The Appendix

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Embryology, Anatomy & Histology

• Development & preservation of GALT, and

maintenance of micro flora.
• Appendix along with colon and ileum develop from
midgut. Appear around 8th week of gestation
• A true diverticulum of cecum
• 6 to 9 cm long
• Appendicular branch of ileo-colic artery
• Visceral innervation; superior mesenteric plexus
(T10-L1) and Vagus
• Intraperitoneal: retrocecal, pelvic(30%),
retroperitoneal (7%)
• Appendiceal base: convergence of cecal taeneia coli

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Acute Appendicitis
• Lifetime incidence of 8.6% in men & 6.7% in women. Most around 2nd and 3rd decade
• One of the most frequent emergent abdominal operation
• Etiology is luminal obstruction: lymphoid hyperplasia (children), in adult fecaliths, FB (food,
parasites & calculi), fibrosis or neoplasia.
• Early obstruction: aerobic. Later on mixed flora
• Obstruction leads to increased intraluminal pressure and referred visceral pain to periumbilical
region
• The most common isolate from perforated appendix: escherichia coli and bacteroide fragilis

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Clinical Diagnosis: • Examination (2)
• Patient lay quite still

• History(1): • to touch
• Focal tenderness and guarding
• Inflammation of visceral peritoneum
progress to parietal peritoneum: • Rovsing’s sign
Migratory pain, Anorexia, nausea,
vomiting and fever. • Dunphy’s sign
• Obturator’s sign
• Regional inflammation: ileus , diarrhea,
SBO and hematuria • Iliopsoas’ sign
• Pertinent negatives including menses. • Pain with rectal or cervical examination
• Laboratory: • Imaging:

• Leukocytosis & CRP • CT scan: enlarged lumen and double wall thickness, wall thickening,
periappendiceal fat stranding, appendiceal wall thickening & appendicolith
• CRP, bilirubin, IL-6, and procalcitonin: perforation
• Abdominal Ultrasound: >6mm, pain with compression, appendicolith,
• Pregnancy test, Urinalysis increased echogenicity of fat and periappendiceal fluid

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 Differential diagnosis
• Acute mesenteric adenitis
• Cecal diverticulitis
• Meckel’s diverticulitis
• Acute ileitis
• Crohn’s disease
• Acute PID
• Torsion of ovarian cyst or
Graafian follicle
• Acute gastroenteritis

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Management of acute appendicitis
• Complicated appendicitis (Perforated or
• Uncomplicated Appendicitis gangrenous. Abscess or phlegmon formation)
• Resuscitation
• Appendectomy
• IV antibiotics
• Within 12h • Percutaneous drainage (image guided):
complete resolution in 79%
• Laparoscopic (shorter LOS,
faster return to work, lower SSI) • Operative: failed nonoperative management,
intra-peritoneal perforation.
and open appendectomy (shorter
operation time and lower intra- • Interval appendicectomy; 6-8 weeks after.
abdominal infection) • Proponents: Recurrent appendicitis
(7.4-8.8%) and neoplasm(1.3%).
• opponents:No future event in 91%.

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Ochsner-Sherren Regimen for appendiceal lump

• NPO
• Ryle tube aspiration
• Antibiotics (cephalosporins, aminoglycosides and metronidazole)
• Recording size of mass daily
• Recording TPR chart 4hourly
• Input and output chart

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Operative Interventions
• Preoperative preparation:
• Resuscitation or non
• Foley catheter (optional)
• ABX 30-60 minutes before
• Cefoxitin, Ampicillin/sulbactum, & cefazolin plus metronidazole… uncomplicated
• B-lactam allergies: clindamycin in combination with fluoroquinilone, gentamicin and aztreonam
• Complicated: mono therapy of piperacillin/tazobactam or combination of Cephalosporin +
metronidazole
• Less than 4 days of ABX once the source control have been achieved
• Incomplete drainage, persistent catheters, complications from surgery and uncertain resolution of
inflammation: longer duration of ABX

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Operative Interventions
Open Appendectomy
• Tracing tinea Liberia distally
• Ligate the mesentery
• GA
• Ligate the appendix
• Wide Prep and drape
• Imbricate with Z-stitch or purse string .
• Incision at McBurney point(McBurney Mucosa fulgurated
incision & Rocky-Davis incision). Lower
midline incision: perforation with • Unexpected bleeding: medial extension of
phlegmon incision also known as Fowler extension
• Muscle splitting approach to access • Skin closure in Layers: primary or delayed
peritoneum primary
• Trendelenburg’s with left side down • Drain or no drain

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Operative Interventions
Laparoscopic appendectomy
• Supine with left arm tucked • Window created with Maryland grasper
• Monitors and assistants positioned • Mesoappendix ligated (Cautery, clip or
• Hasson technique (periumbilical) or A Verees bipolar)
or optical trocar LUQ 3cm below costal
margin at MCL
• Base of appendix divided after placing
stapler or end-loop
• 5-mm ports at suprapubic and LLQ areas
• Appendix retrieve through midline port in
• Third port in RUQ a specimen bag
• Trendelenburg’s position with left side down •
• Appendix grasped and elevated to see the
window between cecum and mesoappendix

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Operative Interventions
Novel Operation Negative exploration
• Single incision appendectomy • No evidence of appendicitis found

• Natural Orifice transluminal endoscopic surgery • Thorough exploration of peritoneum

(NOTES) • Normal appendix removed (reduced future dilemmas)
Incidental appendectomy • Management of Condition mimicking appendicitis:

• Prophylactic appendectomy
• Ovarian torsion: detorsion, oophoropexy

• Children on chemo • Crohn’s terminal ileitis: appendectomy

• Compromised host, unclear physical • Meckel’s diverticulitis: segmental small bowel

resection + Anastomosis
• Crohn’s disease with normal cecum
• Appendiceal mass: laparoscopic appendectomy/
• Traveling to remote area ileocecectomy without capsular disruption or
spillage and retrieve in a bag
• Cytoreductive surgery for ovarian malignancy

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Appendicitis in Special situation
• Appendicitis in children
• Appendicitis in older adults
• Appendicitis in Pregnancy
• Chronic or recurrent appendicitis
•

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Appendicitis in Children
• 1 in 8 workup for appendicitis
• Infants & young children: perforated disease
(51%-100%)
• School age: lower rates of perforation
• Same symptoms as adult
• Neonates: as adult + abdominal distension and
lethargy or irritability
• Pediatric Appendicitis score: 10 points. ( score of 7
or more: 78%-96% chance of appendicitis •

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Differential diagnosis of appendicitis in Pediatrics
population

• Intussusception (currant jelly stool, abdominal mass)

• Gastroenteritis (often no leukocytes)
• Malrotation (Pain out of proportion)
• Pregnancy (ectopic)
• Mesenteric adenitis
• Torsion of omentum
• Ovarian or testicular torsion

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Appendicitis in older adults
• Perforation or abscess ( diminished inflammation)
• Higher rates of complication (premorbid conditions)
• Definitive diagnostic imaging before operation
• Laparoscopic appendectomy

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Appendicitis in Pregnancy
• Clinical features similar but also
• 1 in 800 to 1 in 1000 pregnancy
• Heartburn,
• Mostly 1st & 2nd trimester • bowel irregularity,

• Antepartum: rare • flatulence or

• change in bowel habit
• Postpartum: geriatrics pregnancy
• Point of maximum tenderness displaced
• Abdominal ultrasound
• Risk of fetal loss in appendiceal perforation : 36%
• Acceptable negative exploration rate : 30%
• Nonoperative treatment failure rate: 25%

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Chronic or recurrent appendicitis
• Recurrent RLQ abdominal pain not associated with febrile illness with imaging finding
suggestive of appendicolith or dilated appendix
• Symptoms resolve with appendectomy
• If no imaging abnormalities: prophylactic appendectomy not recommended

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Outcome and Postoperative Course
• Appendectomy is relatively safe: extremely low mortality rate (< 1%)
• The most common adverse event: Soft tissue infection (Superficial or abscess)
• Uncomplicated appendicitis: no antibiotic after appendectomy
• Perforated appendix: 3 to 7 days of antibiotics
• Wound infection: opening and packing
• Deep space abscess: percutaneous drainage and ABX
• Fistulas (appendicocutaneous, appendicovesicular): conservative
• Bowel obstructions & infertility (infrequent)

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Outcome and Postoperative Course
• Stump appendicitis: appendicitis in incompletely excised stump (>0.5cm)
• History, PE and imaging investigation
• Re-excision of stump base
• Appendiceal Neoplasm
• Around 1% of all appendectomies
• Gastroenteropancreatic neuroendocrine tumors (GEP-NET): carcinoid,
• Mucinous neoplasm
• Adenocarcinoma

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GEP-NETs (carcinoid)
• Right colectomy:
• Submucosal rubbery masses
(incidental) • Mesenteric invasion
• Indolent but can have nodal or • Enlarged nodes
hepatic metastasis
• Positives or unclear margin,
• Carcinoid syndrome if hepatic
mets (2.9%) • serum chromogranin A
• Lesion <1cm (95% of carcinoids):
negative margin appendectomy
• 2cm/larger: Right hemicolectomy
• 1cm to 2cm: no consensus reached

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Goblet Cells Carcinoma
• Adenocarcinoid with both adenocarcinoma and neuroendocrine features
• Worse prognosis than carcinoid but better than adenocarcinoma
• High risk of peritoneal recurrence
• Systematic surveillance of peritoneum & peritoneal cancer index score documented
• Right hemicolectomy in absence of mets
• 2cm/larger: right colectomy

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Lymphomas
• Appendiceal lymphomas are rare (1% - 3% of lymphomas)
• Usually non-Hodgkin
• Appendiceal diameter >2.5cm
• Appendectomy in most cases

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Adenocarcinoma
• Primary adenocarcinoma of appendix is a rare • Formal right hemicolectomy
one
• Propensity for early perforation
• 3 major histologic subtypes:
• Mucinous adenocarcinoma • Over-all 5 years survival 55% (varies with
stage and grade)
• Colonic adenocarcinoma
• Synchronous and metachronous neoplasm
• Adenocarcinoid (half in GIT)
• Mode of presentation
• Acute appendicitis
• Ascites or palpable mass
• Incidentally during other operation

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Appendiceal mucocele and mucinous neoplasm of
appendix

• Mucocele: mucus filled appendix from neoplastic or nonneoplastic cause

• Presentation:
• Incidental (most)
• Appendicitis (1/3)
• Cross-sectional imaging: low attenuation, round well encapsulated cystic mass in RLQ
• Ascites, peritoneal disease and scalloping of liver
• Surgical excision without capsular disruption

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Pseudomyxoma Peritonei Syndrome
• Patient with appendiceal mucinous neoplasm develop peritoneal dissemination leading to PMP
syndrome.
• Also occur in gastric, ovarian, pancreatic and colorectal primary tumors
• Prognosis is varied: curative vs palliative
• Treatment:
• Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
• Peritonectomies+ intraperitoneal administration of heated (42 degrees) mitomycin in the
abdomen
• Laparoscopic if early disease and low volume (bulk)

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