Co l o pro c to l o g y

26
Appendicitis
CHAPTER OUTLINE
Introduction, 1 appendix is sometimes found but a small number of ‘negative’
operations may be unavoidable. Laparoscopy improves diagnostic
Anatomy of the Appendix, 1 accuracy, particularly in young women, and is used therapeutically
Pathophysiology of Appendicitis, 1 to remove an inflamed appendix; it also has lower complication
Clinical Features of Appendicitis, 2 rates.
Classic Appendicitis, 2
Other Presentations of Acute Appendicitis, 2 Anatomy of the Appendix
Making the Diagnosis of Appendicitis, 3 The appendix is a blind-ending tube arising from the caecum at
Special Points in the History and Examination, 3 the meeting point of the three taenia coli, just distal to the ileo-
Differential Diagnosis, 4 caecal junction. The appendix base thus most commonly lies in
The Equivocal Diagnosis, 4 the right iliac fossa, close to McBurney point. This is two-thirds
Problems in the Diagnosis of Appendicitis, 5 of the way along a line from umbilicus to anterior superior iliac
Appendicectomy, 5 spine (see later, Fig. 26.6, p. 373). In most cases, the appendix is
Antibiotic Prophylaxis, 6 mobile within the peritoneal cavity, suspended by its mesentery
Technique of Appendicectomy, 6 (mesoappendix), with the appendicular artery in its free edge.
Open Appendicectomy, 6 This is effectively an end-artery, with anastomotic connections
Laparoscopic Appendicectomy, 7 only proximally.
The ‘Lily-White’ Appendix, 7 The appendix is described as lying in several ‘classic’ sites, but
The Appendix Mass, 7 apart from the true retrocaecal appendix, the organ probably floats
in a broad arc about its base (Fig. 26.1); only inflammation will
fix it in a particular place. Its position then determines the clinical
presentation. In about 30% of appendicectomies, it lies over the
Introduction pelvic brim the (‘pelvic appendix’). In some cases, the appendix
lies retroperitoneally behind the caecum and often plastered to
Acute appendicitis is the most common cause of intraabdominal it by fibrous bands. Thus an inflamed retrocaecal appendix may
infection in developed countries and appendicectomy, the most irritate the right ureter and psoas muscle, and may even lie high
common emergency operation. In the United Kingdom, 1.9 enough to simulate gall bladder pain.
females per 1000 have the operation each year compared with Histologically, the appendix has the same basic structure as
1.5 males, and about one in seven people eventually undergo the colon. It is covered by serosa (visceral layer of peritoneum)
the operation. Surprisingly, the incidence of appendicitis fell becoming continuous with the mesoappendix serosa. A retroperi-
by about 30% between the 1960s and the 1980s, for reasons toneal appendix has no serosal covering. A prominent feature of
unknown. the appendix is its collections of lymphoid tissue in the lamina
Appendicitis can occur at any age but is most common below propria. This often has germinal centres and is prominent in child-
40 years, especially between 10 and 20 years. It is rare below the hood, but diminishes with increasing age.
age of 10 years and very rare below 2 years, but more likely to pres- The mucosa contains a large number of cells of the gastroin-
ent with a perforation with a greater than 65% incidence in 0- to testinal endocrine amine precursor uptake and decarboxylation
4-year-olds. Appendicitis is believed to be less common in rural (APUD) system. These secrete mainly serotonin and were for-
parts of developing countries, but the incidence approaches that merly known as argentaffin cells. Carcinoid tumours commonly
of the West in the cities. Different susceptibility in similar people occur in the appendix and arise from these cells.
may be related to reduced dietary fibre in city dwellers.
Acute appendicitis should be considered in any patients Pathophysiology of Appendicitis
presenting to hospital with acute abdominal pain. Even previ-
ous appendicectomy does not absolutely rule out the diagnosis. Appendicitis is probably initiated by luminal obstruction caused
Despite lay impressions, a positive diagnosis is often difficult to by impacted faeces or a faecolith. This explanation fits the epide-
make; this is partly because of the lack of specific tests to con- miological observation that appendicitis is more common with a
firm or exclude appendicitis. At open operation, a noninflamed low dietary fibre intake.

