitive signs of appendicitis
■​ Vomiting
■​ Fever
○​ Migratory pain (visceral to parietal peritoneum) is a classic sign.
○​ Common symptoms: anorexia, nausea, vomiting, fever.
○​ Regional inflammation: ileus, diarrhea, small bowel obstruction,
hematuria.
○​ Pertinent negative history (menstrual) is crucial.
●​ Physical Examination:
○​ Patients often lie still due to parietal peritonitis.
○​ The base of the appendix is identified by tracing the ○​ Low-grade fever, focal tenderness, guarding.
convergence of the cecal taeniae. ○​ McBurney’s point:
●​ Variations in Appendiceal Origin (Treves) ■​ Maximal direct & rebound tenderness on the lateral third
(1/3) from the anterior superior iliac spine (ASlS) to the
umbilicus.
■​ 2-3 cm posteromedial from ileocecal valve
○​ Rovsing’s sign: pain in the right lower quadrant after release of
gentle pressure on left lower quadrant (normal position)
○​ Dunphy’s sign: pain with coughing (retrocecal appendix)
ACUTE APPENDICITIS ○​ Obturator sign: pain with internal rotation of the hip (pelvic
●​ Acute Appendicitis: appendix)
○​ Inflammation of the appendix, a common surgical emergency. ○​ Iliopsoas sign: pain with flexion of the hip (retrocecal appendix
○​ Lifetime incidence: 8.6% (men), 6.7% (women), highest in ○​ Lanz point: right third point of the interspinal line
2nd-3rd decades of life. ○​ Kummel point: right side below the umbilicus
○​ Despite declining rates, appendectomy remains frequent. ○​ Rectal or cervical pain suggests pelvic appendicitis.
●​ Etiology:
○​ Luminal obstruction is a primary cause.
○​ Causes:
■​ Lymphoid hyperplasia (pediatrics)
■​ Fecaliths
■​ Fibrosis
■​ Foreign bodies (food, parasites, calculi)
■​ Neoplasia.
○​ Early obstruction leads to aerobic bacterial overgrowth, then
mixed flora.
○​ Distension of the appendix
■​ Stimulates the nerve endings of visceral afferent stretch
fibers
■​ Increased intraluminal pressure causes referred visceral
pain (periumbilical).
■​ ⇒ Impaired venous drainage leads to mucosal ischemia,
bacterial translocation, gangrene, and intraperitoneal
infection.
■​ As distension, bacterial invasion, compromise of the
vascular supply, and infarction progress, ⇒ perforation
occurs, usually on the antimesenteric border just beyond
the point of obstruction

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○​ Graded compression ultrasonography measures appendix

diameter.
○​ Appendix <5mm (compressible) rules out appendicitis.
○​ Features:
■​ Diameter >6mm
■​ Pain with compression
■​ Appendicolith
●​ Laboratory Findings: ■​ Increased fat echogenicity
○​ Leukocytosis (10,000 cells/mm3), higher in ■​ Periappendiceal fluid.
gangrenous/perforated appendicitis (17,000 cells/mm3). ○​ Advantages: cheaper, readily available, no ionizing radiation.
○​ C-reactive protein, bilirubin, Il-6, procalcitonin may assist in ○​ Limitations: user-dependent, limited in obese patients, painful for
diagnosis. peritonitis.
○​ White blood cell (WBC) count and C-reactive protein are
recommended.
○​ Pregnancy test (women of childbearing age) is essential.
○​ Urinalysis rules out nephrolithiasis or pyelonephritis.

