the retrocolic or retrocecal position.

In cases of malrotation
or situs inversus, the malpositioned appendix may give rise
to signs of inflammation in unusual locations.
The appendix averages 8 cm in length but can vary from
0.3 to 33 cm. The diameter of the appendix ranges from 5
to 10 mm. Its blood supply is the appendiceal branch of the
ileocolic artery, which passes behind the terminal ileum.
The base of the appendix arises at the junction of the three tae-
niae coli, a useful landmark in locating an elusive appendix.
Its colonic epithelium and circular and longitudinal muscle
layers are contiguous with the cecal layers. A few submucosal
lymph follicles are present at birth. These increase to approx-
imately 200 by age 12 and reduce abruptly after the age of 30.
Suppression of cecal development results in appendi-
cular hypoplasia or agenesis. Appendiceal duplication has a
reported incidence of 4 in 100,000.9,10 The duplicated appen-
dix may be partial (bifid appendix) or full, and it may have
separate or common orifices in the cecum, which may also
be duplicated.
The function of the appendix is unknown. Primates have
an appendix, but most mammals do not. Curiously, rabbits
do have an appendix and it is believed to be an important site
for the immunologic development of B cells.11
CHAPTER 100
Spectrum of Disease
------------------------------------------------------------------------------------------------------------------------------------------------

Appendicitis The geographic variation in the incidence of appendicitis

is widespread. Appendicitis occurs less frequently in less
industrialized countries.12 Over the past few decades, the world-
James C. Y. Dunn wide incidence has steadily decreased.12–15 In the United States
over 70,000 children are diagnosed with appendicitis annually,
or approximately 1 per 1000 children per year. The lifetime risk
for appendicitis is 9% for men and 7% for women.16 About one
third of patients with appendicitis are younger than 18 years of
In 1886 Fitz1 coined the term appendicitis. Morton is credited age. Appendicitis occurs more commonly in whites and during
with performing the first deliberate appendectomy for a the summer months. The peak incidence occurs between ages
perforated appendix in the United States in 1887.2,3 In 1889 11 and 12. Although the disorder is uncommon in infants,
McBurney4 reported his treatment of appendicitis with appen- perforated appendicitis can occur even in premature infants.
dectomy before rupture and described “the seat of greatest Perforation may also be the end result of another disease process,
pain . . . has been very exactly between an inch and a half and as is seen in neonates with Hirschsprung disease.17 Although
two inches from the anterior spinous process of the ilium on a the diagnosis and treatment have improved, appendicitis con-
straight line drawn from the process to the umbilicus.” From then tinues to cause significant morbidity and still remains, although
on, this location was known as the McBurney point. Modern sur- rarely, a cause of death.18,19
gical care and antibiotic therapy have turned this once frequently Many terms have been used to describe the varying stages
fatal disease rarely so today. Appendicitis remains the most of appendicitis including acute appendicitis, suppurative
common acute surgical condition of the abdomen5; many aspects appendicitis, gangrenous appendicitis, and perforated appen-
of the treatment of appendicitis remain controversial. dicitis. These distinctions are imprecise, with considerable
variability among surgeons and among surgeons and pathol-
ogists. Clinically the only relevant distinction is between
Embryology and Anatomy simple and complicated appendicitis. In general, acute and
------------------------------------------------------------------------------------------------------------------------------------------------
suppurative appendicitis tend to have a simple clinical course,
During embryogenesis, the appendix first becomes visible whereas gangrenous and perforated appendicitis tend to have
during the eighth week of gestation as a continuation of the a complicated course.
inferior tip of the cecum.6,7 The appendix rotates to its final Whether chronic and recurrent cases of appendicitis exist
position on the posteromedial aspect of the cecum, about has been debated for decades. Literature contends that they do
2 cm below the ileocecal valve, during late childhood. The var- exist and should be considered in the differential diagnosis of
iability in this rotation leads to multiple possible final posi- recurrent lower abdominal pain.20,21 Inflammation of the
tions of the appendix. The appendix is intraperitoneal in appendix does not inevitably lead to perforation because spon-
95% of cases, but the exact location varies widely.8 In 30% taneous resolution does occur.22,23 Antibiotics may also assist
of cases the tip of the appendix is in the pelvis, in 65% it is the resolution of the inflammation. Recognition of this may
behind the cecum, and in 5% it is truly extraperitoneal in contribute to the decreasing number of appendectomies.14,15
1255
1256 PART VII ABDOMEN

