30 chapter The Appendix

Mike K. Liang, Roland E. Andersson,

Bernard M. Jaffe, and David H. Berger

Historical Background 1241 Operative Interventions Acute Appendicitis during

Embryology, Anatomy, for the Appendix 1251 Pregnancy / 1256
and Physiology 1241 Open Appendectomy / 1251 Postoperative Care
Embryology / 1241 Laparoscopic Appendectomy / 1252 and Complications 1257
Anatomy / 1242 Laparoscopic versus Open Surgical Site Infection / 1257
Physiology / 1242 Appendectomy / 1253 Stump Appendicitis / 1257
Laparoscopic Single-Incision Incidental Appendectomy 1257
Acute Appendicitis 1243
Appendectomy / 1254
Epidemiology / 1243 Neoplasms of the Appendix 1257
Natural Orifice Transluminal
Etiology and Pathogenesis / 1243 Endoscopic Surgery / 1254 Prevalence of Neoplasms / 1257
Microbiology / 1243 Carcinoid / 1258
Special Circumstances 1256
Natural History / 1243 Adenocarcinoma / 1258
Acute Appendicitis
Clinical Presentation / 1243 in the Young / 1256 Mucocele / 1258
Differential Diagnosis / 1246 Acute Appendicitis Pseudomyxoma Peritonei / 1258
Initial Management / 1248 in the Elderly / 1256 Lymphoma 1259

HISTORICAL BACKGROUND treated with appendectomy. In 1886, Reginald H. Fitz presented

Appendiceal disease is a frequent reason for emergency hospital
admission, and appendectomy is one of the most common emer-
gency procedures performed in contemporary medicine. Despite
the prevalent role this organ plays in healthcare today, the
human appendix was not noted until 1492. Leonardo da Vinci
depicted the appendix in his anatomic drawings, but these were
not published until the eighteenth century.1 In 1521, Berengario
Da Capri and, in 1543, Andreas Vesalius published drawings
recognizing the appendix.2
Credit is given to Jean Fernel for first describing appen-
diceal disease in a paper published in 1544. He reported on a
7-year-old girl whose diarrhea he treated with doses of quince,
an apple-like fruit used in folk remedies. She developed abdom-
inal pain and died. At autopsy, the quince was found to have
obstructed the lumen of the appendix, causing necrosis and per-
foration.3 Lorenz Heister provided the first description of classic
appendicitis in 1711.1
The first known appendectomy was performed in 1736 by
Claudius Amyand in London. He operated on an 11-year-old
boy with a scrotal hernia and a fecal fistula. Within the hernia
sac, Amyand found a perforated appendix surrounded by omen-
tum. The appendix and omentum were amputated. The patient
was discharged a month later in good condition.4
It would be over a century later before appendicitis was
widely recognized as a common cause of right lower quadrant
pain and early appendectomy advocated as treatment. Through-
out this period, there was extensive discussion of typhlitis and
perityphlitis as the common etiologies of right lower quadrant
pain. Only sporadic cases of right lower quadrant pain were
his findings regarding appendicitis and recommended consid-
eration for operative treatment. In 1889, Charles McBurney
published his landmark paper in the New York State Medical
Journal describing the indications for early laparotomy for the
treatment of appendicitis.5 During the following decade, the
role of surgical treatment was discussed intensely between pro-
ponents of early appendectomy and of a more expectant man-
agement. It was recognized that most instances of appendicitis
could resolve without surgical treatment; but, the problem was
how to identify early the patients who had the progressive, often
lethal form of the disease.6 Eventually, early appendectomy
became the accepted standard of care, with broad indications in
order to prevent perforation. This change in practice resulted in
an enormous increase in the number of appendectomies during
the first decades of the twentieth century. However, this had
almost no impact on the incidence of perforated appendicitis
or on the mortality of appendicitis.7 In the 1970s, the negative
effects of the large number of appendectomies of uninflamed
appendices were noted, and the focus gradually shifted toward
a more conservative approach to exploration.8
EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY
Embryology
In the sixth week of human embryonic development, the appen-
dix and cecum appear as outpouchings from the caudal limb
of the midgut. The appendiceal outpouching, initially noted in
the eighth week, begins to elongate at about the fifth month
to achieve a vermiform appearance.9,10 The appendix maintains

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 Key Points
1 Appendicitis is one of the most common surgical emergen-
cies in contemporary medicine, with a yearly incidence rate
of about 100 per 100,000 inhabitants. Lifetime risk for
appendicitis is 8.6% for males and 6.7% for females, with
the highest incidence in the second decade of life.
2 The natural history of appendicitis is unclear, but it appears
that progression to perforation is not predictable and that
spontaneous resolution is common, suggesting that nonper-
forated and perforated appendicitis may, in fact, be different
diseases.
3 Right lower quadrant pain, gastrointestinal symptoms start-
ing after the onset of pain, and a systemic inflammatory
response with leukocytosis and neutrophilia, increased
C-reactive protein concentration, and fever are considered
diagnostic of appendicitis. The Appendicitis Inflammatory
Response Score or Alvarado score can help improve diag-
nostic accuracy.
4 Computed tomography scan has improved diagnostic accu-
racy in individual studies. However, in population-wide
studies, the rate of misdiagnosis of appendicitis remains con-
stant. Rates of misdiagnosis are highest in female patients of
child-bearing age and patients on the extremes of age (i.e.,
very young and very old).
5 The role of nonoperative treatment for uncomplicated appen-
dicitis remains controversial. Currently, appendectomy
remains the standard of care. Laparoscopic appendectomy
has a slight benefit over open appendectomy.
6 Perforated or complicated appendicitis is more common in
the very young (age <5 years) and very old (age >65 years).
its position at the tip of the cecum throughout development.
The subsequent unequal growth of the lateral wall of the cecum
causes the appendix to find its adult position on the posterior
medial wall, just below the ileocecal valve. The base of the
appendix can be located by following the longitudinally ori-
ented taeniae coli to their confluence on the cecum. The tip of
the appendix can be located anywhere in the right lower quad-
rant of the abdomen, pelvis, or retroperitoneum.
In patients with midgut malrotation and situs inversus, the
cecum (and thus the appendix) will not reside in the usual right
lower quadrant location. With midgut malrotation, the midgut
(small bowel and proximal colon) incompletely rotates or fails
to rotate around the axis of the superior mesenteric artery during
fetal development. In this situation, the appendix will remain
in the left upper quadrant of the abdomen. Situs inversus is a
rare autosomal recessive congenital defect characterized by the
transposition of abdominal and/or thoracic organs. In this situ-
ation, the appendix is found in the left lower quadrant of the
abdomen.11
Anatomy
In the adult, the average length of the appendix is 6 to 9 cm;
however, it can vary in length from <1 to >30 cm. The outer
diameter varies between 3 and 8 mm, whereas the luminal diam-
eter varies between 1 and 3 mm.9
The appendix receives its arterial supply from the appen-
1242 dicular branch of the ileocolic artery. This artery originates pos-
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7 Complicated appendicitis without signs of sepsis or gen-
eralized peritonitis may benefit from nonoperative man-
agement. The role of interval appendectomy in these
cases remains controversial.
8 Single-incision appendectomy provides no obvious
advantage over standard laparoscopic appendectomy.
Natural orifice transluminal endoscopic surgery remains
an investigational procedure.
9 The incidence of fetal loss following normal appendec-
tomy in pregnant patients is 4%, and the risk of prema-
ture delivery is 10%. The greatest opportunity to
improve fetal outcomes may be through improving
diagnostic accuracy and reducing the rate of negative
appendectomy.
10  Antibiotic prophylaxis is effective in the prevention of
postoperative surgical site infection. Postoperative anti-
biotics are unnecessary following uncomplicated appen-
dicitis. For complicated appendicitis, a treatment
duration of 4 to 7 days is recommended.
11  The role of incidental appendectomy is limited to patients
at high risk for misdiagnosis of appendicitis (malrotation,
patients unable to respond or react normally), patients at
high risk for complications with appendicitis (children
ready to undergo chemotherapy), and patients with lim-
ited access to modern healthcare.
12  The prevalence of appendiceal malignancy remains at or
below 1% of appendectomies. Carcinoid and mucinous
adenocarcinoma remain the most frequent histologic
diagnosis.
terior to the terminal ileum, entering the mesoappendix close
to the base of the appendix.12 The lymphatic drainage of the
appendix flows into lymph nodes that lie along the ileocolic
artery. Innervation of the appendix is derived from sympa-
thetic elements contributed by the superior mesenteric plexus
(T10-L1) and afferents from the parasympathetic elements via
the vagus nerves.12
The histologic features of the appendix are contained
within the three following layers: the outer serosa, which is an
extension of the peritoneum; the muscularis layer, which is not
well defined and may be absent in certain locations; and finally,
the submucosa and mucosa. Lymphoid aggregates occur in the
submucosal layer and may extend into the muscularis mucosa.
Lymphatic channels are prominent in regions underlying these
lymphoid aggregates. The mucosa is like that of the large intes-
tine, except for the density of the lymphoid follicles. The crypts
are irregularly sized and shaped, in contrast to the more uniform
appearance of the crypts in the colon. Neuroendocrine com-
plexes composed of ganglion cells, Schwann cells, neural fibers,
and neurosecretory cells are positioned just below the crypts.13,14
Physiology
For many years, the appendix was erroneously believed to be a
vestigial organ with no known function. It is now well recog-
nized that the appendix is an immunologic organ that actively
participates in the secretion of immunoglobulins, particularly
immunoglobulin A.
 Although there is no clear role for the appendix in the
development of human disease, an inverse association between
appendectomy and the development of ulcerative colitis has
been reported, suggesting a protecting effect of the appendec-
tomy. However, this association is only seen in patients treated
with appendectomy for appendicitis before age 20.15-17
The association between Crohn’s disease and appendec-
tomy is less clear. Although earlier studies suggested that appen-
dectomy increases the risk of developing Crohn’s disease, more
recent studies that carefully assessed the timing of appendectomy
in relationship to the onset of Crohn’s disease demonstrated no
correlation.17 A recent meta-analysis demonstrated a significant
risk of Crohn’s disease early following appendicitis.18 This risk
diminishes later, which suggests that a diagnostic (misidentifying
Crohn’s disease as appendicitis) rather than a physiologic rela-
tionship exists between appendectomy and Crohn’s disease.
The appendix may function as a reservoir to recolonize
the colon with healthy bacteria. One retrospective study dem-
onstrated that prior appendectomy may have an inverse relation-
ship to recurrent Clostridium difficile infections.19 However, in
another retrospective study, prior appendectomy did not affect
the rate of C. difficile infections.20 The role of the appendix in
recolonizing the colon remains to be elucidated.
ACUTE APPENDICITIS
Epidemiology
The lifetime risk of developing appendicitis is 8.6% for males
1 and 6.7% for females, with the highest incidence in the
second and third decades.21 The rate of appendectomy for
appendicitis has been decreasing since the 1950s in most coun-
tries. In the United States, it reached its lowest incidence rate
of about 15 per 10,000 inhabitants in the 1990s.22 Since then,
there has been an increase in the incidence rate of nonperforated
appendicitis. The reason for this is not clear, but it has been pro-
posed that the increased use of diagnostic imaging has led to a
higher detection rate of mild appendicitis that would otherwise
resolve undetected.
Etiology and Pathogenesis
The etiology and pathogenesis of appendicitis are not completely
understood. Obstruction of the lumen due to fecaliths or hyper-
trophy of lymphoid tissue is proposed as the main etiologic factor
in acute appendicitis. The frequency of obstruction rises with the
severity of the inflammatory process. Fecaliths and calculi are
found in 40% of cases of simple acute appendicitis,23 in 65% of
cases of gangrenous appendicitis without rupture, and in nearly
90% of cases of gangrenous appendicitis with rupture.24
Traditionally, the belief has been that there is a predict-
able sequence of events leading to eventual appendiceal rupture.
The proximal obstruction of the appendiceal lumen produces
a closed-loop obstruction, and continuing normal secretion by
the appendiceal mucosa rapidly produces distension. Disten-
sion of the appendix stimulates the nerve endings of visceral
afferent stretch fibers, producing vague, dull, diffuse pain in the
mid-abdomen or lower epigastrium. Distension increases from
continued mucosal secretion and from rapid multiplication of
the resident bacteria of the appendix. This causes reflex nausea
and vomiting, and the visceral pain increases. As pressure in
the organ increases, venous pressure is exceeded. Capillaries
and venules are occluded but arterial inflow continues, result-
ing in engorgement and vascular congestion. The inflammatory
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process soon involves the serosa of the appendix and in turn 1243
the parietal peritoneum. This produces the characteristic shift in
pain to the right lower quadrant.
The mucosa of the appendix is susceptible to impair-
ment of blood supply; thus, its integrity is compromised early
in the process, which allows bacterial invasion. The area with
the poorest blood supply suffers the most: ellipsoidal infarcts
develop in the antimesenteric border. As distension, bacterial
invasion, compromise of the vascular supply, and infarction
progress, perforation occurs, usually on the antimesenteric bor-
der just beyond the point of obstruction. This sequence is not
CHAPTER 30 The Appendix
inevitable, however, and some episodes of acute appendicitis
may resolve spontaneously.
Microbiology
Appendicitis may occur in clusters, suggesting an infectious
genesis. However, an association with various contagious bac-
teria and viruses has only been found in a small proportion of
appendicitis patients.25 The flora of the inflamed appendix dif-
fers from that of the normal appendix. About 60% of aspirates
of inflamed appendices have anaerobes compared to 25% of
aspirates from normal appendices.26 Tissue specimens from
the inflamed appendix wall (not luminal aspirates) virtually all
grow Escherichia coli and Bacteroides species on culture.27,28
Fusobacterium nucleatum/necrophorum, which is not present in
the normal cecal flora, has been identified in 62% of inflamed
appendices.29 In addition to the other usual species (Peptostrep-
tococcus, Pseudomonas, Bacteroides splanchnicus, Bacteroides
intermedius, Lactobacillus), previously unreported fastidious
gram-negative anaerobic bacilli have been encountered. Patients
with gangrene or perforated appendicitis appear to have more
tissue invasion by Bacteroides.
Natural History
Because of the current predilection for surgical treatment, the
natural history of appendicitis has not been well described. An
increasing amount of circumstantial evidence suggests that not
all patients with appendicitis will progress to perforation and
that resolution may be a common event.30 Among the
2 strongest evidence are two randomized trials comparing
early laparoscopy with conservative management of patients
with acute abdominal pain. These studies found three to five
times more patients with appendicitis in the group of patients
who were randomized to laparoscopy.31,32 Based on epidemio-
logic differences, it has been proposed that nonperforated and
perforated appendicitis may, in fact, be different diseases.22
Clinical Presentation
The inflammatory process in the appendix presents as pain, which
initially is of a diffuse visceral type and later becomes more local-
ized as the peritoneal lining gets irritated (Table 30-1).33
Symptoms.  Appendicitis usually starts with periumbilical and
diffuse pain that eventually localizes to the right lower quad-
rant (sensitivity, 81%; specificity, 53%).34 Although right lower
quadrant pain is one of the most sensitive signs of appendici-
tis, pain in an atypical location or minimal pain will often be
the initial presentation. Variations in the anatomic location of
the appendix may account for the differing presentations of the
somatic phase of pain.
Appendicitis is also associated with gastrointestinal symp-
toms like nausea (sensitivity, 58%; specificity, 36%), vomiting
(sensitivity, 51%; specificity, 45%), and anorexia (sensitivity,
1244 Table 30-1
Signs and symptoms of appendicitis (data from Andersson33)