●​ MRI:
○​ Sensitivity (0.95), specificity (0.92).
○​ Expensive, requires expertise.
○​ Recommended when radiation risk outweighs CT benefits
(pregnant, pediatric).
MANAGEMENT

UNCOMPLICATED APPENDICITIS MANAGEMENT

●​ Imaging:
○​ Used to confirm appendicitis diagnosis, balancing against
negative operation rates (<10% males, <20% females).
○​ Reduces negative laparotomies.
○​ Appropriate for unclear diagnoses or high-risk patients (pregnant,
comorbidities).
○​ Modalities: CT, ultrasound (US), MRI. ●​ Appendectomy is the preferred approach.
●​ CT Scan: ●​ Nonoperative management (antibiotics) is an alternative, but not
○​ High sensitivity (0.96) and standard.
specificity (0.96). ○​ Meta-analysis shows 26.5% of nonoperative patients require
○​ Features: appendectomy within 1 year.
■​ Enlarged lumen/wall ○​ Higher adverse event rate with antibiotics.
thickness (>6mm) ○​ Recurrent appendicitis more often presents as complicated.
■​ Target sign: Wall ○​ Offered to informed patients via shared decision-making, or those
thickening (>2mm) with severe surgery phobia.
■​ Periappendiceal fat ●​ Timing of Surgery:
stranding ○​ Emergent surgery is common.
■​ Appendicolith ○​ Urgent surgery (within 12 hours) after antibiotics is acceptable.
○​ Ionizing radiation concern, but low-dose CT (2-4 mSv) is ○​ Delaying surgery <12 hours is acceptable in short symptom
comparable to background radiation. duration (<48 hrs) and non-perforated, non-gangrenous cases.
○​ Low-dose CT images do not affect clinical outcomes. ●​ Approach of Surgery:
○​ Intravenous contrast preferred, but avoidable in allergies or low ○​ Laparoscopic vs. open appendectomy: relatively equivalent.
eGFR (<30 mL/minute/1.73m2). ○​ Laparoscopic: shorter length of stay (LOS), faster return to work,
○​ Meta-analyses show CT is more sensitive/specific than US. lower superficial wound infection (especially obese).
●​ Ultrasound (US): ○​ Open: shorter operative times, lower intra-abdominal infection
○​ Sensitivity (0.85), specificity (0.90). rates.

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○​ Costs are similar. ○​ Trendelenburg position (left side down).

