INTESTINAL SURGERY II

Acute appendicitis bowel’. Early accounts of an illness suggestive of appendicitis

were by Celsus and Galen in the 1st and 2nd century, it was
called a ‘colic passion’.3
Hannah Sellars The Italian anatomist Berengius Carpus in 1522 published the
Patricia Boorman first formal description of the appendix (referred to as the
‘additamentum’) but it was not until 1735 whilst operating on a
hernia, military surgeon Claudius Amyand documented the first
appendicectomy. Amyand’s hernia is now the eponymous name
Abstract
given to an inguinal hernia containing the appendix.
Appendicitis is defined as inflammation of the vermiform appendix, the
In 1880, British surgeon Lawson Tait performed the first
most common surgical emergency in children and young adults with
known successful appendicectomy for suspected appendicitis.
abdominal pain. The current standard of care for patients with appendi-
citis is the surgical appendicectomy, either laparoscopic or open. A non-
However the term appendicitis wasn’t coined until the American
Reginald Fitz published his landmark paper in 1886 ‘Perforating
operative strategy with antibiotics is favourable in some cases and
Inflammation of the Vermiform Appendix; With Special Refer-
emerging evidence suggests there could be wider applicability. Diag-
ence to Its Early Diagnosis and Treatment’.3
nosis is based on history, clinical examination and laboratory tests,
In 1894, American surgeon Charles McBurney proposed his
although 30e45% of patients exhibit atypical signs and symptoms on
original approach to the open appendicectomy. Aside from a
presentation. Where the diagnosis remains ambiguous, ultrasound
number of slight modifications, this became the standard
and CT scans are the most widely used imaging modalities. Diagnostic
approach for more than a century. The first laparoscopic ap-
laparoscopy can be a useful approach in low-risk patients, particularly
pendicectomy was performed in 1980 by the German gynaecol-
young women. Appendicitis is classified into simple or complex disease,
ogist Kurt Semm. By the late 1990’s the laparoscopic
complex in the presence of a peri-appendicular abscess, gangrene or
appendicectomy was commonplace alongside the laparoscopic
perforation. Complex appendicitis has significantly higher rates of
morbidity and mortality. Limiting the progression from simple to com-
cholecystectomy and remains so.
plex disease, although not inevitable, is the rationale for early definitive
treatment. An appendicectomy performed for suspected appendicitis Surgical anatomy
resulting in a normal appendix on histopathological examination is
referred to as a negative appendicectomy. A negative appendicectomy
The vermiform appendix is visible as it buds off from the caecum
has a postoperative complication rate of around 10%, demonstrating
around the 8th week of development in-utero. The appendicular
the need for both accurate and timely diagnosis.
lumen is narrow although in newborns and infants it is funnel
shaped, which may account for the rarity of appendicitis in this
Keywords Appendicectomy; appendicitis; appendicular; appendix;
age group. Similarly, in older adults the lumen may be obliter-
McBurney’s point; right iliac fossa pain
ated reducing the likelihood of appendicitis.
The base of the appendix is typically found 2.5 cm inferior to
the ileocaecal valve, where the three taenia coli (longitudinal
Introduction
ribbons of smooth muscle) converge on the surface of the
Appendicitis is defined as inflammation of the vermiform (worm- caecum at the posteromedial aspect. Following the taenia coli
shaped) appendix, a narrow blind ending pouch approximately intraoperatively is a useful strategy to help locate the appendix.
5e9 cm long opening off the caecum. Appendicitis is common; McBurney’s point represents the surface anatomy for the base
over 50,000 emergency appendicectomies are performed each of the appendix, a third of the distance along the line between
year in the UK. the anterior superior iliac spine (ASIS) and the umbilicus
Mortality associated with appendicitis in developed health- (Figure 1).
care settings is estimated between 0.05 and 0.25%; however, for The appendix is usually 5e9 cm in length but can range from
patients presenting with perforated appendicitis and generalized 2 cm to 25 cm. It is a relatively mobile structure and may lie in a
peritonitis mortality remains as high as 5%. Morbidity and number of orientations. This can affect the clinical presentation
mortality is increased in complex appendicitis, defined as of appendicitis as it irritates adjacent structures (Figure 2).
appendicitis in the presence of a peri-appendicular abscess, Although uncommon, the caecum may be aberrant through
gangrenous or perforated appendix.1,2 malrotation, situs inversus, adhesions or hypermobility and the
appendix found in any quadrant of the abdomen (and the chest).
Background The appendix receives its blood supply from the appendicular
artery, a branch of the ileocolic artery derived from the superior
The ancient Egyptians recognized the presence of the appendix
mesenteric artery. The artery travels in the lateral margin of the
during the mummification process, described as the ‘worm of the
mesoappendix, a triangular sheet of fatty connective tissue
continuous with the inferior part of the ileal mesentery
Hannah Sellars MBBS MRCS MSc is a Specialist Registrar in General (Figure 2).
Surgery at Dr Gray’s Hospital, Morayshire, UK. Conflicts of interest: Autonomic innervation of the appendix is via the ileocolic
none. branch of the superior mesenteric plexus. Proliferation of these
Patricia Boorman MBBCh FRCS MD is a Consultant Colorectal Surgeon appendicular nerve fibres and up regulation of neuropeptides has
at Royal Devon and Exeter Hospital, Devon, UK. Conflicts of interest: been proposed as a non-inflammatory cause of right iliac fossa
none. pain and called neurogenic appendicopathy.4