True Positive 95% Confidence True Negative 95% Confidence

Likelihood Ratio Interval Likelihood Ratio Interval
Duration of symptoms (hours)
>9 1.01 0.97–1.05 0.94 0.62–1.42
>12 0.96 0.90–1.04 1.19 0.87–1.63
>24 0.65 0.47–0.90 1.47 1.14–1.90
>48 0.49 0.36–0.67 1.20 1.08–1.34
PART II
UNIT II

Fever 1.64 0.89–3.01 0.61 0.49–0.77

Gastrointestinal dysfunction
Anorexia 1.27 1.14–1.41 0.59 0.45–0.77
Nausea 1.15 1.04–1.36 0.72 0.57–0.91
Vomiting 1.63 1.45–1.84 0.75 0.69–0.80
SPECIFIC CONSIDERATIONS

Pain
Pain migration 2.06 1.63–2.60 0.52 0.40–0.69
Pain progression 1.39 1.29–1.50 0.46 0.27–0.77
Direct tenderness 1.29 1.06–1.57 0.25 0.12–0.53
Indirect tenderness 2.47 1.38–4.43 0.71 0.65–0.77
Psoas sign 2.31 1.36–3.91 0.85 0.76–0.95
Rebound 1.99 1.61–2.45 0.39 0.32–0.48
Percussion tenderness 2.86 1.95–4.21 0.49 0.37–0.63
Guarding 2.48 1.60–3.84 0.57 0.48–0.68
Rigidity 2.96 2.43–3.59 0.86 0.72–1.02
Temperature (degrees centigrade)
>37.7 1.57 0.90–2.76 0.65 0.31–1.36
>38.5 1.87 0.66–5.32 0.89 0.71–1.12
White blood cells (10 /L)
9

≥10 4.20 2.11–8.35 0.20 0.10–0.41

≥15 7.20 4.31–12.00 0.66 0.56–0.78
C-reactive protein (mg/L)
>10 1.97 1.58–2.45 0.32 0.20–0.51
>20 2.39 1.67–3.41 0.47 0.28–0.81
Conclusions: Individually, disease history, clinical findings, and laboratory tests are weak. But, when combined, they yield high discriminatory power.

68%; specificity, 36%). Gastrointestinal symptoms that develop
before the onset of pain suggest a different etiology such as
gastroenteritis.34 Many patients complain of a sensation of
3 obstipation prior to the onset of pain and feel that defeca-
tion will relieve their abdominal pain. Diarrhea may occur in
association with perforation, especially in children.
Signs.  Early in presentation, vital signs may be minimally
altered. The body temperature and pulse rate may be normal
or slightly elevated. Changes of greater magnitude may indi-
cate that a complication has occurred or that another diagnosis
should be considered.35
Physical findings are determined by the presence of peri-
toneal irritation and are influenced by whether the organ has
already ruptured when the patient is first examined. Patients
with appendicitis usually move slowly and prefer to lie supine
due to the peritoneal irritation. On abdominal palpation, there
is tenderness with a maximum at or near McBurney’s point
(Fig. 30-1).5 On deep palpation, one can often feel a muscu-
lar resistance (guarding) in the right iliac fossa, which may be
more evident when compared to the left side. When the pres-
sure of the examining hand is quickly relieved, the patient feels
a ­sudden pain, the so-called rebound tenderness. Indirect ten-
derness (Rovsing’s sign) and indirect rebound tenderness (i.e.,
pain in the right lower quadrant when the left lower quadrant is
palpated) are strong indicators of peritoneal irritation. Rebound
tenderness can be very sharp and uncomfortable for the patient.
It is therefore recommended to start with testing for indirect
rebound tenderness and direct percussion tenderness.
Anatomic variations in the position of the inflamed appen-
dix lead to deviations in the usual physical findings. With a ret-
rocecal appendix, the abdominal findings are less striking, and
tenderness may be most marked in the flank. When the appen-
dix hangs into the pelvis, abdominal findings may be entirely
absent, and the diagnosis may be missed. Right-sided rectal ten-
derness is said to help in this situation, but the diagnostic value
is low. Pain with extension of the right leg (psoas sign) indicates
a focus of irritation in the proximity of the right psoas muscle.
Similarly, stretching of the obturator internus through internal
rotation of a flexed thigh (obturator sign) suggests inflammation
near the muscle.
Laboratory Findings. Appendicitis is associated with an
inflammatory response that is strongly related to the severity of

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 all normal. The inflammatory response in acute appendicitis 1245
is a dynamic process. Early in the process, the inflammatory
response can be weak. CRP elevation, in particular, can have up
to a 12-hour delay. A decreasing inflammatory response may
indicate spontaneous resolution.
Urinalysis can be useful to rule out the urinary tract as the
source of infection; however, several white or red blood cells
can be present from irritation of the ureter or bladder. Bacteri-
uria is generally not seen.
Clinical Scoring Systems.  The clinical diagnosis of appendi-