366
Downloaded for Mariel Capuno ([email protected]) at Ateneo de Manila University Ateneo School of Medicine and Public Health from
ClinicalKey.com by Elsevier on July 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 CHAPTER 26 Appendicitis 367

Ileocolic branch of superior

mesenteric artery

Anterior taenia coli leading to

appendix base

Appendicular artery passing

True retrocaecal position of appendix behind ileum
plastered to posterior wall of caecum
close to right ureter and psoas
Mesoappendix

‘Pelvic’ position of appendix close

to fallopian tube, rectum or ureter

• Fig. 26.1
Surgical Anatomy of the Appendix. The appendix can be positioned anywhere on the circum-
ference shown by the arrowed arc.

Classic Appendicitis
Acute appendicitis classically begins with poorly localised, colicky
central abdominal visceral pain; this results from smooth muscle
spasm as a reaction to appendiceal obstruction. Anorexia and
vomiting often occur at this stage.
As inflammation advances over the ensuing 12 to 24 hours,
it progresses through the appendiceal wall to involve the parietal
peritoneum (innervated somatically). Then pain typically becomes
localised to the right iliac fossa. Signs of local peritonitis can be
elicited, that is, tenderness, guarding and rebound tenderness. This
classic picture is seen in less than half of all cases, largely because
localising symptoms and signs vary with the anatomical relations
of the inflamed appendix and the vigour of the body’s defences.

• Fig. 26.2Acute Appendicitis. Macroscopic photograph showing acutely

Other Presentations of Acute Appendicitis
inflamed appendix. The distended tip shows a purulent exudate on the If the inflamed or perforated appendix lies in the pelvis near the
serosal surface (arrowed). rectum, it may cause local irritation and diarrhoea. Consider a pel-
vic collection secondary to appendicitis in children with abdomi-
In the early stages of appendicitis, the mucosa becomes nal pain, associated with diarrhoea, persisting longer than 5 days.
inflamed first. Inflammation eventually extends through the sub- If it lies near the bladder or ureter, inflammation may cause uri-
mucosa to involve the muscular and serosal (peritoneal) layers. nary frequency, dysuria and (microscopic) pyuria, that is, leuco-
A fibrinopurulent exudate on the serosal surface extends to any cytes in the urine. These findings may be mistakenly interpreted
adjacent peritoneal surface, for example, bowel or abdominal wall, as urinary tract infection. An inflamed retrocaecal appendix pro-
causing localised peritonitis. duces none of the usual localising symptoms or signs, but may
By this stage, the necrotic glandular mucosa sloughs into the irritate the psoas muscle, causing involuntary right hip flexion
lumen, which becomes distended with pus. Finally, the end-arter- and pain on extension. A high retrocaecal appendix may cause
ies supplying the appendix thrombose and the infarcted appendix pain and tenderness below the right costal margin. An inflamed
becomes necrotic or gangrenous at the distal end and the appen- appendix near the Fallopian tube causes pelvic pain suggestive of
dix begins to disintegrate. Perforation soon follows and faecally an acute gynaecological disorder, such as salpingitis or torsion of
contaminated contents spread into the peritoneum. If the spilled an ovarian cyst.
contents are enveloped by omentum or adherent small bowel, a The early phase of poorly localised pain typically lasts for a few
localised abscess results; otherwise spreading peritonitis develops. hours until peritoneal inflammation produces localising signs. If
Acute appendicitis is illustrated histologically in Fig. 26.2. untreated, the inflamed appendix may become gangrenous after
12 to 24 hours and perforate, causing peritonitis unless sealed off
Clinical Features of Appendicitis by omentum. The whole abdomen becomes rigid and tender and
there is marked systemic toxicity. Perforation is common in young
The pathophysiological evolution of appendicitis and correspond- children. Sometimes, the pathological sequence is extremely rapid
ing symptoms and signs are illustrated in Fig. 26.3. and the patient presents with sudden peritonitis.