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 INTESTINAL SURGERY II

mucocele. Mucoceles are usually managed with surgical appen-

dicectomy due to the risk of underlying malignancy.
The appendix was long regarded as a vestigial structure of no
real function but recent work suggests this is not the case. Un-
like the colon it contains lymphoid tissue and specialized im-
mune cells that secrete immunoglobulins, antimicrobial
substances and sample antigens from the intestinal lumen. The
Umbilicus appendix appears to have a role in priming the immune
response to enteric pathogens in the colon and managing the
Anterior superior McBurney’s
iliac spine (ASIS) X normal bacterial flora.5 It is thought the appendix may act as a
point
reservoir for colonic bacteria (microbiome), promoting re-
Appendix colonization following infection with an individual’s normal
array of gut flora.

Epidemiology
Figure 1 McBurney’s point, the surface anatomy representing the The lifetime incidence for appendicitis is around 7e9% with a
base of the appendix slight male preponderance (1.4:1). It may present at any age but
is most prevalent between 10 and 30 years old. Risk factors for
appendicitis include exposure to smoke, repeated antibiotics,
inflammatory bowel disease, cystic fibrosis and a family history
of appendicitis. There is significant geographical and seasonal
variability; it is more prevalent in rural areas, regions associated
Terminal
with low fibre diets and during the summer months. Women are
Taenia coli
ileum more likely to undergo an appendicectomy but have higher rates
of negative appendicectomies due to the number of potentially
mimicking conditions.

Pre (anterior) Aetiology

or post (posterior)
ileal appendix The pathogenesis of acute appendicitis remains unclear.
Caecum
Mesoappendix Obstruction of the lumen by a faecolith (hard lump of obstructing
Retrocaecal faeces) or lymphoid tissue is thought to be the most common
appendix Appendicular cause. This results in distension of the appendix, bacterial
artery
overgrowth and infection, venous and lymphatic congestion,
Subcaecal Pelvic appendix
appendix
ulceration and transmural spread of infection through the
appendicular wall. The inflammation and infection may result in
thrombosis of blood vessels causing ischaemia, necrosis and
perforation. This proposed mechanism is challenged by research
Figure 2 Appendix with its mesoappendix containing the appendicular
artery in its lateral edge. The dotted lines depict a number of orienta- showing: acute appendicitis can occur in the presence of a patent
tions the appendix is found within the population (pelvic, subcaecal, lumen; faecoliths are equally as common in the population
retrocaecal, pre- and post-ileal) without appendicitis; and intra-luminal pressures are frequently
normal despite acute appendicitis.6
Faecoliths, lymphoid hyperplasia, foreign bodies, malignancy
The histological layers of the appendix are similar to that of (predominantly carcinoid and adenocarcinoma), parasitic and
the colon. The outer serosal layer is a thin peritoneal covering. A fungal infections, inflammatory bowel disease and trauma are
muscular layer, muscularis externa, consists of inner circumfer- recognized causes of appendicitis. The associated infection is
ential fibres and a thin external layer of longitudinal fibres. multiorganism; Escherichia coli, Bacteroides and Klebsiella are
Peristalsis of the appendix enables the expulsion of faeces from the most prevalent bacterium cultured. The growth of Fuso-
the lumen back into the caecum. bacterium appears to be associated with a particularly aggressive
The submucosa contains connective and lymphoid tissue, and process and perforated appendicitis.6 For patients presenting
hyperplasia of the lymphoid tissue typically in response to a viral with simple appendicitis, perforation is uncommon even if
illness is one mechanism thought to cause appendicitis. The treatment is delayed for a 24e36 hour period suggesting pro-
lymph tissue occludes the lumen of the appendix resulting in gression from simple to complex disease is variable.7
distension, bacterial overgrowth and infection. This is less likely Following perforation of the appendix intra-abdominal
in older adults as the lymphoid tissue starts to recede around contamination may be contained or generalized. The defect in
puberty. The innermost lining of the appendix is the mucosa. the appendix may seal itself off against adjacent structures
Mucin is secreted by goblet cells in the mucosa and forms mu- forming an abscess or inflammatory mass (phlegmon). If there is
cous. Prolonged occlusion of the appendicular lumen can result widespread contamination then generalized peritonitis and
in mucous accumulating in the distal portion forming a sepsis develops, a potentially fatal process.