Presentation
------------------------------------------------------------------------------------------------------------------------------------------------
obstruction, which leads to tissue ischemia, infarction, and
gangrene. Bacterial invasion of the wall of the appendix then
Traditional teaching is that appendicitis evolves as a con- occurs. Fever, tachycardia, and leukocytosis develop as a
tinuum from simple inflammation to perforation, typically consequence of mediators released by ischemic tissues, white
occurring after 24 to 36 hours of symptoms, and subsequent blood cells, and bacteria. When the inflammatory exudate
abscess formation occurring over a period of 2 to 3 days.24,25 from the appendiceal wall contacts the parietal peritoneum,
Nevertheless, the variability of the clinical presentation of somatic pain fibers are triggered and the pain localizes near
appendicitis leads to laparotomies that do not reveal an the appendiceal site, most typically at the McBurney point.
inflamed appendix. Clinical experience and advances in Pain occasionally occurs only in the right lower quadrant
imaging methods have improved the diagnostic accuracy without the early visceral component. With a retrocecal or
but are not foolproof. The clinical presentation of appendicitis pelvic appendix, this somatic pain is often delayed in onset
can be understood in terms of its pathophysiology. because the inflammatory exudate does not contact the pari-
Appendicitis results from luminal obstruction followed by etal peritoneum until rupture occurs and infection spreads.
infection. This process was first described by van Zwalenberg26 Pain of a retrocecal appendix may be in the flank or back.
in 1905 and experimentally confirmed by Wangensteen27 in A pelvic appendix resting near the ureter or testicular vessels
1939. Wangensteen showed that the human appendix can cause urinary frequency, testicular pain, or both. Inflam-
continues to secrete mucus even when intraluminal pressures mation of the ureter or bladder by an inflamed appendix
exceed 93 mm Hg. Although it is clear that luminal obstruction can also lead to pain on micturition or the deceptive pain of
causes appendicitis, the cause of the obstruction is not always a distended bladder secondary to urinary retention.
clear. Inspissated and sometimes calcified fecal matter, known Further breakdown of the appendiceal wall leads to per-
as a fecalith, often plays a role.28 Fecaliths can be surgically foration with spillage of infected intraluminal contents with
found in approximately 20% of children with acute appendici- localized abscess formation or generalized peritonitis. This
tis and are reported in 30% to 40% of children with perforated process depends on the rapidity of progression to perforation
appendicitis.29,30 The presence of fecaliths can often be and on the patient’s ability to mount a response and contain
documented radiographically. Hyperplasia of appendiceal the spilled contents of the appendix. Signs of perforated
lymphoid follicles frequently causes luminal obstruction, appendicitis include a temperature higher than 38.6 C,
and the incidence of appendicitis closely parallels the amount leukocyte count greater than 14,000,46 and the presence of
of lymphoid tissue present.31 Causes of local or generalized more generalized peritoneal signs. Other reported risk factors
reaction of lymphatic tissue such as Yersinia, Salmonella, and include the male sex, extremes of age, and such anatomic fac-
Shigella32–35 can lead to luminal obstruction of the appendix, tors as a retrocecal position of the appendix.25,47 However,
as can parasitic infestations by Entamoeba, Strongyloides, perforated and nonperforated appendicitis may be entirely
Enterobius vermicularis, Schistosoma, or Ascaris species.36–38 separate entities.13 Spontaneous resolution of appendicitis
Enteric and systemic viral infections such as measles, chicken does occur. Patients may be asymptomatic before perforation,
pox, and cytomegalovirus may also cause appendicitis.39,40 and symptoms may be present for longer than 48 hours with-
Patients with cystic fibrosis have an increased incidence of out perforation. In general, however, the longer duration of
appendicitis, which presumably results from alterations in symptoms is associated with a greater risk for perforation.
the mucous-secreting glands.41,42 Carcinoid tumors can ob- Constipation is unusual, but the sensation of rectal fullness
struct the appendix, especially when they are located in the or tenesmus is common. Diarrhea occurs more frequently in
proximal third. Foreign bodies such as pins, vegetable seeds, children than in adults and can result in a misdiagnosis of
and cherry stones have been implicated as causes of appendi- gastroenteritis. Diarrhea is typically of short duration and
citis for more than 200 years. Trauma has also been reported as often results from irritation of the terminal ileum or cecum;
a cause,43 as has psychologic stress44 and heredity.45 however, it may indicate a pelvic abscess.
Initially the patient may describe mild gastrointestinal Younger children typically present with complicated appen-
symptoms before the onset of pain (e.g., decreased appetite, dicitis due to their inability to give an accurate history and phy-
indigestion, or subtle changes in bowel habits). Anorexia is sicians’ low index of suspicion that leads to misdiagnosis.48–50
a helpful sign, particularly in children, because a hungry child The most frequent presenting symptom in preschool children
rarely has appendicitis. Any severe gastrointestinal symptoms is vomiting, followed by fever and abdominal pain.51 Perfora-
before the onset of pain, however, should suggest an alterna- tion is almost always the finding at laparotomy, and these
tive diagnosis. Distention of the appendix results in activation children may have associated small bowel obstruction second-
of its visceral pain fibers. Typical early visceral pain is non- ary to extensive inflammation in the terminal ileum and cecum.
specific in the periumbilical region. This initial pain is poorly
localized as a deep, dull pain in the T-10 dermatome. The con-
tinued distention of the appendiceal wall elicits nausea and
vomiting, which typically follow the onset of pain within a
Diagnosis
------------------------------------------------------------------------------------------------------------------------------------------------