Downloaded for Mariel Capuno ([email protected]) at Ateneo de Manila University Ateneo School of Medicine and Public Health from
ClinicalKey.com by Elsevier on July 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
368 SE C T I O N D Symptoms, Diagnosis and Management

PATHOLOGICAL SEQUENCE CLINICAL MANIFESTATIONS

Inflammation of mucosa of appendix, Poorly localised central abdominal pain

possibly caused by faecolith or obstruction ± nausea and vomiting (caused by autonomic stimulation)

Extension of symptoms across wall of appendix with Localisation of pain, usually to the right iliac fossa with
involvement of serosa (visceral peritoneum) guarding and rebound tenderness
by inflammation
Other clinical signs include tachycardia, fever
and facial flush

Spread of inflammation to adjacent

structures and gangrene of the appendix OR Formation of an appendix mass occurs OR
wall resulting in perforation. with gradual recovery
An extensive walling-off reaction occurs,
preventing a spreading peritonitis

Spread of inflammation to adjacent

structures and gangrene of the appendix Tenderness extends to whole abdomen
wall resulting in perforation. with increasing abdominal rigidity and
Attempts at walling off the perforation by evidence of systemic toxicity
omentum and adjacent bowel are
inadequate leading to a spreading peritonitis

• Fig. 26.3 Pathophysiology and Clinical Manifestations of Acute Appendicitis.

In older patients, a gangrenous or perforated appendix is more  Cardinal Features of Acute Appendicitis
• BOX 26.1 
likely to be contained by greater omentum or loops of small bowel.
This results in a palpable appendix mass. This may contain free • Abdominal pain for less than 72 hours
pus and is then known as an appendiceal abscess. As with any • Vomiting one to three times
significant abscess, there is a tachycardia and swinging pyrexia. An • Facial flush
appendix mass usually resolves spontaneously over 2 to 6 weeks. • Tenderness concentrated on the right iliac fossa
In the elderly, an appendix abscess is often walled off by loops of • Anterior tenderness on rectal examination
• Fever between 37.3°C and 38.5°C
small bowel. There may be no palpable mass and the symptoms
• No evidence of urinary tract infection on urine microscopy
and signs may not suggest appendicitis. These include nonspecific
abdominal pain and features of small bowel obstruction caused by
localised paralytic ileus. Occasionally, appendicitis may present in
a most unusual way. Examples include discharge of an appendix
abscess into the Fallopian tube presenting as a purulent vaginal
Special Points in the History and Examination
discharge, or appendicitis within an inguinal hernia presenting as Acute appendicitis typically runs a short course, between a few
a groin abscess. hours and about 3 days. If symptoms have been present for longer,
appendicitis is unlikely unless an ‘appendix mass’ has developed.
Making the Diagnosis of Appendicitis A recent or current sore throat or viral-type illness, particularly
in children, favours a diagnosis of mesenteric adenitis (inflam-
Acute appendicitis is a clinical diagnosis, relying almost entirely mation of mesenteric lymph nodes analogous to viral tonsillitis).
on history and examination. Investigations are only useful in Urinary symptoms suggest urinary tract infection but may also
excluding differential diagnoses. Ideally, the diagnosis should be occur with pelvic appendicitis.
made and the appendix removed before it becomes gangrenous The patient with appendicitis is typically quiet, apathetic and
and perforates. This markedly reduces the risk of infective com- flushed with limited abdominal wall movement; the lively child
plications. However, unnecessary appendicectomies must be kept doing jigsaw puzzles almost never has appendicitis! Oral foetor
to a minimum. may be present but is not a reliable sign. Cervical lymphadenopa-
Diagnosis of acute appendicitis poses little difficulty if the thy may suggest a viral origin for the abdominal pain. Mild tachy-
patient exhibits the classic symptoms and signs summarised in cardia and pyrexia are typical of appendicitis, but a temperature
Box 26.1. However, the patient may present at a very early stage, much over 38°C makes the diagnosis of acute viral illness or uri-
or the signs may have some other pathological cause. At least two nary tract infection more likely. A perforated appendix may be the
out of three children admitted to hospital with suspected appen- exception to this rule.
dicitis do not have the condition. Signs of peritoneal inflammation in the right iliac fossa are
If evidence for acute appendicitis is insufficient and no other often absent in the early stages. The patient should be asked to
diagnosis can be made, the patient should be kept under observa- cough, blow the abdominal wall out and draw it in; these all cause
tion, admitted to hospital if necessary and reexamined periodi- pain if parietal peritoneum is inflamed. In children, it may be
cally. Eventually, the symptoms settle or the diagnosis becomes difficult to interpret apparent tenderness, especially if the child
clear. Diagnostic laparoscopy may be needed in equivocal cases. cries and refuses to cooperate. This can usually be overcome by