○​ Laparoscopic appendectomies are increasingly utilized in the US. ○​ Appendix grasped, mesoappendix divided (cautery, clip, bipolar
COMPLICATED APPENDICITIS MANAGEMENT energy).
○​ Appendix base divided (endoscopic stapler or endoloop).
○​ Nonviable base: staple line through cecum (avoiding ileocecal
valve).
○​ Appendix retrieved in specimen bag.
○​ Periappendiceal phlegmon/perforated: blunt dissection,
conversion to open if needed.
●​ Complicated Appendicitis: ○​ Ileocecectomy may be necessary.
○​ Perforated appendicitis ●​ No difference for open and laparoscopic approach
○​ Gangrenous appendicitis
NEGATIVE EXPLORATION
○​ Abscess
○​ Phlegmon formation ●​ If no appendicitis is found during laparoscopy/laparotomy, a thorough
●​ Patients are often acutely ill, dehydrated, requiring resuscitation. peritoneal exploration is necessary.
●​ Perforated abscess is usually walled off in the right lower quadrant. ●​ A normal appendix is often removed to prevent future diagnostic issues.
●​ Immediate surgery is required for septic patients, but has higher
complication rates.
●​ Staged management is used for long-duration, complicated cases:
○​ Resuscitation and IV antibiotics.
○​ Percutaneous image-guided drainage for longstanding perforation
(successful in 79%).
○​ Operative intervention for failed conservative management or free
intraperitoneal perforation.
●​ Interval Appendectomy
○​ Performed 6-8 weeks after initial inflammatory episode.
○​ Debate exists regarding its value.
○​ Proponents: recurrent appendicitis risk (7.4%-8.8%), appendiceal
neoplasms.
○​ Opponents: high rate of no future events (91% at median
34-month follow-up).
○​ Shared decision-making is necessary. INCIDENTAL APPENDECTOMY
OPERATIVE INTERVENTION ●​ Prophylactic appendectomy during other surgeries to prevent future
appendicitis.
PREOPERATIVE PREPARATION ●​ Historically performed in:
●​ Expeditious transfer to the operating room. ○​ Children undergoing chemotherapy.
●​ Resuscitation for dehydrated or compromised patients. ○​ Compromised hosts with unclear physical exams.
●​ Foley catheter placement is optional. ○​ Crohn’s disease patients with normal cecum.
●​ Preoperative antibiotics (30-60 minutes before incision): ○​ Patients traveling to remote areas.
○​ Uncomplicated: cefoxitin, ampicillin/sulbactam, cefazolin + ○​ Patients undergoing cytoreductive surgery for ovarian
metronidazole. malignancies.
■​ ß-lactam allergies: clindamycin + fluoroquinolone, ●​ Currently, it is generally not advocated due to:
gentamicin, or aztreonam. ○​ Lack of clear evidence supporting long-term benefits.
○​ Postoperative antibiotics usually not needed for uncomplicated ○​ Increased risk of adhesions and future complications.
appendicitis. ○​ Increased economic costs.
●​ Perforated appendicitis: SPECIAL CIRCUMSTANCES
○​ Antibiotics covering gram-negative and anaerobes
APPENDICITIS IN CHILDREN
(piperacillin/tazobactam or cephalosporin + metronidazole).
●​ 1 in 8 children undergo appendicitis workup.
○​ Postoperative antibiotics <4 days (STOP-IT trial) if source control
●​ Infants/young children: higher perforation rates (51%-100%).
achieved.
●​ Neonates: abdominal distension, lethargy, irritability.
○​ Longer duration for incomplete drainage, persistent catheters,
●​ Pediatric Appendicitis Score:
complications, or uncertain resolution.
○​ Similar to Alvarado Score (10 points).
OPERATIVE TECHNIQUE ○​ Right lower quadrant tenderness and pain with cough,
●​ Open Appendectomy: (less expensive) percussion, or hopping (2 points each).
○​ General anesthesia (regional possible). ○​ Score ≥7: high appendicitis likelihood (78%-96%).
○​ Incision: ●​ Differential diagnoses: intussusception, gastroenteritis, malrotation,
■​ McBurney’s (oblique) ectopic pregnancy, mesenteric adenitis, omental torsion,
■​ Rocky-Davis (transverse) ovarian/testicular torsion.
■​ Lower midline (perforated appendicitis). ●​ Early appendicitis: laparoscopic appendectomy preferred.
○​ Muscle-splitting approach. ●​ Complicated appendicitis: urgent appendectomy (no abscess/mass),
○​ Trendelenburg position (left side down). laparoscopic benefits retained.
○​ Appendix located by tracing anterior taenia of cecum. ●​ Perforation: postoperative antibiotics (≥3 days, preferably 5).
○​ Mesentery ligated early. ●​ Perforated appendicitis with abscess: management similar to adults,
○​ Viable appendix base: ligation, Z-stitch, purse-string, or mucosal early laparoscopic acceptable.
fulguration. ●​ Nonoperative management (antibiotics): safe for early presentation (<48
○​ Fowler extension for bleeding control. hours), limited inflammation (WBC <18,000/[Link]), appendicoliths, no
○​ Skin closure: layered, secondary intention, or delayed primary (no rupture.
difference in surgical site infection). ○​ High success rate reducing inflammation, high recurrence rate.
○​ Drains not beneficial. APPENDICITIS IN OLDER ADULTS
●​ Laparoscopic Appendectomy: (more expensive)
●​ Diminished inflammation, higher perforation/abscess rates.
○​ Supine position, left arm tucked.
●​ Higher complication risk due to comorbidities.
○​ Peritoneal access:
●​ Definitive imaging before surgery is prudent.
■​ Hasson (periumbilical)
●​ Laparoscopic appendectomy safe, reduces pain and hospital stay.
■​ Verees/optical trocar (left upper quadrant).
○​ 5-mm ports (suprapubic, left lower quadrant, right upper quadrant
possible).
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APPENDICITIS IN PREGNANCY ●​ Management: right hemicolectomy.