few hours. Nausea is common, but vomiting is typically not

PHYSICAL EXAMINATION
severe. The appearance of these symptoms before the onset
of pain casts doubt on the diagnosis. As with most disease processes, much can be learned before
The obstructed appendix is a perfect breeding ground the patient is touched. Children with appendicitis usually
for trapped bacteria. As intraluminal pressure increases, lie in bed with minimal movement. A squirming, screaming
lymphatic drainage is inhibited, leading to further edema child rarely has appendicitis. An exception to this is the child
and swelling. Finally, the increase in pressure causes venous with retrocecal appendicitis and subsequent irritation of the
 CHAPTER 100 APPENDICITIS 1257

ureter presenting with pain similar to renal colic. Older chil- teenagers are more likely to have an organized abscess. The
dren may limp or flex the trunk, whereas infants may flex the physical examination in cases of an organized abscess reveals
right leg over the abdomen. A recall of localized pain elicited a boggy, tender mass over the abscess.
by bumps in the road on the ride to the hospital is helpful. A frequently unreported but critical aspect of the evalua-
Before starting palpation of the abdomen, it is useful to ask tion is serial examinations done by the same person. The safety
the child to point with one finger to the location of the abdom- and efficacy of serial observation was first reported by White
inal pain. With the knees bent to relax the abdominal muscles, in 197555 and has since been reinforced by other studies.
gentle palpation of the abdomen should begin at a point away Surana56 reported a prospective study showing no increase
from the location of perceived pain. Palpating the abdomen in in morbidity with appendectomy after active observation in
an area remote from the site of pain may elicit tenderness in a hospital compared with urgent appendectomy. When the
the right lower quadrant (Rovsing sign of referred pain), indi- diagnosis is unclear, serial abdominal examinations permit
cating peritoneal irritation. Younger children may be more the physician to decrease the number of unnecessary laparot-
cooperative if their hand or the stethoscope is used for palpa- omies without increased risk to the patient.
tion. The stethoscope can have several roles in the evaluation
of a patient who potentially has appendicitis, the least impor-
LABORATORY STUDIES
tant of which is auscultation. Although patients often have
diminished or absent bowel sounds, this is not uniform and Much has been discussed concerning the laboratory findings
auscultation of the abdomen is of little benefit. However, aus- of appendicitis. Total leukocyte and neutrophil counts have
cultation of the chest to examine for lower respiratory infec- been extensively investigated.57–59 The sensitivity of an
tion is useful because right lower lobe pneumonia can elevated leukocyte count ranges from 52% to 96% and that
mimic appendicitis. Cutaneous hyperesthesia, a sensation of a left-shifted neutrophil count ranges from 39% to 96%.
derived from the T10 to L1 nerve roots, is often an early The latter is of better diagnostic value, but misinterpretation
although inconsistent sign of appendicitis. Lightly touching of the values is still common. Normal leukocyte count occurs
the patient with the stethoscope creates this uncomfortable in 5% of patients with appendicitis. Greater specificity and
sensation. sensitivity have been reported using a neutrophil-lymphocyte
Localized tenderness is essential for diagnosis and is noted ratio greater than 3.5.60
either on palpation or percussion. Tenderness can be mild and In the majority of children with suspected appendicitis, the
even masked by more generalized abdominal pain, especially combination of clinical history, physical findings, and labo-