Downloaded for Mariel Capuno ([email protected]) at Ateneo de Manila University Ateneo School of Medicine and Public Health from
ClinicalKey.com by Elsevier on July 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 CHAPTER 26 Appendicitis 369

distracting the child’s attention, whilst palpating the abdomen • BOX 26.2  Main Differential Diagnoses of Acute
through the bedclothes, or even with the child’s own hand under Appendicitis
the examiner’s hand. Several signs (e.g., Rovsing sign—pressure
in the left iliac fossa causing pain in the right iliac fossa) are said Urinary Tract Infection (Cystitis or Pyelonephritis)
to point to a diagnosis of appendicitis but all are unreliable. One • Unlikely if nitrites are absent from dipstick testing of the urine and can
useful test is to ask the child to stand, then to hop on the right leg. be excluded if there are not significant numbers of white blood cells or
If this can be achieved, there is unlikely to be significant peritoneal bacteria on urine microscopy
inflammation.
Rebound tenderness was traditionally demonstrated by pal- Mesenteric Adenitis
• Common in children and often associated with an upper respiratory
pating deeply, then suddenly releasing the hand. However, this
infection or sore throat
can cause excessive and unexpected pain. A kinder and more pre- • Inflammation and enlargement of the abdominal lymph nodes, probably
cise method is to perform gentle percussion in the right iliac fossa. viral in origin
This displaces and irritates inflamed peritoneum in a controlled • Fever is typically higher than in appendicitis (i.e., greater than 38.5°C)
way; if this is painful, then rebound is present. Anterior peritoneal and settles rapidly
tenderness on rectal examination (i.e., pelvic peritonitis) supports • A firm diagnosis can only be made at laparotomy or laparoscopy, but
the diagnosis of appendicitis, provided other signs are consistent, gradual resolution favours this diagnosis
but note the appendix itself cannot be palpated. In pelvic appen-
dicitis, rectal tenderness may be the only abdominal sign. Lack of Large Bowel Disorders
this sign does not, however, exclude appendicitis. • Constipation may cause colicky abdominal pain and iliac fossa
tenderness. There is no fever and the rectum is loaded with faeces
• Diverticulitis affecting the caecum or the sigmoid colon (when lying in
Differential Diagnosis the right iliac fossa) is usually diagnosed only at operation

This theoretically includes all the causes of an acute abdomen. Gynaecological Disorders
However, the conditions of practical importance are summarised • The pain of ovulation about 14 days after the last menstrual period
in Box 26.2. These other conditions rarely need operation. Cer- (mittelschmerz) may cause right iliac fossa pain. There is often a history
tain uncommon conditions, such as Yersinia ileitis and inflamed of similar pain in the past. There are no signs of infection and the pain
Meckel diverticulum (Fig. 26.4) are included in the list but they settles quickly
can only be distinguished from appendicitis at laparoscopy or • Salpingitis (most commonly chlamydial) causes lower abdominal pain,
operation. often with a vaginal discharge. Digital vaginal examination typically
reveals adnexal tenderness, and moving the cervix from side to side
induces pain (‘cervical excitation’)
The Equivocal Diagnosis • Torsion of, or haemorrhage into a right ovarian cyst may produce
symptoms like appendicitis, but there is no fever. A tender mobile
If acute appendicitis can be confidently diagnosed clinically, no mass may be palpable in the right suprapubic region or on vaginal
further investigations are needed except for potential comorbidity, examination. This diagnosis can be confirmed with ultrasound
anaemia or dehydration. It is worth emphasising there are no spe- • Ectopic pregnancy. May present with anaemia and/or hypotension. A
cific diagnostic tests; where the diagnosis is in doubt, the patient pregnancy test is mandatory
must be reexamined every few hours to detect clinical changes to
ensure deterioration is detected early. Missing an evident clinical Small Bowel Pathology
diagnosis and sending the patient home causes unnecessary prob- • An inflamed or perforated Meckel diverticulum (see Fig. 26.4) may
present exactly like appendicitis
lems and is likely to prompt a claim for medical negligence.
• Terminal ileitis because of Crohn disease (or, more rarely, Yersinia
Certain investigations may be useful where the diagnosis is in pseudotuberculosis)
doubt. The white blood cell count is usually unhelpful, as a mod- • Necrotic small bowel from strangulation usually presents with intestinal
est rise occurs in many conditions. If there is a great rise (say to obstruction
over 16 × 103), appendicitis is usually already clinically obvious,
but a low white blood cell count helps exclude nonsuppurative Acute Pancreatitis
gynaecological pathology. Urinalysis must be performed if urinary • Pain is predominantly central
tract infection is possible. A pregnancy test should be performed • If there is tenderness in the right iliac fossa, it will also be present in the
in females of childbearing age. epigastrium
Various scoring systems have been devised to improve the • If in doubt, the serum amylase should be measured
accuracy of clinical diagnosis. The best known is the Alvarado Gastroenteritis
score (Table 26.1) but results are too variable for it to be of much • Vague abdominal pain and tenderness, which may be associated with
clinical benefit. The Alvarado scoring system is an objective, struc- vomiting and diarrhoea
tured means of assessing patients with right iliac fossa pain but • Usually improves steadily during a period of observation
has proved unreliable in diagnosing acute appendicitis. However,
its value lies with patients with an initial score of 4 or less who
are very unlikely to have appendicitis and do not need hospital
admission unless symptoms worsen. In patients with appendicitis, dilatation suggests local adynamic bowel disorder caused by appen-
40% have rising scores, confirming this as a progressive disorder dicitis causing functional obstruction, but this is an uncommon
in which symptoms and signs evolve with time. finding. Even less commonly, a perforated appendix may allow suf-
Abdominal x-rays are not needed unless there is confusing evi- ficient free gas to escape to show on plain x-rays. In adults with an
dence of abdominal pathology after a period of observation. A equivocal diagnosis of appendicitis, the plasma amylase should be
single right iliac fossa fluid level or even widespread small bowel measured to exclude acute pancreatitis. Abdominal ultrasound can