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 INTESTINAL SURGERY II

Presentation may cause pelvic, groin or testicular pain and urinary symptoms. In
children further questions around peri-natal history, immunization
Most diagnoses are made based upon the history, clinical exami-
status and recent viral or bacterial illnesses are relevant.
nation and laboratory tests. In all cases there is no value in with-
holding analgesia for fear of concealing symptoms. Active
Physical examination
monitoring is a useful strategy in systemically well patients with
equivocal symptoms, serial examinations and blood tests performed Patients with appendicitis are classically flushed, dehydrated,
over a 24e48 hour period significantly improves sensitivity. Imag- sometimes ketotic and prefer to remain still. Physiological pa-
ing is mostly performed in the UK when there is diagnostic uncer- rameters may show a low-grade fever with tachycardia.
tainty and widely employed in children, young women and older Abdominal tenderness in the right iliac fossa and evidence of
adults. Particular vigilance is needed in high-risk groups, extremes localised peritonism such as involuntary guarding, rebound
of age, immunocompromised, morbidly obese, diabetic and preg- tenderness and percussion tenderness are indicative of appen-
nant patients. These groups are more likely to present with subtle dicitis. Other means of testing for peritonism in children include
and atypical signs in the presence of complex appendicitis. blowing out and sucking in the abdomen or hopping by the bed.
Diagnostic laparoscopy is an option usually reserved where In slim patients the appendix or an associated appendiceal mass
symptoms persist in patients considered low risk for surgery. It may be palpable. A number of eponymous tests exist (Table 2).
has the advantage of high sensitivity and specificity, particularly Testicular examination is essential in young males to look for
in young women and diagnoses such as endometriosis, pelvic testicular torsion. Pelvic and rectal examinations are not
inflammatory disease and adhesions. The history, examination routinely performed unless there is a suspicion of an alternative
and further tests are focused on discriminating between the likely diagnosis warranting examination. Ear, nose and throat exami-
differentials (Table 1). nation should be performed in younger children; concurrent or
recent upper respiratory tract infection and lymphadenopathy
Presenting history may suggest mesenteric adenitis.
Presentation with a ‘rigid abdomen’, i.e. diffuse abdominal
The primary symptom is abdominal pain, the classical history guarding, indicates generalized peritonitis and a perforated
one of vague peri-umbilical pain migrating to the right iliac fossa gastrointestinal tract. It may be associated with sepsis and shock
in the first 12e24 hours. Pain exacerbated on coughing and necessitating immediate resuscitation. A history of preceding
moving (or speed bumps) may indicate some degree of periton- right iliac fossa may raise the suspicion of a perforated appendix.
ism.8 Patients often describe anorexia, nausea, vomiting and less Other non-perforated causes of generalized peritonitis include
frequently constipation or diarrhoea. Low-grade pyrexia is pancreatitis, pelvic inflammatory disease and spontaneous bac-
common, less so a high grade pyrexia (>39 C) or rigors. terial peritonitis.
The history should establish the duration, pattern and char-
acteristics of pain and associated symptoms. Normal bowel Pregnancy
habits should be explored and any change, such as diarrhoea, Appendicitis is the most common non-obstetric surgical emer-
constipation, mucous and rectal bleeding. Night sweats, weight gency during pregnancy; there is an incidence of one presenta-
loss, lethargy and other systemic signs are also particularly tion in every 1500 pregnancies. Fetal loss associated with
helpful in distinguishing between a discrete acute episode and a appendicitis is around 1% up to 36% in the presence of perfo-
chronic or recurring process. ration with the greatest risk in the 1st trimester, maternal mor-
Lower urinary tract symptoms, menstrual and sexual history tality is very rare.9,10 There is almost twice the risk of fetal loss
assists in finding a genitourinary or gynaecological cause for the during or after a negative appendicectomy but preoperative
pain although an inflamed pelvic, subcaecal and post-ileal appendix diagnosis can be very challenging.