during initial stages. The McBurney point is the most common ratory studies should provide sufficient data for making the
location. Retrocecal appendicitis may be detected by tender- diagnosis. Nevertheless, misdiagnosis leading to negative ap-
ness midway between the twelfth rib and the posterior supe- pendectomy ranging from 10% to 30% has been reported.61
rior iliac spine. Pelvic appendicitis produces rectal tenderness. An appendicitis score based on weighing eight clinical factors
A child with malrotation will have localized tenderness that (localized right lower quadrant tenderness, leukocytosis, pain
corresponds to the position of the exudative drainage from migration, left shift, fever, nausea-vomiting, anorexia, perito-
the inflamed appendix. neal irritation) was proposed to improve the diagnostic accu-
As the disease progresses to perforation, peritonitis ensues. racy.62,63 In prospective evaluations of children with acute
The pattern of pain depends on the location of the appendix. abdominal pain, the sensitivity of the scoring system ranged
Perforation may result in temporary relief of symptoms as the from 76% to 100% and its specificity ranged from 79% to
pain of the distended viscus is relieved. Initially, peritonitis is 87%.64,61 In cases where the diagnosis is equivocal, serial
reflected as local muscular rigidity. This progresses from observation is warranted and imaging studies may be useful.
simple involuntary guarding to generalized rigidity of the
abdomen. Other signs include rigidity of the psoas muscle
IMAGING STUDIES
(demonstrated by right hip extension or raising the straight
leg against resistance) or of the obturator muscle (demon- Imaging studies have variable success in improving diagnostic
strated by passive internal rotation of the right thigh), both accuracy. Plain radiography can be helpful. Fecaliths are
of which indicate irritation of these muscles due to retrocecal present in 10% to 20% of patients and may be an indication
appendicitis. Other tests of peritoneal inflammation such as for surgery when symptoms are present. An abnormal gas
rebound tenderness are seldom necessary for diagnosis and pattern in the right lower quadrant, lumbar scoliosis away
cause unnecessary discomfort. from the right lower quadrant, and obliteration of the psoas
The routine use of rectal examination in the diagnosis of shadow or fat stripe on the right are also helpful. A chest
appendicitis has recently been questioned.52–54 Pain during radiograph to rule out pneumonia may be indicated.
this examination is nonspecific for appendicitis. If other signs A barium enema contrast radiograph may show absent
point to appendicitis, the rectal examination is unnecessary. or incomplete filling of the appendix, irregularities of the
However, it may be a helpful diagnostic maneuver in question- appendiceal lumen, and an extrinsic mass effect on the cecum
able cases such as when a pelvic appendix or abscess is sus- or terminal ileum. The sensitivity and specificity of this tech-
pected or when uterine or adnexal pathologic conditions nique are low,65 and it is best used in the diagnosis of non-
are being considered. specific abdominal pain.
If appendicitis is allowed to progress, two results are In skilled hands, ultrasonography has proven to be an
possible: (1) diffuse peritonitis and shock will occur or effective diagnostic aid. A prospective study showed that
(2) the infection will become isolated and an abscess will form. ultrasonography was more accurate than the surgeon’s initial
Diffuse peritonitis is more common in infants, probably be- clinical impression.66 Most studies demonstrate a sensitivity
cause of the absence of omental fat. Older children and greater than 85% and a specificity greater than 90%.67
1258 PART VII ABDOMEN