Downloaded for Mariel Capuno ([email protected]) at Ateneo de Manila University Ateneo School of Medicine and Public Health from
ClinicalKey.com by Elsevier on July 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
370 SE C T I O N D Symptoms, Diagnosis and Management

Problems in the Diagnosis of Appendicitis

The Very Young
Appendicitis is rarely seen below 2 years of age, but when it does
occur, the ‘typical’ abdominal symptoms and signs are obscure or
absent. An infant or toddler may display signs of infection without
revealing an abdominal origin. Abdominal x-rays may demonstrate
dilated loops of bowel and fluid levels. Generalised peritonitis super-
venes all too rapidly in this age group because abdominal defences
are rudimentary, in particular the greater omentum ‘wrapping’
effect. Laparotomy is usually indicated in an ill infant with abdomi-
nal signs. Children under 5 years often present with peritonitis and
A should ideally be referred to a specialised Paediatric Surgical Unit.

The Elderly
Appendicitis usually develops more slowly in the elderly. The appen-
dix wall becomes fibrotic with age and the area is more readily walled
off by omentum and adherent small bowel. Indeed, many cases prob-
ably resolve spontaneously. In those who reach hospital, the history
is often as long as 1 week. Features of obstruction may be present,
• Fig. 26.4Perforated Meckel Diverticulum. This man of 28 years pre- including vomiting, colicky abdominal pain and obstructed bowel
sented with a typical history and clinical findings of acute appendicitis. sounds. A mass may be palpable if the patient is relaxed and not too
However, at operation he was found to have a normal appendix but a tender but often it can be palpated only under general anaesthesia.
perforated Meckel diverticulum (arrowed). The diverticulum was resected Abdominal x-rays may reveal fluid levels in the right iliac fossa.
and the appendix also removed to prevent future confusion and the patient
made a good recovery. On histological examination, the Meckel’s diver- Pregnancy
ticulum was found to contain gastric mucosa. Appendicitis occurs at least as often during pregnancy as at other
times but the diagnosis can be difficult. The appendix is displaced
TABLE 26.1  Paediatric Appendicitis Scoring (PAS)
upwards by the enlarging uterus and abdominal pain and tender-
ness are in a higher position. The management of the pregnant
System in Suspected Acute Appendicitis patient must be shared with an obstetrician. Laparoscopy may
Based on the Alvarado Score be indicated, but becomes technically difficult beyond 26 weeks.
Clinical Variable Point Value Mortality from appendicitis for both mother and foetus rises as
the pregnancy progresses and can be as high as 9% for the mother
Migration of pain to RIF 1 and 20% for the foetus in the third trimester.
RIF tenderness 2
The ‘Grumbling’ Appendix
Nausea/vomiting 1 Recurrent bouts of right iliac fossa pain are often labelled ‘grum-
Anorexia 1 bling appendix’. Appendicular pathology is probably not the
cause in most. Persistent chronic appendiceal inflammation prob-
Pain with cough/percussion/hopping 2
ably does not occur, but recurrent bouts of appendicular colic or
Fever >38°C 1 low-grade acute appendicitis undoubtedly do. These children may
have several abortive admissions for abdominal pain and it may
Leucocytosis (WBC >10,000 cells/mL) 1
eventually be justifiable to remove the appendix to allay parental
Neutrophils left shift increase in immature forms 1 anxiety. A noninflamed appendix containing a faecolith or thread-
MAXIMUM TOTAL SCORE 10
worms (assumed to have caused the pain) is often found. The pain
will be cured in no more than half.
<4 = low risk; >6 = high risk of acute appendicitis The management of suspected appendicitis is summarised in
Fig. 26.5.