List of potential differential diagnoses based upon age and gender

Children Adults
General Male Female Elderly

Mesenteric adenitis Gastroenteritis Testicular torsion Pelvic inflammatory disease Colonic cancer
Gastroenteritis Gallstone disease Epididymo-orchitis Mittelschmerz pain Diverticulitis
Constipation Peptic ulcer Endometriosis Bowel obstruction
Pneumonia Right sided urinary tract disease/UTI Ectopic pregnancy Volvulus
Meckel’s diverticulum IBD/terminal iletis Ruptured/torted ovarian cyst Ischaemic colitis
Intussusception Bowel obstruction, adhesions Torted ovary Lymphoma
HenocheScho €nlein purpura Hernias Aortic/iliac Aneurysm
Porphyria, sickle cell Acute epiploic appendagitis
Rectus sheath haematoma
Porphyria, sickle cell

Table 1

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 INTESTINAL SURGERY II

diaphragmatic gas in a patient with upper abdominal peritonitis.

Description of a number of eponymous signs and An abdominal X-ray may show an appendicular faecolith but has
symptoms for appendicitis poor sensitivity and specificity. Women and children with equiv-
Test About ocal symptoms often undergo abdominal ultrasound, which has
reasonable sensitivity for appendicitis (44e88%) and useful for
McBurney’s sign Deep tenderness over McBurney’s point (1/3rd detecting tubo-ovarian and biliary disease. The limitations of ul-
distance from the anterior superior iliac spine trasound include operator dependence, abdominal pain restricting
to the umbilicus, Figure 1) the examination and views impaired by obesity and overlying
Rovsing’s sign Pain in the right iliac fossa on palpation or bowel gas.
percussion of the left iliac fossa indicating CT is highly sensitive and specific for appendicitis, up to 98%,
peritonism if positive but is disadvantaged by its dose of ionizing radiation. It is widely
Obturator sign Pain on internal rotation of right hip (may used in older adults where appendicitis is less common and
indicate inflammation of a pelvic appendix) alternative diagnoses such as malignancy, right-sided diverticu-
Psoas sign Pain on full extension of the right hip due to litis or ischaemic colitis should be considered and requires
the contraction of the psoas (may indicate different treatment. Obese and immunocompromised patients
inflammation of a retrocaecal appendix) and those with inflammatory bowel disease are also groups
Dunphy’s sign Increased pain in the right iliac fossa with where CT is often considered. MRI although a lower dose of ra-
coughing indicating peritonism if positive diation and being accurate in diagnosing appendicitis is rarely
used. Patients may not tolerate the longer duration of scan and
Table 2 enclosed space, it is a more costly imaging modality and there is
often limited accessibility.
The gravid uterus displaces the appendix upwards and it is
Management
frequently in the right upper quadrant during the later stages of
pregnancy. Laboratory tests may be confounded by physiological Patients with suspected appendicitis should be admitted and
leucocytosis. Imaging is often needed to assist diagnosis, usually managed with analgesia, anti-sickness, intravenous fluids and
an abdominal ultrasound scan in the first instance and if equiv- broad-spectrum antibiotics as indicated. Antibiotics are given
ocal magnetic resonance imaging (MRI) is preferred ahead of a just prior to surgery or immediately in the event of delays to
computed tomography (CT) scan to minimize the exposure to theatre or sepsis. Concern over Clostridium difficile infection and
ionizing radiation. The standard approach in pregnancy is the antibiotic resistance has led to increasingly restricted use of
open appendicectomy; there are concerns over higher rates of cephalosporins; the combination of amoxicillin, metronidazole
foetal loss with laparoscopy although the evidence is conflicting. and gentamicin is an alternative strategy. Perioperative care
should involve regular review of the appropriate level of care,
Other tests fluid status, infection and antibiotics, comorbidities and regular
medications and thromboprophylaxis. The minimization of
Urinalysis
indwelling catheters, early mobilization and nutrition may also
A pregnancy test is mandatory in fertile women as an ectopic
improve outcomes.
pregnancy may mimic appendicitis. Urinalysis and culture may
In simple appendicitis antibiotics are not required following
support a diagnosis of urinary tract infection or renal colic,
appendicectomy and the patient may go home the same day if
although detection of leucocytes and blood in the urine can
well recovered. If there is significant intra-abdominal contami-
result from bladder irritation due to an inflamed pelvic
nation antibiotics are usually continued intravenously for at least
appendix.
24e48 hours and a 5-day course completed. If the appendix ap-
Laboratory pears normal intraoperatively most UK surgeons will remove it if
A rise in inflammatory markers, both white blood count (pre- no other cause for the right iliac fossa pain is found; 30% of
dominantly neutrophilia) and CRP, are sensitive for appendicitis macroscopically normal looking appendixes show signs of
but not specific. The rise in inflammatory markers is not imme- inflammation on histopathological examination.12 This is not a
diate and patients particularly with a short duration of symptoms universal strategy. A negative appendicectomy is associated with
can have normal blood tests. Sequential blood tests over a 24- a complication rate of around 10%. It is not a completely benign
hour period, provides better diagnostic sensitivity.11 procedure and with limited evidence decision-making tends to be
at the surgeon’s discretion.
Scoring A non-operative strategy with antibiotics is favourable in
There are a number of diagnostic scores, although they are rarely some cases. It is most frequently considered in patients without
used in practice. The more widely known are the Alvarado score, generalized peritonitis or sepsis who have a significant operative
Paediatric Appendicitis score and Appendix Inflammatory risk, appendicular mass or active inflammatory bowel disease.
Response score (Table 3). Immediate surgery in these groups is associated with increased
morbidity and potentially avoidable ileocaecal resection. A
Imaging number of recent studies have compared antibiotics only to the
X-rays are typically done to exclude other differential diagnoses, a surgical appendicectomy as a first line treatment (predominantly
chest X-ray may also be performed to look for free sub- for simple appendicitis) with conflicting recommendations; at