CHAPTER 30 The Appendix

Figure 30-1.  McBurney’s point (1 = anterior superior iliac spine;
2 = umbilicus; x = McBurney’s point).
the disease. Laboratory examinations are therefore an impor-
tant part of the diagnosis. Mild leukocytosis is often present in
patients with acute, uncomplicated appendicitis and is usually
accompanied by a polymorphonuclear prominence. It is unusual
for the white blood cell count to be >18,000 cells/mm3 in uncom-
plicated appendicitis. Counts above this level raise the possibility
of a perforated appendix with or without an abscess. An increased
C-reactive protein (CRP) concentration is a strong indicator of
appendicitis, especially for complicated appendicitis.36
White blood cell counts can be low due to lymphopenia
or septic reaction, but in this situation, the proportion of neutro-
phils is usually very high. Therefore, all inflammatory variables
should be viewed together. Appendicitis is very unlikely if the
white blood cell count, proportion of neutrophils, and CRP are
citis is a subjective estimate of the probability of appendicitis
based on multiple variables that individually are weak discrimi-
nators; however, used in conjunction, they possess a high pre-
dictive value. This process can be made more objective by the
use of clinical scoring systems, which are based on variables
with proven discriminating power and assigned a proper weight.
The Alvarado score is the most widespread scoring system. It
is especially useful for ruling out appendicitis and selecting
patients for further diagnostic workup.37 The Appendici-
3 tis Inflammatory Response Score resembles the Alvarado
score but uses more graded variables and includes CRP
(Table 30-2).38,39 Studies have shown it to perform better than
the Alvarado score in accurately predicting appendicitis.38,39
However, clinical scoring systems have not gained widespread
acceptance in making the diagnosis of appendicitis.
Imaging Studies.  Plain films of the abdomen can show the
presence of a fecalith and fecal loading in the cecum associ-
ated with appendicitis but are rarely helpful in diagnosing acute
appendicitis40; however, they may be of benefit in ruling out other
pathology. A chest radiograph is helpful to rule out referred pain
from a right lower lobe pneumonic process. If the appendix fills
on barium enema, appendicitis is unlikely41; however, this test
is not indicated in the acute setting. Technetium-99m–labeled

Table 30-2
Scoring systems

Alvarado Score37 Appendicitis Inflammatory Response Score38,39

Findings Points Findings Points
Migratory right iliac fossa pain 1 Vomiting 1
Anorexia 1 Pain in the right inferior fossa 1
Nausea or vomiting 1 Rebound tenderness or muscular defense
Tenderness: right iliac fossa 2 Light 1
Rebound tenderness right iliac fossa 1 Medium 2
Fever ≥36.3°C 1 Strong 3
Leukocytosis ≥10 × 109 cells/L 2 Body temperature ≥38.5°C 1
Shift to the left of neutrophils 1 Polymorphonuclear leukocytes
70%–84% 1
≥85% 2
White blood cell count
10.0–14.9 × 109 cells/L 1
≥15.0 × 109 cells/L 2
C-reactive protein concentration
10–49 g/L 1
≥50 g/L 2
Score: <3: Low likelihood of appendicitis Score: 0–4: Low probability. Outpatient follow-up.
4–6: Consider further imaging 5–8: Indeterminate group. Active observation or diagnostic laparoscopy.
≥7: High likelihood of appendicitis 9–12: High probability. Surgical exploration.

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1246 leukocyte scan has been reported for use in diagnosing appendi-
citis with good results but has not gained widespread use due to
its relative unavailability and impracticality in daily use.42
Ultrasonography and computed tomography (CT) scan are
the most commonly used imaging tests in patients with abdomi-
nal pain, particularly in evaluation of possible appendicitis.
Multiple meta-analyses have been performed comparing the two
imaging modalities (Table 30-3).43-47 Overall, CT scan is more
sensitive and specific than ultrasonography in diagnosing
4 appendicitis.
Graded compression ultrasonography is inexpensive, can
be performed rapidly, does not require a contrast medium, and
PART II
UNIT II
can be used in pregnant patients. Sonographically, the appen-
dix is identified as a blind-ending, nonperistaltic bowel loop
originating from the cecum. With maximal compression, the
diameter of the appendix is measured in the anterior-posterior
direction. Thickening of the appendiceal wall and the presence
SPECIFIC CONSIDERATIONS
of periappendiceal fluid are highly suggestive of appendicitis.
Demonstration of an easily compressible appendix measur-
ing <5 mm in diameter excludes the diagnosis of appendicitis.
The sonographic diagnosis of acute appendicitis has a reported
sensitivity of 55% to 96% and a specificity of 85% to 98%.
Ultrasonography is similarly effective in children and pregnant
women, although its application is limited in late pregnancy.
Ultrasonography has its limitations, particularly the operator-
dependent nature of results. In the adult population, ultrasonog-
raphy remains limited in its use.
With high-resolution helical CT, the inflamed appendix
appears dilated (>5 mm), and the wall is thickened. There is
often evidence of inflammation, which can include periappen-
diceal fat stranding, thickened mesoappendix, periappendiceal
phlegmon, and free fluid. Fecaliths can be often visualized;
however, their presence is not pathognomonic of appendicitis.
CT scanning is also an excellent technique for identifying other
inflammatory processes masquerading as appendicitis. Several
CT techniques have been used, including focused and nonfo-
cused CT scans and contrast and noncontrast scans. Surpris-
ingly, all of these techniques have yielded essentially identical
rates of diagnostic accuracy: 92% to 97% sensitivity, 85% to
94% specificity, 90% to 98% accuracy, 75% to 95% positive
predictive value, and 95% to 99% negative predictive value.
The additional use of rectal contrast does not improve the results
of CT scanning.
A number of studies have documented improvement in
diagnostic accuracy with the liberal use of CT scanning in the
workup of suspected appendicitis. CT lowered the rate of nega-
tive appendectomies from 19% to 12% in one study48 and the
incidence of negative appendectomies in women from 24% to
5% in another study.49 Use of CT altered the care of 24% of
patients studied and provided an alternative diagnosis in half of
the patients with normal appendices on CT scan.
Despite the potential usefulness of CT, there are signifi-
cant disadvantages. CT scanning is expensive, exposes the
patient to significant radiation, and has limited use during preg-
nancy. Allergy to iodine or contrast limits the administration of
contrast agents in some patients, and others cannot tolerate the
oral ingestion of luminal dye.
The role of CT scanning in patients who present with right
lower quadrant pain is unclear. One rationale is universal CT
scanning. There is, however, an argument that indiscriminate
diagnostic imaging can increase the detection of clinically non-
significant appendicitis that would resolve without treatment.
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Alternatively, selective CT scanning based on the likelihood of
appendicitis takes advantage of the clinical skills of the surgeon
and, when indicated, adds the expertise of the radiologist.
Despite the increased use of ultrasonography and CT,
the rate of misdiagnosis of appendicitis has remained constant
(15%). The percentage of misdiagnosed cases of appendici-
tis is significantly higher among women than men (22% vs.
9.3%).50,51 The negative appendectomy rate is highest in women
of reproductive age.
Differential Diagnosis
The differential diagnosis of acute appendicitis is essentially the
diagnosis of acute abdomen. An identical clinical picture can
result from a wide variety of acute processes within the peri-
toneal cavity that produce the same physiologic alterations as
acute appendicitis.
The accuracy of preoperative diagnosis should be higher
than 85%. If it is consistently less, it is likely that unnecessary
operations are being performed and a more rigorous preopera-
tive differential diagnosis is needed.
The most common findings in the case of an erroneous
preoperative diagnosis of appendicitis—together accounting
for more than 75% of cases—are, in descending order of fre-
quency, acute mesenteric adenitis, no organic pathologic condi-
tion, acute pelvic inflammatory disease, twisted ovarian cyst or
ruptured graafian follicle, and acute gastroenteritis.
The differential diagnosis of acute appendicitis depends on
four major factors: the anatomic location of the inflamed appen-
dix; the stage of the process (uncomplicated or complicated);
the patient’s age; and the patient’s gender.52-56
Pediatric Patient.  Acute mesenteric adenitis is the disease
most often confused with acute appendicitis in children. Almost
invariably, an upper respiratory tract infection is present or has
recently subsided. The pain usually is diffuse, and tenderness
is not as sharply localized as in appendicitis. Voluntary guard-
ing is sometimes present, but true rigidity is rare. Generalized
lymphadenopathy may be noted. Laboratory procedures are of
little help in arriving at the correct diagnosis, although a rela-
tive lymphocytosis, when present, suggests mesenteric adenitis.
Observation for several hours is appropriate if the diagnosis of
mesenteric adenitis is suspected, as it is a self-limited disease.
Elderly Patient.  Diverticulitis or perforating carcinoma of
the cecum or of a portion of the sigmoid that overlies the right
lower abdomen may be impossible to distinguish from appendi-
citis. These entities should be considered, particularly in older
patients. CT scanning is often helpful in making a diagnosis in
older patients with right lower quadrant pain and atypical clini-
cal presentations. In patients successfully managed conserva-
tively, interval surveillance of the colon (colonoscopy or barium
enema) may be warranted.
Female Patient.  Diseases of the female internal reproductive
organs that may erroneously be diagnosed as appendicitis are,
in approximate descending order of frequency, pelvic inflam-
matory disease, ruptured graafian follicle, twisted ovarian cyst
or tumor, endometriosis, and ruptured ectopic pregnancy. As a
result, the rate of misdiagnosis remains higher among female
patients.
In pelvic inflammatory disease, the infection is usually
bilateral but, if confined to the right tube, may mimic acute
appendicitis. Nausea and vomiting are present in patients with
appendicitis but in only approximately 50% of those with pelvic
Table 30-3
Meta-analyses comparing CT scan and US outcomes

Author Summary

Terasawa Weston Doria Al-Khayal Van Randen

Year 2004 2005 2006 2007 2008
No. of studies 22 21 57 25 6
No. of patients CT 1172 NR NR NR NR
US 1516 NR NR NR NR
Total 2688 5039 13697 13046 671
Sensitivity CT 94% (CI: 91%–95%) 97% (CI: 95%–98%) 94% (CI: 92%–97%) 93% (CI: 92%–95%) 91% (CI: CT more sensitive than US in five of
US 86% (CI: 83%–88%) 87% (CI: 85%–89%) 88% (CI: 86%–90%) 84% (CI: 82%–85%) 84%–95%) five meta-analyses
78% (CI:
67%–86%)
Specificity CT 95% (CI: 93%–96%) 95% (CI: 93%–96%) 94% (CI: 94%–96%) 93 (CI: 92%–94%) 90% (CI: CT more specific than US in four of
US 81% (CI: 78%–84%) 93% (CI: 92%–94%) 93% (CI: 90%–96%) 96 (CI: 95%–96%) 85%–94%) five meta-analyses
83% (CI:
76%–88%)
Positive CT NR 94% (CI: 92%–95%) NR 90% (CI: 89%–92%) NR CT has superior positive predictive
predictive US NR 89% (CI: 87%–90%) NR 90% (CI: 89%–91%) NR value in one of two meta-analyses
value
Negative CT NR 97% (CI: 96%–98%) NR 96% (CI: 95%–97%) NR CT has superior negative predictive
predictive US NR 92% (CI:91%–93%) NR 93% (CI: 92%–94%) NR value in both ­
value meta-analyses
Accuracy CT NR NR NR 94% (CI: 93%–94%) NR CT is more accurate in the one study
US NR NR NR 92% (CI: 92%–96%) NR reporting results
CI = confidence interval; CT = computed tomography; NR = not reported; US = ultrasonography.