Appendicectomy
be helpful to detect an abscess or mass, or nonappendiceal pathol-
ogy, but cannot be relied upon to show uncomplicated appendici- The annual death rate from appendicitis has fallen dramatically
tis. Computed tomography scanning is claimed to be accurate, but since 1960. There were 3193 deaths in 1934 in the United King-
submits the patient to a high radiation dose and greatly increases dom, whereas by 1982 this had fallen to 110 and to 9 by 1997.
the cost of investigation. In patients over 50 years, this disadvan- This results from better general nutrition, earlier presentation,
tage must be balanced against the fact that incidental pathology, better preoperative preparation and better anaesthesia. Deaths
such as tumours may be diagnosed before operation. Laparoscopy that now occur are usually caused by dehydration and electrolyte
is increasingly used in women of menstruating age in whom gyn- changes unrecognised or ineffectively treated before surgery, often
aecological pathologies are common. However, this is an invasive as a result of a late or missed diagnosis. Infective complications of
investigation requiring a general anaesthetic and is best used when appendicitis have fallen dramatically since the 1970s because of
an operation is clearly indicated but the diagnosis is still ambiguous. the widespread use of prophylactic antibiotics.

Downloaded for Mariel Capuno ([email protected]) at Ateneo de Manila University Ateneo School of Medicine and Public Health from
ClinicalKey.com by Elsevier on July 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 CHAPTER 26 Appendicitis 371

Right iliac fossa pain

Review periodically
Conclusive features of Other cause apparent
appendicitis (see Box 26.2)
Still inconclusive

APPENDICECTOMY Treat accordingly

Ward urinalysis;
pregnancy test if
appropriate;
WBC with differential;
CRP

Still inconclusive

Patient clinically stable: Patient deteriorating:

arrange ultrasound scan arrange laparoscopy if
available, otherwise open
surgery

Still inconclusive

Consider diagnostic
laparoscopy

• Fig. 26.5 Summary—Management of Suspected Appendicitis. CRP, C-reactive protein; WBC, white
blood cell.

Antibiotic Prophylaxis marked in children) is incised and the three musculoaponeurotic