Demonstration of a noncompressible appendix that is 7 mm TABLE 100-1

or larger in anteroposterior diameter is the primary criterion Differential Diagnosis of Acute Appendicitis
for the diagnosis. The presence of an appendicolith is helpful. Appendix
Such techniques as graded compression, self-localization,68 Appendiceal tumor, carcinoid tumor
and transvaginal or transrectal ultrasound approaches69 have Appendiceal mucocele
also improved results. Crohn disease
Computed tomography (CT) has become more widely
used in the diagnosis of appendicitis.70–73 The findings of Cecum and Colon
an enlarged appendix (>6 mm), appendiceal wall thickening Cecal carcinoma
(>1 mm), periappendiceal fat stranding, and appendiceal Diverticulitis
wall enhancement are useful diagnostic criteria.74,75 The sen- Crohn disease
sitivity of CT scans is over 90%, and its specificity is over Intestinal obstruction
80%.76 Comparisons of ultrasonography and CT have shown Stercoral ulcer
that the latter is more sensitive, whereas the former is more Typhlitis (leukemic, amebic)
specific.67,70,77 These two imaging modalities, however, Hepatobiliary
should be employed only if the diagnosis is uncertain. In a Cholecystitis
protocol that evaluated children with equivocal clinical find- Hepatitis
ings for appendicitis, the combination of pelvic ultrasound Cholangitis
followed by limited CT with rectal contrast, if necessary, Small Intestine
yielded a sensitivity of 94% and a specificity of 94%.78 The Adenitis
same protocol reduced the negative appendectomy rate from Duodenal ulcer
12% to 6% at the same institution during the study period but Gastroenteritis
performed imaging in almost 80% of children with suspected Intestinal obstruction
appendicitis. The perceived improved diagnostic accuracy led Intussusception
to a dramatic increase in the number of CT performed in the Meckel diverticulitis
pediatric population,79–81 even though there is no good Tuberculosis
evidence that supports the routine use of CT in the diagnosis Typhoid (ulcer perforation)
of appendicitis.82 In addition to the hospital resource utiliza-
Urinary Tract
tion and the delay in surgical care, the potential cancer risk
Hydronephrosis
associated with ionizing radiation from CT should be
Pyelonephritis
considered.79
Ureteral or renal calculus
Wilms’ tumor
DIFFERENTIAL DIAGNOSES Uterus, Ovary
Acute appendicitis can mimic virtually any intra-abdominal Ectopic pregnancy
process.83 The differential diagnosis of appendicitis is listed Ovarian torsion
in Table 100-1. Consideration of these other disease processes Ruptured ovarian cyst
before surgery is as important as it is to examine for them Salpingitis
carefully when the patient is under anesthesia and during Tubo-ovarian abscess
surgery in the case of a normal appendix. Other
The clinical diagnosis of appendicitis is challenging be- Cytomegalovirus infection
cause many symptoms of appendicitis are nonspecific and Diabetic ketoacidosis
the presentations can be variable. Acute gastroenteritis is a Schönlein-Henoch purpura
common cause of abdominal pain in children. It is usually Kawasaki disease
due to a viral illness and is self-limited. The symptoms include Burkitt lymphoma
watery diarrhea, crampy abdominal pain, fever, nausea, and Omental torsion
vomiting. Constipation is another common pediatric problem Rectus sheath hematoma
and may cause abdominal pain, nausea, and vomiting. Pain is Pancreatitis
usually persistent but not progressive. History and a plain Parasitic infection
radiograph will suggest the diagnosis. Urinary tract infection Pleuritis
will also cause fever, nausea, and vomiting. A urinalysis Pneumonia
should be obtained if urinary symptoms are present. Porphyria
Despite advances in diagnostic imaging, operation done for Psoas abscess
appendicitis does not always reveal an inflamed appendix. Sickle cell disease
Formerly accepted rates of laparotomy that did not reveal Torsion of appendix epiploica
appendicitis range from 15% to 40%.25 These rates are not
supported by the recent literature that report negative appen-
dectomy rates to be less than 10%.84–87 When a normal quadrant should be performed to look for other causes of the
appendix is encountered, most surgeons recommend that it symptoms. The terminal ileum may demonstrate mesenteric
be removed to allow for pathologic examination and to avoid adenitis, enlarged lymph nodes in the ileal mesentery that
potential confusion if the patient experiences right lower may be secondary to an upper respiratory infection. These pa-
quadrant pain in the future. An exploration of the right lower tients may have abdominal pain, fever, and nausea, but their
 CHAPTER 100 APPENDICITIS 1259