●​ Early perforation propensity, 5-year survival ~55%.
●​ 1 in 800-1000 pregnancies, mostly 1st/2nd trimesters.
●​ Risk of synchronous and metachronous neoplasms.
●​ Symptoms: heartburn, bowel irregularity, flatulence, altered bowel
habits. Appendiceal Mucoceles and Mucinous Neoplasms of the Appendix
○​ Point of maximum tenderness displaced. ●​ Mucocele: mucus-filled appendix (neoplastic or nonneoplastic).
●​ Ultrasound preferred imaging (variable sensitivity/specificity). ●​ Causes:
●​ MRI alternative (high sensitivity/specificity). ○​ Mucosal hyperplasia
●​ CT avoided due to fetal irradiation risk (unless inconclusive). ○​ Cysts
●​ High fetal loss risk (36%) with perforation. ○​ Mucinous cystadenomas/adenocarcinomas.
●​ Lower threshold for surgery, higher acceptable negative exploration rate ●​ Presentation: incidental, appendicitis (~1/3 of cases).
(30%). ●​ Imaging: cystic mass, wall irregularity, soft tissue thickening.
●​ Laparoscopic appendectomy safe, but higher fetal loss risk than open. ●​ Assess for ascites, peritoneal disease, liver surface scalloping.
●​ Lower intra-abdominal pressure during insufflation recommended. ●​ Diagnosis: surgical excision without capsular disruption.
●​ Nonoperative management has a high treatment failure rate. ○​ Avoid rupture (pseudomyxoma peritonei risk in adenocarcinoma).
CHRONIC OR RECURRENT APPENDICITIS ○​ Peritoneal examination, peritoneal cancer index score.
●​ Biopsies: epithelial cell, neoplastic cell, mucin analysis.
●​ Recurrent right lower quadrant pain, imaging suggests
○​ Homogeneous cyst (no nodularity/dissemination): laparoscopic
appendicolith/dilated appendix.
excision (stapled cecal base).
●​ Appendectomy often resolves symptoms.
●​ Management:
●​ Prophylactic appendectomy not encouraged without imaging
○​ Appendectomy with lymphadenectomy (no mesenteric/peritoneal
abnormalities.
involvement).
OUTCOME & POSTOPERATIVE COURSE ○​ Peritoneal spread: biopsies, peritoneal disease burden
●​ Appendectomy is safe, low mortality (<1%). documentation.
●​ Common adverse events: soft tissue infections (superficial/deep, ○​ Appendectomy (acute appendicitis), avoid suboptimal debulking.
abscesses). ○​ Colorectal, ovarian, endometrial cancers may coexist.
●​ Uncomplicated appendicitis: no post-op antibiotics. ○​ Peritoneal histology takes priority over primary lesion histology.
●​ Perforated appendicitis: 3-7 days antibiotics (4 days from STOP-IT trial). ○​ AJCC 8th edition and PSOGI 2016 classification for mucinous
●​ Wound infections: wound opening and packing, delayed primary closure neoplasms.
not beneficial.
PSEUDOMYXOMA PERITONEI SYNDROME
●​ Deep space abscesses: percutaneous drainage and antibiotics.
●​ Peritoneal dissemination from appendiceal mucinous neoplasms.
●​ Fistulas (appendicocutaneous/appendicovesicular): conservative
●​ Also occurs in gastric, ovarian, pancreatic, and colorectal tumors.
management.
●​ Varied prognosis (curative to palliative).
●​ Bowel obstructions and infertility: infrequent.
●​ Standard of care: cytoreductive surgery and hyperthermic intraperitoneal
STUMP APPENDICITIS
chemotherapy (HIPEC).
●​ Uncommon complication: appendicitis in incompletely excised stump ●​ Early detection and management of limited peritoneal disease is
(>0.5 cm). preferred.