CHAPTER 30 The Appendix

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1248 inflammatory disease. Pain and tenderness are usually lower,
and motion of the cervix is exquisitely painful. Intracellular dip-
lococci may be demonstrable on smear of the purulent vaginal
discharge. The ratio of cases of appendicitis to cases of pelvic
inflammatory disease is low in females in the early phase of the
menstrual cycle and high during the luteal phase. The careful
clinical use of these features has reduced the incidence of nega-
tive findings on laparoscopy in young women to 15%.
Ovulation commonly results in the spillage of sufficient
amounts of blood and follicular fluid to produce brief, mild
lower abdominal pain. If the amount of fluid is unusually copi-
ous and is from the right ovary, appendicitis may be simulated.
PART II
UNIT II
Pain and tenderness may be rather diffuse, and leukocytosis and
fever minimal or absent. Because this pain occurs at the mid-
point of the menstrual cycle, it is often called mittelschmerz.
Serous cysts of the ovary are common and generally remain
asymptomatic. When right-sided cysts rupture or undergo tor-
SPECIFIC CONSIDERATIONS
sion, the manifestations are similar to those of appendicitis.
Patients develop right lower quadrant pain, tenderness, rebound,
fever, and leukocytosis. Both transvaginal ultrasonography and
CT scanning can be diagnostic.
Torsion requires emergent operative treatment. If the tor-
sion is complete or longstanding, the pedicle undergoes throm-
bosis, and the ovary and tube become gangrenous and require
resection. However, simple detorsion, fenestration of the cyst,
and fixation of the ovary as a primary intervention, followed by
a laparoscopy a few days later, can be recommended because
it is often difficult to preoperatively determine the viability of
the ovary.
Blastocysts may implant in the fallopian tube (usually the
ampullary portion) and in the ovary. Rupture of right tubal or
ovarian pregnancies can mimic appendicitis. Patients may give
a history of abnormal menses, either missing one or two periods
or noting only slight vaginal bleeding. Unfortunately, patients
do not always realize they are pregnant. The development of
right lower quadrant or pelvic pain may be the first symptom.
The diagnosis of ruptured ectopic pregnancy should be rela-
tively easy. The presence of a pelvic mass and elevated levels
of human chorionic gonadotropin are characteristic. Although
the leukocyte count rises slightly, the hematocrit level falls as
a consequence of the intra-abdominal hemorrhage. Vaginal
examination reveals cervical motion and adnexal tenderness,
and a more definitive diagnosis can be established by culdocen-
tesis. The presence of blood and particularly decidual tissue is
pathognomonic. The treatment of ruptured ectopic pregnancy is
emergency surgery.
Immunosuppressed Patient.  The incidence of acute appen-
dicitis in patients infected with human immunodeficiency
virus (HIV) is reported to be 0.5%. This is higher than the
0.1% to 0.2% incidence reported for the general population.57
The presentation of acute appendicitis in HIV-infected patients
is similar to that in noninfected patients. The majority of HIV-
infected patients with appendicitis have fever, periumbilical
pain radiating to the right lower quadrant (91%), right lower
quadrant tenderness (91%), and rebound tenderness (74%).
HIV-infected patients do not manifest an absolute leukocyto-
sis; however, if a baseline leukocyte count is available, nearly
all HIV-infected patients with appendicitis demonstrate a rela-
tive leukocytosis.57
The risk of appendiceal rupture appears to be increased in
HIV-infected patients. In one large series of HIV-infected patients
who underwent appendectomy for presumed appendicitis, 43% of
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patients were found to have perforated appendicitis at laparot-
omy.58 The increased risk of appendiceal rupture may be related
to the delay in presentation seen in this patient population.57,58 A
low CD4 count is also associated with an increased incidence of
appendiceal rupture.57
The differential diagnosis of right lower quadrant pain is
expanded in HIV-infected patients compared with the general
population. In addition to the conditions discussed elsewhere
in this chapter, opportunistic infections should be considered as
a possible cause of right lower quadrant pain.57,58 Neutropenic
enterocolitis (typhlitis) should also be considered in the differential
diagnosis of right lower quadrant pain in HIV-infected patients.57,58
Initial Management
Uncomplicated Appendicitis
Operative versus Nonoperative Management of Uncompli-
cated Appendicitis  In patients with uncomplicated appendici-
tis, surgical treatment has been the standard of treatment since
McBurney reported his experiences. The concept of nonopera-
tive treatment for uncomplicated appendicitis developed from
two lines of observations. First, for patients in an environment
where surgical treatment is not available (e.g., submarines,
expeditions in remote areas), treatment with antibiotics alone
was noted to be effective. Second, many patients with signs
and symptoms consistent with appendicitis who did not pursue
medical treatment would occasionally have spontaneous resolu-
tion of their illness.
A handful of observational studies and controlled trials
have reported the outcomes of nonoperative versus opera-
tive treatment of presumed uncomplicated appendicitis
(Table 30-4).59-64 Overall, there is a reported 9% short-term
(<30 days) failure rate with nonoperative management of
appendicitis (13% if evaluated per protocol). In patients in
whom nonoperative treatment fails, nearly half of patients have
complicated (perforated or gangrenous) appendicitis. After 1
month, about 1% of patients in the trials underwent an interval
appendectomy, and 13% of patients who initially were success-
fully treated with nonoperative measures developed recurrent
appendicitis, with an 18% rate of complicated appendicitis.
Follow-up was not longer than 1 year in any study. In addition,
one-third of patients declined or dropped out from nonoperative
management of appendicitis.
In comparison, operative appendectomy demonstrated a
relatively low dropout rate (2%), lower proportion of compli-
cated appendicitis (25%), small proportion of a normal appendix
(5%), and low rates of superficial surgical site infection (3.7%)
and intra-abdominal abscess (1.3%).
The results in these studies must viewed with caution due
to unclear selection of patients, incomplete diagnostic workup
5 inoperated
the nonoperated patients, unclear gold standard for the
patients, and high rates of crossover between the
treatment arms. The consequences in terms of use of hospital
beds, length of hospital stay, morbidity of delayed surgical treat-
ment after failed nonsurgical treatment, delayed diagnosis for
patients with an underlying cancer in the appendix or cecum,
and risk of increased antibiotic resistance need to be further
investigated. Thus, operative treatment of presumed uncom-
plicated appendicitis still remains the standard of care. Certain
subgroups with uncomplicated appendicitis may do well with
nonoperative therapy. Patients pursuing nonoperative manage-
ment should be carefully counseled regarding the risks of treat-
ment failure and recurrent appendicitis.
Table 30-4
Outcomes associated with nonoperative and operative management of acute appendicitis

Nonoperative Outcomes

Dropout Failed Follow-Up Dura-

after Ran- Therapy in Complicated Interval Failed Therapy Complicated tion in Months
Author Study Type No. Male Age domization 0–30 Days Appendicitis Appendectomy in >30 Days Appendicitis (range)
Vons PRCT 120a 75 21±9b 3 14 9 NR 30 3 12
Hansson PRCT 202 103 38±1c 96 9 6/11 d
NR 11 4/12 d
12
Turhan PCT 107 65 21c
5 14 0 NR 8 0 NR
Liu RT 19 8 34±1 e NA 0 0 5 6 1 NR
Styrud PT 128 128 18–50 79/104 f
15 7 NR 16 5 4 (1–10)
Eriksson PRCT 20 14 28 (18–53) 5g 1 1 NR 7 1 7 (3–12)

Overall 596 393 (66%) 23 188 (33%) 53 (8.9%) 23 (42%) 5 (0.8%) 78 (13%) 14 (17.7%) <1 year

Operative Outcomes

Dropout after Complicated Intra-abdominal

Author Study Type No. Male Age Randomization Appendicitis Normal Appendix SSI, Superficial Abscess
Vons PRCT 120 70 34±12b 1 21 NR 1 NR
Hansson PRCT 167 92 38±1 c 13 92/250 f
30/250 f
7 5
Turhan PCT 183 125 26±1 NR 34 NR 6 2
Liu RT 151 104 34±1 e NR 47 5 9 0
Styrud PT 124 124 18-50 NR 7 4 NR NR
Eriksson PRCT 20 13 35 (19–85) NR 9 3 1 0

Overall 765 528 (69%) 33 14 (1.8%) 210 (24.8%) 42 (5.0%) 24 (3.7%) 7 (1.3%)
a
Although 123 patients were randomized to nonoperative management and 3 patients dropped out, only 120 patients were included in the intent-to-treat analysis.
b
Standard deviation.
c
Standard error of the mean.
d
Study only reported pathology results based on the per-protocol group and not the intent-to-treat group.
e
Study did not report the meaning of these values.
f
Study did not report the intent-to-treat values; instead, at one institution, 79 of 104 patients declined to be included in the trial.
g
These patients declined to be included in the study and opted for surgical management.
NA = not applicable; NR = not reported; PCT = prospective controlled trial; PRCT = prospective randomized controlled trial; RT = retrospective trial; SSI = surgical site infection.

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1250 Urgent versus Emergent Appendectomy for Uncomplicated
Appendicitis  Traditionally, appendicitis has been considered a
surgical emergency. Once diagnosed, a patient was emergently
taken to the operating room for surgical treatment. However,
delays in diagnosis, lack of access to available operating suites,
and nonoperative management of appendicitis have challenged
the notion that uncomplicated appendicitis is a surgical emer-
gency.
Three retrospective studies have evaluated the role of
emergent or urgent surgery for uncomplicated appendicitis;
the emergent group had a time from presentation to the operat-
ing room of <12 hours, whereas the urgent group had a time
PART II
UNIT II
consider performing appendectomy in an urgent fashion as
opposed to emergently.
Complicated Appendicitis.  Complicated appendicitis typi-
cally refers to perforated appendicitis commonly associated
with an abscess or phlegmon. The yearly incidence rate of
perforated appendicitis is about 2 per 10,000 persons and has
remarkable little variance over time, geographic region, and
age.51,68,69 The proportion of perforated appendicitis, commonly
around 25%, is often used as an indicator of quality of care.
Differences in this proportion are almost entirely related to dif-
ferences in the incidence of nonperforated appendicitis. A low

proportion of perforations may therefore be the consequence

from presentation to the operating room of 12 to 24 hours
(Table 30-5).65-67 There was no statistically significant increase
in the number of complicated appendicitis cases in the urgent
group when compared to the emergent group. Similarly, rates
of surgical site infection, intra-abdominal abscesses, conversion
SPECIFIC CONSIDERATIONS
of a higher rate of detection and treatment of early or resolving
appendicitis.
Children less than 5 years of age and patients more than
65 years of age have the highest rates of perforation (45% and