tenderness is not as well localized as that in appendicitis. Lym- effectiveness of other antibiotic combinations are usually mea-
phocytosis may be noted on the blood count differential. sured against this empiric regimen. More recently, it has been
A search for a Meckel diverticulum should be done, but it shown that a single or double broad-spectrum antibiotic is
rarely causes pain. Painless bleeding and obstruction are the equally effective for the treatment of complicated appendicitis.
more common presenting symptoms. If the patient has Crohn There is a trend toward decreasing the duration of antibi-
disease, the appendix should not be removed if it or the cecum otic therapy.99 Only perioperative antibiotics are required for
is involved in the disease process because removal is associ- simple appendicitis. The recommended duration is from a sin-
ated with a high incidence of subsequent fistula formation.88 gle, preoperative dose to 24 hours of postoperative antibiotic
The diagnostic accuracy for appendicitis is lowest among therapy for simple appendicitis.100,101 For complicated ap-
young women because of the variety of gynecologic condi- pendicitis, recent studies have suggested that as little as 48
tions that can cause low abdominal pain. Ectopic pregnancy hours of coverage is adequate.69 Others suggest that treatment
should be considered in teenage girls with low abdominal be continued as clinically indicated using the leukocyte count
pain. They may present with vaginal bleeding, amenorrhea, and presence of fever as guides.102–104 There is also a trend to
dizziness, nausea, and vomiting. Rupture of ovarian cysts use oral antibiotics instead of intravenous antibiotics when gas-
and ovarian torsion may also present with low abdominal trointestinal function returns. A prospective, randomized
pain. Sexually active girls with pelvic inflammatory disease study demonstrates equivalency between a 10-day course of
may present with low abdominal pain, vaginal discharge, intravenous antibiotics and a 10-day course of combined intra-
and adnexal enlargement. Most will have cervical motion venous and oral antibiotics for complicated appendicitis.105
tenderness and will respond to antibiotics. Operative inter-
vention may be indicated for those who do not respond or
APPENDECTOMY
persistent abscess.
Carcinoid tumors are present in less than 1% of patients The most widely accepted treatment of appendicitis is appen-
undergoing appendectomy.89 Most appendiceal carcinoid tu- dectomy. Randomized trials that compared medical therapy
mors lack the serotonin-containing cells that are typical of with appendectomy in adults with appendicitis showed that
midgut carcinoid tumors, so they are rarely symptomatic medical therapy is associated with a 10% to 20% chance of
and typically present incidentally at appendectomy.90 Most recurrence but has lower rates of complications. There is a
are benign, and simple appendectomy is curative.91,92 Con- trend away from performing immediate operation.106,107
troversy surrounds the proper surgical management of poten- There was no increased rate of complications noted between
tially malignant carcinoid tumors. The consensus is that a group of patients diagnosed with acute appendicitis and op-
carcinoid tumors larger than 2 cm in diameter, those that have erated upon within 6 hours of admission and those with de-
obviously metastasized, and those located at the base of the lays between 6 and 18 hours of admission.55,56 Nevertheless,
appendix require right hemicolectomy,90,93 whereas those the majority of pediatric surgeons will perform appendectomy
that are smaller than 1 cm in diameter and have not metasta- within 8 hours.94
sized at the time of diagnosis are treated by appendectomy In the open technique, a transverse or oblique right lower
alone. Treatment of tumors that are 1 to 2 cm in diameter quadrant incision is made through the McBurney point
remains controversial. Moertel91 believes that a conservative (Fig. 100-1). The muscles of the abdominal wall are usually
surgical procedure is all that is required regardless of tumor split. After the abdomen is entered, the cecum and appendix
size or location as long as metastases are not present. are mobilized and the appendix is brought out through the in-
cision. The mesoappendix is then divided, and the base of the
appendix is ligated. A short base is left to avoid inflammation
Treatment in the stump.108 The stump is managed by simple ligation,
------------------------------------------------------------------------------------------------------------------------------------------------
ligation with inversion using a purse-string or Z-stitch suture,
Although it is generally agreed that the treatment for appendi- or inversion without ligature. Simple ligation can be done
citis is appendectomy, the details of the management vary quickly and may reduce adhesions.109 Inversion theoretically
considerably.94 For example, surgical techniques such as the leads to better hemorrhage control, a doubly secure closure,
laparoscopic approach, the use of drains, the necessity of peri- and less chance of contamination; however, it can create arti-
toneal irrigation, the handling of the appendiceal stump, and facts on future contrast examinations and can cause intussus-
the closure of the incision continue to be debated. The need ception.110 For simple appendicitis, irrigating the wound is
for interval appendectomy after initial nonoperative manage- unnecessary. The wound is closed in layers, and no drains
ment of an appendiceal phlegmon is unclear. The choice of are placed. A normal diet can be given soon after appendec-
antibiotics and the length of its use vary considerably from tomy, and the patient can be discharged in 1 to 2 days. If a nor-
surgeon to surgeon. mal appendix is found, the peritoneal cavity should be
inspected for inflammatory bowel disease, mesenteric adeni-
ANTIBIOTICS tis, Meckel diverticulitis, or, in females, pathologic conditions
of the ovary.
The use of antibiotics for the treatment of appendicitis is “Endoscopic” appendectomy was first described in
clearly beneficial.95 Intraoperative cultures have not been 1983.111 Laparoscopic appendectomy can be done by a lapa-
shown to alter the treatment outcome.96,97 The best regimen roscopic-assisted technique in which the appendix is mobi-
and duration of antibiotics use is a subject of continued lized laparoscopically using one or two ports and is drawn
controversy. A 10-day course of intravenous ampicillin, genta- through a small abdominal opening and removed by standard
micin, and clindamycin or metronidazole is the gold standard open technique.112,113 Alternatively, the appendix can be
for the treatment of complicated appendicitis,98 and the removed entirely laparoscopically. Three trocars are usually
1260 PART VII ABDOMEN

Mesoappendix

Exterior oblique
Rectus

D Inflamed appendix

Cecal
taenia
Interior oblique
muscle Transverse
C abdominal muscle
Exterior oblique
B fascia