●​ Management: reexcision of appendiceal base. ●​ Surgical technique: parietal and visceral peritonectomies, heated
●​ Diagnosis: challenging, requires careful assessment. intraperitoneal chemotherapy (mitomycin).
●​ “appendiceal critical view” helps to appropriately identify the base of the ●​ Morbidity and mortality are now comparable to major open GI
appendix to prevent this. procedures in high-volume centers.
●​ Prior appendectomy does not rule out future appendicitis. ●​ Laparoscopic HIPEC is possible for early, low-volume disease.
APPENDICEAL NEOPLASMS
●​ Incidence: ~1% of appendectomy specimens.
●​ Types: gastroenteropancreatic neuroendocrine tumors (GEP-NETs or
carcinoids), mucinous neoplasms, adenocarcinomas.
●​ ~1/3 present as acute appendicitis, others are incidental or detected after
spread.
GASTROENTEROPANCREATIC NEUROENDOCRINE TUMORS
(GEP-NETS OR CARCINOID)
●​ Submucosal rubbery masses, incidental findings.
●​ Relatively indolent, potential for nodal/hepatic metastases.
●​ Carcinoid syndrome (rare, with hepatic metastases).
●​ Surgical evaluation: nodal basin, liver metastases.
●​ Lesions <1 cm: negative margin appendectomy.
●​ Lesions ≥2 cm: right hemicolectomy.
●​ Lesions 1-2 cm: right hemicolectomy is often performed.
●​ Right colectomy for mesenteric invasion, enlarged nodes, or
positive/unclear margins.
●​ Serum chromogranin A measurement recommended.
GOBLET CELL CARCINOMAS
●​ Adenocarcinoid with adenocarcinoma and neuroendocrine features.
●​ Worse prognosis than carcinoids, better than adenocarcinomas.
●​ High risk of peritoneal recurrence.
●​ Management: peritoneal surveillance, peritoneal cancer index score,
right hemicolectomy (no metastatic disease).
LYMPHOMAS
●​ Rare (1-3% of lymphomas, usually non-Hodgkin's).
●​ Difficult to diagnose preoperatively.
●​ Management: appendectomy.
ADENOCARCINOMA
●​ Rare neoplasm.
●​ Histologic subtypes: mucinous, colonic, adenocarcinoid.
●​ Presentation: acute appendicitis, ascites, palpable mass, incidental
finding.
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Difference Between Local and Generalized Peritonitis

Feature Local Peritonitis Generalized Peritonitis

Definition Inflammation confined to a Widespread inflammation

specific area of the involving the entire peritoneal
peritoneal cavity cavity

Cause Usually due to localized Often results from perforation

infection (e.g., appendicitis, (e.g., perforated ulcer,
diverticulitis, cholecystitis) ruptured appendix, bowel
perforation) or systemic
infection

Symptoms - Localized abdominal pain - Diffuse abdominal pain,

and tenderness tenderness, and rigidity
- Guarding and rebound (board-like abdomen)
tenderness in a specific - Severe systemic symptoms
quadrant (fever, tachycardia,
hypotension)

Physical - Tenderness limited to one - Diffuse tenderness and

Exam region rigidity
- Possibly localized - Generalized rebound
guarding tenderness

Complication May progress to generalized High risk of septic shock,

s peritonitis if not treated multi-organ failure, and death

Management - Treat underlying cause - Emergency surgery (e.g.,

(e.g., appendectomy, laparotomy, drainage)
cholecystectomy) - Broad-spectrum IV
- Antibiotics antibiotics and aggressive fluid
resuscitation

Would you like further details on diagnosis or management?