In appendicitis, most intraabdominal infective complications abdominal wall layers split along the line of their fibres. This pro-
and wound infections occur in perforated or gangrenous appen- duces the ‘gridiron’ incision, described as such because the fibres
dicitis (Box 26.3). Most uncomplicated infecting organisms are of external oblique and internal oblique run at right angles to each
anaerobes and infections can largely be prevented by prophylactic other. Peritoneum is then lifted and opened and may reveal pus
metronidazole. Rectal suppositories are as effective as intravenous or mucopurulent watery fluid; a swab is taken for microscopy and
metronidazole and are cheaper, but are best given 2 hours before culture. The appendix is located with a finger and delivered into
operation. Aerobic organisms are involved in fewer cases and some the wound; further exploration may be needed if it does not lie
surgeons advocate additional prophylaxis with an antibiotic, such nearby. A retrocaecal appendix requires mobilisation of the cae-
as a cephalosporin. In adults with moderate appendicitis, trials of cum by dividing the peritoneum along its lateral side.
antibiotic treatment alone compare favourably with appendicec- Once the appendix has been delivered, its blood supply in the
tomy but about a quarter present later with recurrent appendicitis. mesoappendix is divided between clips and ligated. The appendix
base is crushed with a haemostat, which is then reapplied more
distally. An absorbable ligature is tied around the crushed area.
Technique of Appendicectomy After this preparation, the appendix is then excised. A ‘purse-
The principal steps are illustrated in Fig. 26.6 and should be under- string’ suture may be placed in the caecum near the appendix
stood by any doctor assisting with the operation. Increasingly, lap- base to invert the appendix, although this is not used in laparo-
arotomy is being replaced by laparoscopic diagnosis and surgery, scopic surgery and patients have not suffered from its omission.
but the principles are similar. Surgeons performing appendicec- If the appendix is perforated or gangrenous, or if pus was found,
tomy need to be aware of possible appendiceal neoplasms, present thorough peritoneal toilet is performed. A sump sucker is guided
in 0.5% to 0.9% of appendectomies. Most are innocent carci- down into the pelvis with a finger to aspirate fluid, and the area is
noid-type tumours but others are mucinous adenocarcinomas. gently swabbed with gauze to remove adherent infected material.
Any pus or a faecolith left behind predisposes to a pelvic abscess.
The peritoneum, internal oblique and external oblique are
Open Appendicectomy each closed with two or three absorbable sutures. Drainage is not
A low skin-crease incision (Lanz) rather than a higher and more usually recommended unless there is a thick-walled abscess cav-
oblique one centred on McBurney point is now favoured, as it ity, which will not collapse. If the appendix is perforated or gan-
gives a better cosmetic result. The superficial (Scarpa) fascia (well grenous, delayed primary closure of the skin is advisable as this

Downloaded for Mariel Capuno ([email protected]) at Ateneo de Manila University Ateneo School of Medicine and Public Health from
ClinicalKey.com by Elsevier on July 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
372 SE C T I O N D Symptoms, Diagnosis and Management

• BOX 26.3  Complications of Appendicitis operation but laparoscopic appendicectomy may be performed if
appropriate skills and instruments are available.
Intraperitoneal Complications The principles and techniques are similar to open surgery, but
Early laparoscopy is more technically demanding. The mesoappendix
• Appendix stump blow-out—spillage of colonic contents into the may be clipped or divided by diathermy and the appendix base is
peritoneal cavity ligated using preformed ‘endo-loop’ sutures. The appendix base is
• Generalised peritonitis—perforated or gangrenous appendix, virulent rarely buried and must never be diathermied. Superior visualisa-
organisms, late presentation or diagnosis tion and good access allow a thorough washout to be performed.
• Abscesses—local, pelvic, subhepatic, subphrenic Laparoscopic removal of the appendix has a lower wound infec-
• Retained faecolith causing chronic local infection
tion rate and may allow an earlier return to normal activities.
• Haematoma caused by slippage of a vascular ligature or a mesenteric or
omental tear
• Small bowel injury at laparoscopy The ‘Lily-White’ Appendix
Early or Late (Even Many Years Later) If the appendix is found not to be inflamed at open operation (col-
• Intestinal obstruction caused by adhesions
loquially termed lily-white), it should always be removed because
Late an appendicectomy scar would lead future doctors to assume the
• Infertility caused by tubal occlusion following pelvic infection appendix has been removed. The abdomen is explored as allowed
by the incision to search for a cause for the symptoms:
Abdominal Wall Complications • Mesenteric lymph nodes in children may be grossly enlarged
Early by mesenteric adenitis—probably viral in origin.
• Superficial wound infection
• Deep wound infection
• The terminal ileum may be thickened and reddened by Crohn
• Dehiscence disease or, more rarely, by Yersinia ileitis. The latter is a self-
limiting condition caused by the organism Yersinia pseudotu-
Late berculosis and requires no specific treatment. The appendix is
• Incisional hernia
removed but the bowel left untouched. If possible, an enlarged
Notes mesenteric node is removed for histological examination.
1. Gangrenous or perforated appendix has much higher risk of infective complications.
• A Meckel diverticulum may be found within 60 cm of the
2. Undiagnosed appendicitis or a late diagnosis is likely to lead to a higher incidence of ileocaecal valve—if inflamed, this is removed but a wide-
complications, particular infective ones, such as generalised peritonitis and systemic sepsis. mouthed noninflamed diverticulum is usually left alone.
• Both ovaries can usually be palpated—ovaries may be
twisted, inflamed or enlarged or an inflamed Fallopian tube
may be seen.
reduces the high risk of wound infection. The superficial layers are • Cholecystitis, sigmoid diverticulitis (with the sigmoid dis-
left open initially and closed after 48 hours if the wound is clean. placed to the right), inflammation of a caecal diverticulum,
After operation, oral fluids, followed by solids, are gradually hydronephrosis, a perforated peptic ulcer with fluid tracking
increased unless vomiting or other complications occur, and most via the right paracolic gutter or a leaking aneurysm are rarely
patients can be discharged on the second or third postoperative found.
day.
The Appendix Mass
Laparoscopic Appendicectomy
A vigorous response to appendicitis may result in a right iliac
Laparoscopy is a valuable technique that allows the appendix to fossa mass, often with fever. Usually the patient has few systemic
be found wherever it lies. It also permits visual examination of symptoms or signs of ill health. A conservative regimen followed
the rest of the abdominal cavity and pelvis, improving diagnostic by interval appendicectomy 6 weeks later (Ochsner–Sherren
accuracy over open operation and minimising negative appen- regimen) was advocated in preantibiotic days, but is now less
dicectomies. It is strongly indicated in patients who are clearly favoured. Early operation under antibiotic cover is now performed
unwell and in need of an operation but in whom the diagnosis is more frequently.
not clear. It is also useful in women of menstruating age and in
any patient with pelvic symptoms. If the appendix is abnormal PAS Score
or if there is free fluid in the peritoneal cavity for which no other <5 Appendicitis unlikely
cause can be found, appendicectomy is performed. Laparoscopic 5 Appendicitis possible
≥6 Appendicitis probable
appendicectomy is valuable in the obese, obviating the need for a
large incision and a high risk of wound infection. Some surgeons RIF, Right Iliac Fossa; WBC, white blood cell.
use laparoscopy as a diagnostic tool and then convert to an open