51%, respectively). The proportion of perforation increases

to an open procedure, or operative time showed no difference
between the two groups. While length of stay was longer for
the urgent group, it was not statistically or clinically different
from the emergent group. Important caveats in consideration
of urgent as opposed to emergent surgical care include the
patient’s clinical examination, time of presentation from onset
of symptoms, and duration of “delay” in surgery. Patients with
clinical signs of perforation, patients with delayed presentation
of greater than 48 hours from onset of symptoms, and patients
whose definitive therapy may be delayed for more than 12 hours
were beyond the scope of these studies.
Emergent versus urgent operation for uncomplicated
appendicitis is dependent on each institution and surgeon. Insti-
tutions without readily available operating rooms and staff may
6 with increasing duration of symptoms. There is, however,
no association of in-hospital delay with perforation. This suggests
that most perforations occur early, before the patient arrives to
hospital. It has also been proposed that the increasing propor-
tion of perforations with time is explained by selection due to
spontaneous resolution of noncomplicated appendicitis.
Perforated appendicitis has been suggested to increase the
risk of female infertility due to impaired tubal function, but this
has not been shown in epidemiologic studies.70
Rupture should be suspected in the presence of generalized
peritonitis and a strong inflammatory response. In many cases,
rupture is contained and patients display localized peritonitis.
In 2% to 6% of cases, a palpable mass is detected on physical
examination. This could represent a phlegmon, which consists

Table 30-5
Emergent versus urgent surgery

Author

Abou-Nukta Stahlfeld Ingraham Summary

Year 2006 2007 2010
No. of patients Emergent 233 53 24,647
Urgent 76 18 4934
Time from presentation to Emergent 6.7±2.7 3.2±2.4 1.5
OR (hours) Urgent 16.7±3.6 15.8±5.5 8.5
% Complicated Emergent 32% NR NR No difference in complicated appendicitis
Urgent 37%
Conversion to open, % Emergent NR 15% NR No difference in conversion rates
Urgent 7%
Operative duration Emergent 81±31 54 51 No difference in operative duration
(minutes) Urgent 82±31 56 50
SSI, % Emergent 1% 7.5% NR One study demonstrates increased infections
Urgent 1% 0% with emergent operation
Intra-abdominal abcess, % Emergent 2% NR NR No difference in intra-abdominal abscess
Urgent 1% rates
Length of stay (days) Emergent 2.5±2.3 2.7 1.8 No significant difference in length of stay
Urgent 2.9±1.8 2.1 1.8
NR = not reported; OR = operating room; SSI = surgical site infection.

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of matted loops of bowel adherent to the adjacent inflamed
appendix or a periappendiceal abscess. Patients who present
with a mass have experienced symptoms for a longer dura-
tion, usually 5 to 7 days. Distinguishing acute, uncomplicated
appendicitis from acute appendicitis with perforation based on
clinical findings is often difficult, but it is important to make
the distinction because the treatments may differ. CT scan may
be beneficial in establishing a diagnosis and guiding therapy.
Operative versus Nonoperative Management of Complicated
Appendicitis  Patients who present with signs of sepsis and gen-
eralized peritonitis should be taken to the operating room imme-
diately with concurrent resuscitation. The surgical approach is
based on the surgeon’s level of comfort; however, open appen-
dectomy through a lower midline incision may be necessary to
treat these complicated cases.
In patients with complicated appendicits and a contained
abscess or phlegmon but limited peritonitis (focal right lower
quadrant pain), the treatment options become more complicated.
Often, these patients will require a challenging procedure with
a high risk for development of a postoperative intra-abdominal
abscess. Options include operative management versus conser-
vative management (antibiotics, bowel rest, fluids, and possible
percutaneous drainage).
There have been no prospective randomized controlled
studies comparing operative versus conservative management of
complicated appendicitis in adults; all studies have been retro-
spective cohort studies. Two meta-analyses have been performed.
In Andersson and Petzold’s 2007 analysis of 61 studies evaluating
this issue, they noted that initial nonoperative management had
superior outcomes.70 Nonoperative management included intra-
venous fluids, minimizing gastrointestinal stimulation, parenteral
antibiotics, and percutaneous drainage where deemed appropri-
ate. The morbidity of immediate operative treatment was 36.5%,
whereas the morbidity of conservative management was 11%. Of
patients undergoing conservative treatment, 7.6% failed conser-
vative treatment and underwent operative management. This sub-
group had an overall complication rate of 13.5%. The recurrence
rate was 7.4%, which does not necessitate interval appendectomy.
The authors concluded that conservative treatment was favored
over early operation in complicated appendicitis.30
Simillis and colleagues performed a meta-analysis of 17
studies.71 They noted that conservative treatment was associ-
ated with fewer overall complications (odds ratio, 0.24;
7 95% confidence interval [CI], 0.13 to 0.44), intra-abdom-
inal abscesses (odds ratio, 0.19; 95% CI, 0.07 to 0.58), bowel
obstructions (odds ratio, 0.35; 95% CI, 0.17 to 0.71), and reop-
erations (odds ratio, 0.17; 95% CI, 0.04 to 0.75).71 The authors
concluded that conservative treatment was favored over early
operation in complicated appendicitis.
In the pediatric literature, there have been two prospec-
tive randomized controlled trials72,73 demonstrating that early
operative intervention had equivalent or superior outcomes to
conservative management, but these studies included interval
appendectomy for all patients in their calculations. St. Peter
and colleagues72 demonstrated that 20% of patients failed con-
servative treatment. Early surgical intervention had equivalent
results to interval appendectomy. Alternatively, Blakely and
colleagues73 noted that interval appendectomy, versus early
appendectomy, had a higher incidence of adverse events (50%
vs. 30%, P = .003), intra-abdominal abscesses (37% vs. 19%,
P = .02), small bowel obstruction (10.4% vs. 0%, P = .01), and
readmissions (31% vs. 8%, P = .06). In addition, Blakely and
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colleagues noted that 9% of the group treated conservatively 1251
developed recurrent appendicitis. The authors concluded that
immediate surgical treatment was superior to conservative treat-
ment with interval appendectomy.
Interval Appendectomy Following Nonoperative Manage-
ment of Complicated Appendicitis  Interval appendectomy is
defined as performing an appendectomy following initial suc-
cessful nonoperative management in patients with no further
symptoms. The major argument against interval appendectomy
is that many patients treated conservatively never develop mani-
CHAPTER 30 The Appendix
festations of appendicitis, and those who do generally can be
treated without additional morbidity. The major argument for
interval appendectomy is to prevent future attacks of appendici-
tis or to identify other disease, such as appendiceal malignancy.
There has only been one small prospective randomized
controlled trial (n = 40) investigating this subject. The litera-
ture is largely populated with small case series and retrospective
cohort studies; there is no meta-analysis evaluating the subject
(Table 30-6).74-81 Of the 1434 patients who had presumed com-
plicated appendicitis and were successfully treated conserva-
tively, 8.8% developed recurrent appendicitis with a median
follow-up of 35 months. The incidence of complicated appen-
dicitis following recurrence was low (2.4%). Malignancy was
noted in 1.3% of cases where pathology was reported. Many
of the patients were excluded from these studies due to persis-
tent symptoms, persistent infections, or note of malignancy on
screening colonoscopy.
Alternatively, of the 344 patients who had presumed com-
plicated appendicitis, were successfully treated conservatively,
and subsequently underwent interval appendectomy, surgical
complications occurred in 9.4% of the patients. Most patients
underwent interval appendectomy 2 to 4 months after their acute
presentation. Although operative and pathologic details were
not uniformly reported in these patients, many continued to
have evidence of appendicitis or abscess at the time of interval
appendectomy; 3.6% of patients had malignancy in cases where
pathology was reported.
The role of interval appendectomy following successful
management of conservative treatment of complicated appen-
dicitis is unclear. Close clinical follow-up, a complete history
searching for persistent symptoms, and screening colonoscopy
(when age appropriate) should all be used to help guide the dis-
cussion with the patient on the role of interval appendectomy fol-
lowing conservative management of complicated appendicitis.
OPERATIVE INTERVENTIONS FOR THE APPENDIX
Open Appendectomy
Typically performed with a patient under general anesthesia, the
patient is placed in supine position. The entire abdomen should
be prepped and draped in case a larger incision is needed. For
early nonperforated appendicitis, a right lower quadrant inci-
sion at McBurney’s point (one-third of the distance from the
anterior superior iliac spine to the umbilicus) is commonly used.
A McBurney (oblique) or Rocky-Davis (transverse) right lower
quadrant muscle splitting incision is made. If perforated appen-
dicitis is suspected or the diagnosis is in doubt, a lower midline
laparotomy can be considered. Although it has been reported
that the position of the base of the appendix can change with
pregnancy, prospective studies have demonstrated that preg-
nancy does not change the proportion of patients with the appen-
diceal base within 2 cm of McBurney’s point.82
1252 Table 30-6
Interval appendectomy following nonoperative management of complicated appendicitis
No Interval Appendectomy

Follow-Up
Study Recurrent Duration
Author Year Type No. Appendicitis Appendectomy Complicated Complications Malignancy (months)
Youssef 2010 PCT 51 9 7 1 1 NR 24
Tekin 2008 CS 89 15 NR NR NR NR NR
PART II
UNIT II

Lai 2006 RT 94 24 20 NR NR 2 33
Kaminski 2005 CS 1012 39 39 NR NR NR 48
Kumar 2004 PRCT 20 2 2 NR NR 1 34
Eryilmaz 2004 CS 25 3 3 NR NR NR 35
SPECIFIC CONSIDERATIONS

Dixon 2003 RT 116 32 22 0 NR 0 NR

Adalla 1996 CS 27 2 2 NR NR NR NR
Overall 1434 126 (8.8%) 95 (7.1%) 1 (2.4%) 1 (11%) 3 (1.3%) 35
Interval Appendectomy

Author Year Study Type No. Complications Malignancy Time of Surgery (months)
Lugo 2010 PT 46 3 2 2
Youssef 2010 PCT 10 1 NR 3
Lai 2006 RT 70 NR 2 2
Kumar 2004 PRCT 20 0 1 3
Dixon 2004 RCT 114 NR NR 2
Friedell 2000 CS 5 0 1 2
Yamini 1998 CS 41 6 1 2
Eriksson 1998 CS 38 5 1 4
Overall 344 15 (9.4%) 8 (3.6%) 3
CS = case series; NR = not reported; PCT = prospective controlled trial; PRCT = prospective randomized controlled trial; RT = retrospective trial.