Crushing clamps
FIGURE 100-1 A, A transverse in- applied
cision is made in the right lower
quadrant over the lateral muscula-
E
ture. B, The external oblique fascia
is incised exposing the internal obli-
que fascia and muscle. C, The trans-
verse abdominal muscle and
peritoneum are opened, and the ce-
cum is identified. D, An inflamed ap-
pendix is identified, and the
mesoappendix is isolated, clamped,
divided, and tied. E, A purse-string
suture is placed in the cecal wall.
F, The base of the appendix is
crushed and tied, and the appendix
is excised. G, The appendiceal F
stump is inverted into the cecal wall,
and the purse-string suture is tied.
(From Rowe M, O’Neill JS, Grosfeld
JL: Essentials of Pediatric Surgery, G
Philadelphia, Mosby, 1995.)
 CHAPTER 100 APPENDICITIS 1261

employed: one at the umbilicus for the scope, one in the Despite prospective, randomized trials that compared open
suprapubic area, and one in the left lower quadrant and laparoscopic appendectomy, the advantages and dis-
(Fig. 100-2), although a single-incision multiport approach advantages of laparoscopic appendectomy continue to be
may also be employed. The appendix is found by following debated.115–124 Advantages claimed include shorter hospital-
the cecum, and the mesoappendix is grasped near the tip to izations, decreased postoperative pain, decreased wound
lift the appendix toward the abdominal wall. A window is complications, increased ability to diagnose uncertain cases,
made in the mesoappendix near the base to allow its division surgical ease in an obese patient, and faster postoperative
by applying electrocautery, clips, staples, or the harmonic scal- recovery.84,85,125–129 Disadvantages are a higher cost because
pel. Many variations of ligating and removing the appendix of equipment needs and longer time for surgery, increased
have been described.85,114 The simplest technique applies training and experience required for surgeons and ancillary
an endoscopic stapler to the base of the appendix, and the support staff, increased incidence of finding a normal
appendix is delivered through the umbilical trocar site. There appendix, and an increased incidence of intra-abdominal
is now early experience with single port/incision techniques. infection.84,130–133 Although the conclusions regarding the

FIGURE 100-2 A, Three ports are placed for laparoscopic appendectomy. The umbilical port is 12 mm in size to accommodate the endoscopic stapler.
The other two ports are 3 or 5 mm in size for dissecting instruments. B, The appendix is lifted upwards by a grasper placed on the mesoappendix, and a
window is made at the base of the mesoappendix by a dissector. The mesoappendix is divided by electrocautery or harmonic scalpel. C, The scope is
switched to the left lower quadrant port to allow the endoscopic stapler to come through the umbilical port to divide the appendix.
1262 PART VII ABDOMEN

advantages of this technique over the open technique vary and recurrence within 2 years after initial diagnosis is uncom-
widely, laparoscopic appendectomy is a safe and effective mon. The current standard of treatment is conservative man-
means of performing an appendectomy and its utilization agement with interval appendectomy after 8 to 12 weeks.
has increased dramatically over the past decade.
Treatment of patients with complicated appendicitis is
more controversial. Due to social, cultural, economic, and Complications
medical influences on the diagnosis and treatment of this dis- ------------------------------------------------------------------------------------------------------------------------------------------------