Downloaded for Mariel Capuno ([email protected]) at Ateneo de Manila University Ateneo School of Medicine and Public Health from
ClinicalKey.com by Elsevier on July 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 CHAPTER 26 Appendicitis 373

1 The skin incision 2 Abdominal wall incision 3 Abdominal wall incision

The layers The muscles
Skin
Fat
Superficial (Scarpa) fascia
Classical
‘gridiron’ Fat
incision External oblique aponeurosis
2/
3
Internal oblique muscle
McBurney’s
1/
3 point Transversus abdominis
Cosmetic Vascular layer
Lanz skin Parietal peritoneum
incision Visceral peritoneum
Appendix

4 Finding and delivering 5 Dividing the blood supply

the appendix

The forefinger palpates for the Unless obvious, the arteries are
appendix located by transillumination of
the mesoappendix
—If mobile, it is pushed out
from within The vessels are clipped and
ligated individually after pushing
—If adherent by inflammation, holes in the mesoappendix on
it is dissected out either side
Babcock forceps
—If truly retrocaecal, lateral Note that the mesoappendix is
peritoneum is divided and the often thick and friable when
appendix dissected out inflamed, and that the
appendiceal artery is an
end-artery

6 Removing the appendix Tie to appendix base Haemostat applied here first to
crush appendix at site of tie

A ‘two-layer’ Four-square
anastomosis is usually purse-string
made by: suture 1.5 cm
from appendix
1. Tying the appendix allows inversion
base before removal

2. Inverting the stump

with a purse-string
suture

Haemostat
crushing appendix

7 Peritoneal toilet 8 Closure

If pus is found, the pelvic ‘sump’ is carefully Absorbable sutures, e.g., gauge 0 polyglactin, for the deep layers
sucked and swabbed out to minimise the
risk of pelvic infection 1. Peritoneum
—continuous
2. Internal oblique muscle
—a few loose interrupted sutures in muscle sheath
(transversus not closed to avoid including nerves)

3. External oblique aponeurosis

—continuous
4. Skin
—subcuticular if not inflamed, if infected leave open for delayed
primary closure. Drain only if established thick-walled abscess
cavity is found

• Fig. 26.6 Appendicectomy—Operative Technique.

Downloaded for Mariel Capuno ([email protected]) at Ateneo de Manila University Ateneo School of Medicine and Public Health from
ClinicalKey.com by Elsevier on July 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.