Following entry into the abdomen, the patient should be
placed in slight Trendelenburg position with rotation of the bed
to the patient’s left. If the appendix is not easily identified, the
cecum should be located. Tracing the taenia libera (anterior tae-
nia), the most visible of the three taeniae coli, distally, the base
of the appendix can be identified.
The appendix will often have attachments to the lateral
wall or pelvis that can be dissected free. Dividing the mesen-
tery of the appendix first will often allow improved exposure of
the base of the appendix. The appendiceal stump can be man-
aged by simple ligation or by ligation and inversion. As long
as the stump is clearly visible and the base of the cecum is not
involved with the inflammatory process, the stump can be safely
ligated. Obliteration of the mucosa with electrocautery with the
intention to obviate the development of a mucocele is recom-
mended by some surgeons; however, no data have evaluated the
risk or benefit of this surgical maneuver. Inversion of the stump
with plication of the cecum has also been described. Placement
of surgical drains for both uncomplicated83 and complicated
appendicitis,84-87 practiced by many surgeons, has not been sup-
ported in clinical trials. Pus in the abdomen should be aspirated,
but irrigation in complicated appendicitis is not recommended.88
The skin can also be closed primarily in patients with perforated
appendicitis.
If appendicitis is not found, a methodical search must be
made for an alternative diagnosis. The cecum and mesentery
should be inspected. The small bowel should be evaluated in a
retrograde fashion beginning at the ileocecal valve. Concerns
for Crohn’s disease or Meckel’s diverticulum should be of
priority. In female patients, the reproductive organs should be
closely inspected. If purulent or bilious fluid is encountered, it
is imperative that the source be identified. For example, Val-
entino’s appendicitis, or a perforated duodenal ulcer presenting
as appendicitis, should be excluded in such cases. A medial
extension of the incision (Fowler-Weir) or superior extension
of the lateral incision is appropriate if further evaluation of the
lower abdomen or right colon is warranted. Selective laparos-
copy through a right lower quadrant incision has also been
described.89 If upper abdominal pathology is encountered, a
midline incision should be made.
Laparoscopic Appendectomy
The first reported laparoscopic appendectomy was performed
in 1983 by Semm; however, the laparoscopic approach did

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not come into widespread use until much later, following the
success of laparoscopic cholecystectomy. This may be due to
the small incision already commonly used with open appen-
dectomy.
Laparoscopic appendectomy is performed under general
anesthesia. An oro- or nasogastric tube and urinary catheter are
placed. The patient should be placed supine with his or her left
arm tucked and securely strapped to the operating table. Both
surgeon and assistant should be standing on the patient’s left
facing the appendix. The laparoscopic screens should be posi-
tioned on the patient’s right or at the foot of the bed. Standard
laparoscopic appendectomy typically uses three ports. Typi-
cally, a 10- or 12-mm port is placed at the umbilicus, whereas
two 5-mm ports are placed suprapubic and in the left lower
quadrant. The patient should be placed in Trendelenburg and
tilted to the left (Fig. 30-2).
The appendix should be identified similarly as in open sur-
gery by tracking the taenia libera/coli to the appendiceal base.
Through the suprapubic port, the appendix should be grasped
securely and elevated to the 10 o’clock position. An “appendi-
ceal critical view” should be obtained where the taenia libera
is at the 3 o’clock position, the terminal ileum at the 6 o’clock
Anesthesiologist
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position, and the retracted appendix at the 10 o’clock posi- 1253
tion to allow proper identification of the base of the appendix
(Fig. 30-3).90 Through the infraumbilical port, the mesentery
should be gently dissected from the base of the appendix and a
window created. Typically the base of the appendix is stapled,
followed by stapling of the mesentery. Alternatively, the mesen-
tery may be divided by an energy device or clipped and the base
of the appendix secured with an Endoloop. The stump should
be carefully examined to ensure hemostasis, complete transec-
tion, and ensure that no stump is left behind. The appendix is
removed through the infraumbilical trocar in a retrieval bag.
CHAPTER 30 The Appendix
Laparoscopic versus Open Appendectomy
There have been multiple prospective, randomized controlled
trials comparing laparoscopic and open appendectomy out-
comes. A number of meta-analyses have been performed evalu-
ating the cumulative outcomes (Table 30-7).91-99
Laparoscopic appendectomy is associated with fewer inci-
sional surgical site infections compared to open appendectomy.
However, laparoscopic appendectomy may be associated with
increased risk of intra-abdominal abscess compared to open
appendectomy. There is less pain, shorter length of stay, and
Assistant
Surgeon
Figure 30-2.  Operating room setup.
1254
PART II
UNIT II
SPECIFIC CONSIDERATIONS
Figure 30-3.  A and B. Appendiceal critical view.
quicker return to normal activity with laparoscopic appendec-
tomy when compared to open appendectomy. Laparoscopic
appendectomy is associated with increased operative duration
and increased operating rooms costs; however, overall costs are
likely similar when compared to open appendectomy. Patients
tend to have improved satisfaction scores with laparoscopic
appendectomy. Many of the differences, while statistically sig-
nificant, have nominal clinical difference, such as length of stay
where differences are measured in hours.91-99
In addition, laparoscopic appendectomy may provide a
benefit when the diagnosis is in question, such as in female
patients of reproductive age, older patients in whom malignancy
is suspected, and morbidly obese patients for whom larger open
appendectomy incisions may be required.
Laparoscopic Single-Incision Appendectomy
There has been growing interest in laparoscopic single-incision
appendectomy. Instead of two or three incisions, a single inci-
sion is made, typically periumbilical. The first published lapa-
roscopic-assisted, single-incision appendectomy was reported
by Inoue in 1994, where the appendix was identified laparo-
scopically and grasped and pulled through the laparoscopic
incision and the appendectomy completed in an open manner.
The first reports of a pure laparoscopic single-incision appen-
dectomy were described in 2009 by multiple surgical groups.
By this time, industry had designed multiple options for true
single-port access as opposed to makeshift single-incision
access.
With laparoscopic single-incision appendectomy, the
patient is prepared similarly to laparoscopic appendectomy.
Under general anesthesia, the patient is secured in a supine posi-
tion with the left arm tucked. The surgeon and assistant stand on
the left side facing the appendix and the screen. When perform-
ing laparoscopic single-incision appendectomy, the surgeon’s
hands perform the opposite function that they would normally
in standard laparoscopic surgery. The surgeon’s right hand will
grasp the appendix and retract it to the right lower quadrant at
the 10 o’clock position.90 The surgeon’s left hand will dissect
the mesenteric window and, upon identifying the appendiceal
critical view, staple across the base of the appendix and mesen-
tery. If the base of the appendix cannot be definitively identified
or the appendiceal critical view cannot be obtained, additional
ports can be placed to perform a “plus one” or even standard
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laparoscopic appendectomy. The appendix may be placed in a
retrieval bag or removed through the single incision.
There have been multiple small trials evaluating the effi-
cacy of laparoscopic single-incision appendectomy compared
to standard appendectomy; however, there has only been one
prospective randomized study (in the pediatric population) and
one meta-analysis. Gill and colleagues, in 2012, reviewed nine
studies for a total of 275 laparoscopic single-incision appen-
dectomies and 348 standard laparoscopic appendectomy proce-
dures. In this meta-analysis, there was no difference in operative
time (57 ± 10 vs. 55 ± 13 minutes), complications (11% vs.
8.3%), incisional surgical site infections (5.6% vs. 4.9%), intra-
abdominal abscesses (1.8% vs. 1.4%), or length of stay (3 ± 2
vs. 4 ± 1 days). Cases were converted to open or additional ports
were placed in 4% of laparoscopic single-incision appendecto-
mies and 0.9% of standard laparoscopic procedures. There was
no difference in return to bowel function, postoperative pain,
or return to normal activity. There was no difference in overall
cost. The incidence of hernia formation following the laparo-
scopic single-incision appendectomy procedure compared to
standard laparoscopy has not been reported.100
Although further study is needed, it appears that in lapa-
roscopic appendectomy, laparoscopic single-incision appendec-
tomy conveys no discernible advantage or disadvantage with
short-term outcomes. Late outcomes and patient quality-
8 of-life outcomes remain to be investigated.
Natural Orifice Transluminal Endoscopic
Surgery
Natural orifice transluminal endoscopic surgery (NOTES) is a
new surgical procedure using flexible endoscopes in the abdom-
inal cavity. In this procedure, access is gained by way of organs
that are reached through a natural, already-existing external
orifice. The hoped-for advantages associated with this method
include the reduction of postoperative wound pain, shorter con-
valescence, avoidance of wound infection and abdominal wall
hernias, and the absence of scars.
One hundred thirteen NOTES appendectomies in human
patients have been reported in the medical literature. Eighty-
seven were performed transvaginally, and 26 were performed
transgastrically.101 The vast majority of these cases are hybrid
procedures (NOTES plus laparoscopic assist port) with only
14 cases of pure NOTES appendectomies (three transvaginal
Table 30-7
Meta-analysis comparing laparoscopic versus open appendectomy outcomes

Author Summary
Wei Lui Li Markides Bennet Temple Garbutt Sauerland Golub
Year 2011 2010 2010 2010 2007 1999 1999 1998 1998
No. of studies 25 16 44 12 34 8 11 28 16
No. of patients LA 2220 1587 2609 NR 2064 730 2877 887
OA 2474 1674 2683 NR 2350 653 795
Total 4694 3261 5292 4414 1383 1375 1682
SSI LA (%) 3.8 2.8 9/9 favor LA
OA (%) 8.4 7.0 3/9 not SS
Odds Ratio∗ 0.51 0.45 0.43 0.52 0.40 –5.6 to –0.8 06.1 to –2.3
95% CI 0.36–0.73 0.34–0.59 0.34–0.55 0.39–0.70 0.24–0.59 –3.2 –4.2 0.19–0.47
Pooled effect 0.30–0.56
IAA LA (%) NR 2.0 3/8 LA = OA
OA (%) 0.94 7/8 not SS
Odds Ratio∗ 1.56 1.24 2.29 1.94
95% CI 0.93–2.14 1.01–2.43 0.84–1.84 1.48–3.53 0.98–5.58 –0.8 to 2.4 –0.4 to 2.3 0.88–6.64
Pooled effect 0.8 0.52
Pain Difference∗ –0.52 NR –0.7 NR –0.8 NR –1.19 –.05 NR 6/6 favor LA
1 not SS
LOS LA (days) 1.2 1.9 1.4 3.2 9/9 favor LA
OA (days) 1.8 3.0 2.0 3.8 3/9 not SS
Differencea –0.68 –0.82 –0.60 –1.10 –0.62 –0.16 –0.58 –15.0
Return activity LA (days) 8.0 NR 7.8 11.9 8/8 favor LA
OA (days) 12.5 10.0 19.0 1/8 not SS
Differencea –3.1 –6.9 –4.5 –2.2 –5.7 –5.5 –6.5 –7.1
Operative time LA (min) 24.0 30.0 25.0 69.8 9/9 favor OA
OA (min) 11.7 17.2 10.4 52.9
Differencea 10.7 7.6 12.35 12.8 14.6 18.1 16.8 15.7 16.2
Cost Difference a
11% NR NR NR NR NR NR NR –3% 1/3 favors LA
1/3 favors OA
1/3 LA = OA
2/3 not SS
Conversion rate NR NR NR NR NR 11% 11% 8% NR
a
Index is open.
IAA = intra-abdominal abscess (specifically organ/space surgical site infection); LA = laparoscopic appendectomy; LOS = length of stay; NR = not reported; OA = open appendectomy; SS = statistically significant;
SSI = surgical site infection (specifically superficial and deep).