ease process, perforation rates vary from 16% to 57% in dif- The incidence of complications increases with the degree of
ferent institutions. There is no consensus on the optimal severity of the appendicitis. The complications include wound
treatment of patients with complicated appendicitis. Opinions infection, intra-abdominal abscess formation, postoperative
range from nonoperative treatment to aggressive surgical intestinal obstruction, prolonged ileus, and rarely entero-
resection with antibiotic irrigation, drainage of the peritoneal cutaneous fistula. Wound infection is the most common
cavity, and delayed wound closure.134–138 Weiner139 reported complication, but the rate has fallen from 50% to less than
no significant differences in the number of hospital days, cost 5%, even in complicated appendicitis.29,30,47,85–87 Intra-
of treatment, or overall complication rates using initial non- abdominal abscess formation is also more common in compli-
operative treatment of complicated appendicitis followed by cated appendicitis but is still less than 2%. The abscess can be
interval appendectomy in 8 weeks. In another study that ex- drained percutaneously under CT guidance or transrectally in
amined initial nonoperative therapy for complicated appendi- the operating room, although others have advocated more
citis confirmed by imaging, 22% of the patients were conservative management.153–155 Postoperative intestinal
converted to appendectomy because of small bowel obstruc- obstruction occurs in 1% of patients with complicated
tion.140 Operative treatment remains the standard approach appendicitis, which often requires operative adhesiolysis.156
because of the difficulty in determining whether perforation Enterocutaneous fistula is a rare complication and will usually
has occurred before exploration. respond to nonoperative management. Suppurative pylephle-
The operative procedure for complicated appendicitis is bitis is a particularly serious, although rare, complication.157
appendectomy. Controversy continues regarding the details Sepsis and multisystem organ failure can occur in young
of the procedure: whether to drain the peritoneal cavity, children who had prolonged illness before diagnosis. Major
whether to close the wound or leave it open with delayed complications including postoperative intestinal obstruction
closure, whether to irrigate the peritoneal cavity and, if so, and intra-abdominal abscess formation have also fallen to
whether to use antibiotic solutions. Drains have been de- an incidence of less than 5%.
scribed as both increasing infectious complications and pre- An unresolved issue is the effect of complicated appendi-
venting them.29,30,46,141–143 Most studies do not support citis on fertility in females; available studies contradict each
the use of drains, with the possible exception of retrocecal ab- other. Puri, McGuinness, and Guiney158 report that compli-
scesses that cannot be properly debrided. Delayed wound clo- cated appendicitis before puberty plays little if any role in
sure is not supported by the literature46,85–87,98 and does not the cause of tubal infertility, whereas Mueller159 reports that
seem to be warranted because the wound infection rate asso- the condition is associated with a fourfold risk for tubal
ciated with appendectomy is less than 3%. Irrigation remains infertility. The consequences of complicated appendicitis
controversial. Putnam, Gagliano, and Emmons87 suggest that may be mitigated through both public and medical education
irrigation prolongs ileus and may cause small intestinal that ensures prompt, early treatment before perforation.
obstruction and report excellent results without irrigation.
Other recent studies support saline irrigation of the peritoneal
cavity with or without antibiotics.29,46,85,86,98 Outcomes
Management of patients with a palpable abdominal mass is ------------------------------------------------------------------------------------------------------------------------------------------------

another controversial topic. It occurs in a small but significant The mortality rate for complicated appendicitis has dropped
fraction of patients with complicated appendicitis, especially to nearly zero. Antibiotics have markedly decreased the
in young children after perforation. Some advocate immediate incidence of infectious complications. Although the length
appendectomy,144 whereas others perform the procedure only of hospitalization and the morbidity of patients with compli-
if a mass is confirmed with the patient under anesthesia. If an cated appendicitis still far exceed those with simple appendi-
operation is done, care should be taken to avoid damage to citis, the overall morbidity in children with complicated
adjacent structures subject to inflammatory processes such appendicitis is less than 10%.
as the small intestine, the fallopian tubes and ovaries, and The widely varied postoperative management of appen-
the ureter. Surana145 and Nitecki146 recommend treatment dicitis is beginning to be addressed by implementing evi-
with intravenous antibiotics until the leukocyte count is dence-based clinical pathways.160,161 Prompted primarily
normal and the patient remains afebrile for 24 hours. If the by economic pressures, there is increasing scrutiny of patient
patient’s condition worsens or the mass enlarges on serial ul- treatment and outcome.162–164 Early outcome research has
trasonography, the mass is drained percutaneously, followed shown that hospitals that perform fewer than one appendec-
by interval appendectomy. Interval appendectomy prevents tomy per week are associated with higher likelihood of
repeated episodes of appendicitis and affords the surgeon misdiagnosis.165 There are also reports that suggest better
the opportunity to evaluate the patient for other conditions outcome in younger children with appendicitis when they
that can masquerade as an appendiceal mass. Whether an in- are cared for by pediatric surgeons.166,167 The combination
terval appendectomy is necessary is also debated.146–152 of surgical evaluation, prompt operation when the diagnosis
Nitecki116 has suggested that interval appendectomy is unnec- is clear, a period of observation if the diagnosis is equivocal
essary because only 14% of patients have recurrent symptoms, followed by imaging if necessary, and care provided by
 CHAPTER 100 APPENDICITIS 1263

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Mason RJ. Surgery for appendicitis: Is it necessary? Surg Infect (Larchmt)
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Solomkin JS, Mazuski JA, Bradley JS, et al. Diagnosis and management of com-
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Fraser JD, Aquayo P, Sharp SW, et al. Accuracy of computed tomography sus initial nonoperative management and interval appendectomy for perfo-
in predicting appendiceal perforation. J Pediatr Surg 2010;45:231. rated appendicitis with abscess: A prospective, randomized trial. J Pediatr
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