CHAPTER 30 The Appendix

1255
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1256 and 11 transgastric). Although reported complication rates
appear low, conversion rates (to hybrid procedures) remain
high.
The main concern with NOTES has been complications
with closure of the enterotomy. To date, there is no reliable
method of closure of the gastrotomy site, and there has been
significant morbidity reported with this approach.
Although the transvaginal approach appears to be more
promising, in women surveyed on their perception of NOTES,
three-quarters were either neutral or unhappy about the pros-
pects of NOTES.102
Much work remains to demonstrate whether NOTES is
PART II
UNIT II
able to provide the theoretical benefits purported. Great care
must be taken to prevent significant morbidity or mortality en
route to studying these procedures.
SPECIFIC CONSIDERATIONS
SPECIAL CIRCUMSTANCES
Acute Appendicitis in the Young
The establishment of a diagnosis of acute appendicitis is more
difficult in young children than in the adult. The inability of
young children to give an accurate history, diagnostic delays
by both parents and physicians, and the frequency of gastro-
intestinal distress in children are all contributing factors to the
misdiagnosis and delay in diagnosis.103 In children, the physical
examination findings of maximal tenderness in the right lower
quadrant, the inability to walk or walking with a limp, and pain
with percussion, coughing, and hopping were found to have the
highest sensitivity for appendicitis.104
The more rapid progression to rupture and the inability of
the underdeveloped greater omentum to contain a rupture lead
to significant morbidity rates in children. Children <5 years of
age have a negative appendectomy rate of 25% and an appendi-
ceal perforation rate of 45%. These rates may be compared with
a negative appendectomy rate of <10% and a perforated appen-
dix rate of 20% in children 5 to 12 years of age.50,51 The inci-
dence of major complications after appendectomy in children
is correlated with appendiceal rupture. The wound infection
rate after the treatment of nonperforated appendicitis in chil-
dren is 2.8%, compared with a rate of 11% after the treatment
of perforated appendicitis. The incidence of intra-abdominal
abscess also is higher after the treatment of perforated appen-
dicitis than after nonperforated appendicitis (6% vs. 3%).105
The treatment regimen for perforated appendicitis generally
includes immediate appendectomy. Antibiotic coverage is lim-
ited to 24 to 48 hours in cases of nonperforated appendicitis.
For perforated appendicitis, intravenous antibiotics usually are
given until the white blood cell count is normal and the patient
is afebrile for 24 hours. Laparoscopic appendectomy has been
shown to be safe and effective for the treatment of appendicitis
in children.106
Acute Appendicitis in the Elderly
Compared with younger adults, elderly patients with appendi-
citis often pose a more difficult diagnostic problem because of
the atypical presentation, expanded differential diagnosis, and
communication difficulty. These factors may be responsible for
the disproportionately high perforation rate seen in the elderly.
In the general population, perforation rates range from 20% to
30%, compared with 50% to 70% in the elderly.107 In addition,
the perforation rate appears to increase with age greater than
80 years.108
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Elderly patients usually present with lower abdominal
pain, but on clinical examination, localized right lower quadrant
tenderness is not as common as in younger patients. A ­history
of periumbilical pain migrating to the right lower quadrant
is reported infrequently. Although currently there are no criteria
that definitively identify elderly patients with acute a­ ppendicitis
who are at risk of rupture, prioritization should be given to
patients with a temperature of greater than 38°C (100.4°F) and a
shift to the left in leukocyte count of more than 76%, especially
if they are male, are anorexic, or have had pain of long duration
before admission.65
As a result of increased comorbidities and an increased
rate of perforation, postoperative morbidity, mortality, and hos-
pital length of stay are increased in the elderly compared with
younger populations with appendicitis. Although no random-
ized trials have been conducted, it appears that elderly patients
benefit from a laparoscopic approach to treatment of appen-
dicitis. The use of laparoscopy in the elderly has significantly
increased in recent years. In general, laparoscopic appendec-
tomy offers elderly patients with appendicitis a shorter length
of hospital stay, a reduction in complication and mortality rates,
and a greater chance of discharge to home (independent of fur-
ther nursing care or rehabilitation).109
Acute Appendicitis during Pregnancy
Appendectomy for presumed appendicitis is the most common
surgical emergency during pregnancy. The incidence is approxi-
mately 1 in 766 births. Acute appendicitis can occur at any time
during pregnancy but is rare in the third trimester.110 The overall
negative appendectomy rate during pregnancy is approximately
25% and appears to be higher than the rate seen in nonpregnant
women.110,111 A higher rate of negative appendectomy is seen
in the second trimester, whereas the lowest rate is in the third
trimester. The diversity of clinical presentations and the diffi-
culty in making the diagnosis of acute appendicitis in pregnant
women are well established. This is particularly true in the late
second trimester and the third trimester, when many abdominal
symptoms may be considered pregnancy related. In addition,
during pregnancy, there are anatomic changes in the appendix
and increased abdominal laxity that may further complicate clini-
cal evaluation.
Appendicitis in pregnancy should be suspected when a
pregnant woman complains of abdominal pain of new onset.
The most consistent sign encountered in acute appendicitis dur-
ing pregnancy is pain in the right side of the abdomen. Sev-
enty-four percent of patients report pain located in the right
lower abdominal quadrant, with no difference between early
and late pregnancy. Only 57% of patients present with the clas-
sic history of diffuse periumbilical pain migrating to the right
lower quadrant. Laboratory evaluation is not helpful in estab-
lishing the diagnosis of acute appendicitis during pregnancy.
The physiologic leukocytosis of pregnancy has been defined as
high as 16,000 cells/mm3. In one series, only 38% of patients
with appendicitis had a white blood cell count of more than
16,000 cells/mm3.110 Recent data suggest that the incidence of
perforated or complex appendicitis is not increased in pregnant
patients.111
When the diagnosis is in doubt, abdominal ultrasound
may be beneficial. Another option is magnetic resonance
imaging, which has no known deleterious effects on the fetus.
The American College of Radiology recommends the use
of nonionizing radiation techniques for front-line imaging in
pregnant women.70 Laparoscopy has been advocated in equiv-
ocal cases, especially early in pregnancy; however, laparo-
scopic appendectomy may be associated with an increase in
pregnancy-related complications. In an analysis of outcomes
in California using administrative databases, laparoscopy was
found to be associated with a 2.31 times increased risk of fetal
loss compared with open surgery.111
The overall incidence of fetal loss after appendectomy
is 4%, and the risk of early delivery is 7%. Rates of fetal loss
are considerably higher in women with complicated appendici-
tis than in those with a negative appendectomy or with simple
appendicitis. It is important to note that a negative appendectomy
is not a benign procedure. Removing a normal appendix is associ-
ated with a 4% risk of fetal loss and 10% risk of early delivery.
9 Maternal mortality after appendectomy is extremely rare
(0.03%). Because the incidence of complicated appendix is simi-
lar in pregnant and nonpregnant women and because maternal
mortality is so low, it appears that the greatest opportunity to
improve fetal outcomes is by improving diagnostic accuracy and
reducing the rate of negative appendectomy.110-113
POSTOPERATIVE CARE AND COMPLICATIONS
Following uncomplicated appendectomy, complication rates are
low,114 and most patients can quickly be started on a diet and
discharged home the same day or the following day.115 Postop-
erative antibiotic therapy is unnecessary.116
Alternatively, with complicated appendectomy, compli-
cation rates are increased compared to uncomplicated appen-
dicitis.114 Patients should be continued on broad-spectrum
antibiotics for 4 to 7 days.117,118 Postoperative ileus may
10 occur, so diet should be started based on daily clinical
evaluation. These patients are at increased risk for surgical site
infections.
Surgical Site Infection
In patients with incisional (superficial or deep) surgical site
infection, treatment should be opening of the incision and
obtaining a culture. Following laparoscopic appendectomy,
the extraction port site is the most common site of surgical site
infection. Patients with cellulitis can be started on antibiotics.
The cultured organisms are typically bowel flora, as opposed to
skin flora.119
Patients with postoperative intra-abdominal abscesses can
present in a variety of ways. Although fever, leukocytosis, and
abdominal pain are common presentations, patients with ileus,
bowel obstruction, diarrhea, and tenesmus may also harbor intra-
abdominal abscesses. Small abscesses can be simply treated with
antibiotics; however, larger abscesses require drainage. Most
commonly, percutaneous drainage with CT or ultrasound guid-
ance is effective. For abscesses not amenable to percutaneous
drainage, laparoscopic abscess drainage is a viable option.
Stump Appendicitis
Incomplete appendectomy represents a failure of removing the
entire appendix on the initial procedure. A review of literature
has revealed only 60 reports of this phenomenon. Likely, incom-
plete appendectomy is underreported, and the true prevalence is
much higher. Reported as “stump appendicitis,” patients typi-
cally present with recurrent symptoms of appendicitis approxi-
mately 9 years after their initial surgery. There was no difference
in initial surgery between laparoscopic and open procedures.
However, there were more complicated appendectomies on
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initial surgery. Patients ­presenting with stump appendicitis are 1257
more likely to have complicated appendicitis, have an open pro-
cedure, and undergo colectomy.
The key to avoiding stump appendicitis is prevention.
Use of the “appendiceal critical view” (appendix placed at
10 o’clock, taenia coli/libera at 3 o’clock, and terminal ileum at
6 o’clock) and identification of where the taeniae coli merge and
disappear is paramount to identifying and ligating the base of
the appendix during the initial operation. The remaining stump
should be no longer than 0.5 cm, as stump appendicitis has only
been noted in stumps ≥0.5 cm in the literature.
CHAPTER 30 The Appendix
In patients who have had prior appendectomy, a low index
of suspicion is important to prevent delay in diagnosis and com-
plications. Prior appendectomy should not be an absolute crite-
rion in ruling out acute appendicitis.
INCIDENTAL APPENDECTOMY
Decisions regarding the efficacy of incidental appendectomy
should be based on the epidemiology of appendicitis. The best data
were published by the Centers for Disease Control and Prevention
based on the period from 1979 to 1984.120 During this period, an
average of 250,000 cases of appendicitis and 310,000 incidental
appendectomies occurred annually in the United States. It was esti-
mated that 36 incidental appendectomies had to be performed to
prevent one patient from developing appendicitis.121 In view of the
added costs and risk of morbidity for each extension of a surgical
intervention, this does not seem to justify incidental appendectomy.
The financial aspects of the decision to perform inciden-
tal appendectomy were assessed.122 For open appendectomy,
there was a financial disincentive to perform incidental appen-
dectomy. On an annual basis, $20,000,000 had to be spent to
save the $6,000,000 cost of appendicitis. With the laparoscopic
approach, it was cost-effective to perform incidental appen-
dectomy only in patients less than 25 years of age and only
if the reimbursement for surgeons was 10% of the usual and
customary charges. At a higher rate of reimbursement, inci-
dental appendectomy was not cost-effective in any age group.
Although incidental appendectomy is generally neither clini-
cally nor economically appropriate, there are some special patient
groups in whom it should be performed during laparotomy or
laparoscopy for other indications. These include children about to
undergo chemotherapy, the disabled who cannot describe symp-
toms or react normally to abdominal pain, patients with Crohn’s
disease in whom the cecum is free of macroscopic disease, and
individuals who are about to travel to remote places where
11 there is no access to medical or surgical care.123
Appendectomy is routinely carried out during the perfor-
mance of Ladd’s procedure for malrotation because displace-
ment of the cecum into the left upper quadrant would complicate
the diagnosis of subsequent appendicitis.
NEOPLASMS OF THE APPENDIX
Prevalence of Neoplasms
Multiple studies have evaluated the prevalence of mass lesions
present in appendectomy specimens (Table 30-8).124-132 The
prevalence of identifying a mass within the appendix is less than
1%. Appendiceal carcinoid and appendiceal adenomas are the
most common lesions identified. There is no clear age
12 relationship associated with the identification of these
masses.
1258 Table 30-8
Prevalence of malignancy associated with appendix specimens

Author No. Male Gender Age (mean) Age (range) Adenoma Carcinoid Other Overall
Ozer 2376 22 (81.5%) 26.7 NR NR 27 (1.13%) NR 27 (1.13%)
Lee 3744 NR NR NR 14 (0.35%) 9 (0.24%) 5 (0.12%) 28 (0.7%)
Sieren 141 6 (60%) 47 NR NR NR NR 10 (7.1%)
Debnath 1941 11 (69%) 41.8 NR NR 16 (0.82%) NR 16 (0.82%)
In’t Hof 1485 4 (57%) 32.7 20–59 NR 7 (0.47%) NR 7 (0.47%)
PART II
UNIT II

Smeenk 167,744 608 (41%) 61 7–93 NR NR NR 1482 (0.9%)

O’Donnel 2154 8 (36%) 30 14–83 NR 11 (0.5%) 11 (0.5%) 22 (1.02%)
Marudanayagam 2660 NR NR NR 16 (0.6%) 14 (0.52%) 10 (0.39%) 40 (1.50%)
Overall 184,118 30 (0.47%) 57 (0.54%) 26 (0.30%) 1558 (0.89%)
SPECIFIC CONSIDERATIONS

Laia 1873 11 (69%) 69 42–89 NR NR 16 (0.85%) 16 (0.85%)

Lai reported only the incidence of colon cancer presenting as appendicitis.
a

NR = not reported.

In older patients, the prevalence of identifying colon can-
cer appearing as appendicitis has been reported in a single study
with a prevalence of less than 1%. The mean age in this case
series was 69 years (range, 42 to 89 years).
Carcinoid
The finding of a firm, yellow, bulbar mass in the appendix
should raise the suspicion of an appendiceal carcinoid. The
appendix is the most common site of gastrointestinal carcinoid,
followed by the small bowel and rectum. Carcinoid syndrome is
rarely associated with appendiceal carcinoid unless widespread
metastases are present, which occur in 2.9% of cases. Symp-
toms attributable directly to the carcinoid are rare, although the
tumor can occasionally obstruct the appendiceal lumen much
like a fecalith and result in acute ­appendicitis.131,133,134
The majority of carcinoids are located in the tip of the
appendix. Malignant potential is related to size, with tumors
<1 cm rarely resulting in extension outside of the appendix
or adjacent to the mass. The mean tumor size for carcinoids is
2.5 cm.133 Carcinoid tumors usually present with localized dis-
ease (64%). Treatment for tumors ≤1 cm is appendectomy. For
tumors larger than 1 to 2 cm located at the base, involving the
mesentery, or with lymph node metastases, right hemicolectomy
is indicated. Despite these recommendations, surveillance, epi-
demiology, and end results data indicate that proper surgery for
carcinoids is not performed at least 28% of the time.133
Adenocarcinoma
Primary adenocarcinoma of the appendix is a rare neoplasm with
three major histologic subtypes: mucinous adenocarcinoma,
colonic adenocarcinoma, and adenocarcinoid.135 The most com-
mon mode of presentation for appendiceal carcinoma is that of
acute appendicitis. Patients also may present with ascites or a
palpable mass, or the neoplasm may be discovered during an
operative procedure for an unrelated cause. The recommended
treatment for all patients with adenocarcinoma of the appendix
is a formal right hemicolectomy. Appendiceal adenocarcinomas
have a propensity for early perforation, although they are not
clearly associated with a worsened prognosis.134 Overall 5-year
survival is 55% and varies with stage and grade. Patients with
appendiceal adenocarcinoma are at significant risk for both syn-
chronous and metachronous neoplasms, approximately half of
which will originate from the gastrointestinal tract.135
Mucocele
A mucocele of the appendix is an obstructive dilatation by
intraluminal accumulation of mucoid material. Mucoceles may
be caused by one of four processes: retention cysts, mucosal
hyperplasia, cystadenomas, and cystadenocarcinomas. The
clinical presentation of a mucocele is nonspecific, and often it
is an incidental finding at operation for acute appendicitis. An
intact mucocele presents no future risk for the patient; however,
the opposite is true if the mucocele has ruptured and epithelial
cells have escaped into the peritoneal cavity. As a result, when
a mucocele is visualized at the time of laparoscopic examina-
tion, conversion to open laparotomy is recommended. Conver-
sion from a laparoscopic approach to a laparotomy ensures that a
benign process will not be converted to a malignant one through
mucocele rupture. In addition, laparotomy allows for thorough
abdominal exploration to rule out the presence of mucoid fluid
accumulations.135
The presence of a mucocele of the appendix does not
mandate performance of a right hemicolectomy. The princi-
ples of surgery include resection of the appendix, wide resec-
tion of the mesoappendix to include all the appendiceal lymph
nodes, collection and cytologic examination of all intraperito-
neal mucus, and careful inspection of the base of the appendix.
Right hemicolectomy or, preferably, ileocecectomy is reserved
for patients with a positive margin at the base of the appen-
dix or positive periappendiceal lymph nodes. Recently, a more
aggressive approach to ruptured appendiceal neoplasms has
been advocated. This approach includes a thorough but mini-
mally aggressive approach at initial laparotomy, as described
earlier, with subsequent referral to a specialized center for con-
sideration of reexploration and hyperthermic intraperitoneal
chemotherapy.134
Pseudomyxoma Peritonei
Pseudomyxoma peritonei is a rare condition in which diffuse
collections of gelatinous fluid are associated with mucinous

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implants on peritoneal surfaces and omentum. Pseudomyxoma
is two to three times more common in females than in males.
Recent immunocytologic and molecular studies suggest that the
appendix is the site of origin for the overwhelming majority of
cases of pseudomyxoma. Pseudomyxoma is invariably caused
by neoplastic mucus-secreting cells within the peritoneum.
These cells may be difficult to classify as malignant because
they may be sparse, widely scattered, and have a low-grade
cytologic appearance. Patients with pseudomyxoma usually
present with abdominal pain, distention, or a mass. Primary
pseudomyxoma usually does not cause abdominal organ dys-
function. However, ureteral obstruction and obstruction of
venous return can be seen.136 Pseudomyxoma is a disease that
progresses slowly and in which recurrences may take years to
develop or become symptomatic.136 In a series from the Mayo
Clinic, 76% of patients developed recurrences within the abdo-
men.137 Lymph node metastasis and distant metastasis are
uncommon.
The use of imaging before surgery is advantageous to plan
surgery. CT scanning is the preferred imaging modality. At sur-
gery, a variable volume of mucinous ascites is found together
with tumor deposits involving the right hemidiaphragm, right
retrohepatic space, left paracolic gutter, ligament of Treitz, and
the ovaries in women. Peritoneal surfaces of the bowel are usu-
ally free of tumor. Thorough surgical debulking is the main-
stay of treatment. All gross disease and the omentum should be
removed. If not done previously, appendectomy is routinely per-
formed. Hysterectomy with bilateral salpingo-oophorectomy is
performed in women. Survival is better in patients who undergo
R0 or R1 resection than in patients who undergo R2 resection
(visible gross disease remaining).138 Because 5-year survival of
mucinous appendiceal neoplasms is only 30%, adjuvant intra-
peritoneal hyperthermic chemotherapy is advocated as a stan-
dard adjunct to radical cytoreductive surgery.139 ­Cytoreductive
surgery with intraperitoneal hyperthermic chemotherapy
is a long, tedious procedure with operative times of 300 to
1020 minutes reported. In addition, morbidity (38%) and mor-
tality (6%) are high. Cytoreductive surgery with intraperitoneal
hyperthermic chemotherapy is associated with a 5-year survival
rate of 53% to 78%. Survival is associated with initial patient
performance status.138-140
Any recurrence should be investigated completely. Recur-
rences are usually treated by additional surgery. It is important
to note that surgery for recurrent disease is usually difficult and
is associated with an increased incidence of enterotomies, anas-
tomotic leaks, and fistulas.136,137
Lymphoma
Lymphoma of the appendix is extremely uncommon. The gas-
trointestinal tract is the most frequently involved extranodal
site for non-Hodgkin’s lymphoma.141 Other types of appendi-
ceal lymphoma, such as Burkitt’s lymphoma, as well as leu-
kemia, have also been reported.142 Primary lymphoma of the
appendix accounts for 1% to 3% of gastrointestinal lymphomas.
Appendiceal lymphoma usually presents as acute appendicitis
and is rarely suspected preoperatively. Findings on CT scan
of an appendiceal diameter ≥2.5 cm or surrounding soft tissue
thickening should prompt suspicion of an appendiceal lym-
phoma. The management of appendiceal lymphoma confined
to the appendix is appendectomy. Right hemicolectomy is indi-
cated if tumor extends beyond the appendix onto the cecum or
mesentery. A postoperative staging workup is indicated before
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i­ nitiating adjuvant therapy. Adjuvant therapy is not indicated for 1259
lymphoma confined to the appendix.142,143
REFERENCES
Entries highlighted in bright blue are key references.
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