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 INTESTINAL SURGERY II

The scoring methods for three well-known appendicitis scores estimating likelihood of having the disease; Alvarado
score, Paediatric Appendicitis score and Appendix Inflammatory Response score
Alvarado scale Score Paediatric appendicitis score Score Appendix Inflammatory Response Score

Migration of pain 1 Migration of pain 1

Anorexia 1 Anorexia 1
Nausea and/or vomiting 1 Nausea and/or vomiting 1 Vomiting 1
RIF tenderness 2 RIF tenderness 2 RIF tenderness 1
Rebound tenderness 1 Cough/percussion/hopping 2 Guarding/rebound tenderness 1 (light)
tenderness RIF 2 (medium)
3 (strong)
Pyrexia 1 Pyrexia 1 Pyrexia >38.5C 1
Raised white blood 2 (>10) Raised white blood count (109/L) 1 (10) Raised white blood count (109/L) 1 (10e14.9)
count (109/L) 2 (15.0)
Leukocytes left shift 1 Neutrophilia (109/L) 1 (>75%) Neutrophilia (109/L) 1 (70e84%)
2 (85%)
CRP (mg/L) 1 (10e49)
2 (50)
Appendicitis risk Total score Total score Total score
Low risk 0e4 0e5 0e4
High risk 7e10 6e10 9e12

Table 3

present the surgical appendicectomy remains the standard transverse in order to lie parallel with the skin crease for cosm-
treatment in the UK.6 esis and extension if necessary. Following dissection of the
Following a non-operative approach the appendix may be subcutaneous tissue down to the external oblique aponeurosis,
removed electively at a later stage once the infection has the aponeurosis is incised in line with its fibres. The internal
resolved, known as an interval appendicectomy. The interval oblique and transversalis muscles are split bluntly, again in the
appendicectomy has the advantage of obtaining histology, ma- direction of the fibres. Prior to opening, the transversalis fascia
lignancy is found in 0.9% of appendix specimens.13 Another and peritoneum are lifted using clips excluding any underlying
advantage is the prevention of recurrent appendicitis or devel- bowel.
oping chronic inflammation. Where an interval appendicectomy If there is gross contamination then the incision may need to
is not performed colonoscopy and CT scanning is indicated in be more extensive. In the case of a normal appendix a systematic
patients over 40 years of age. examination of the terminal ileum, pelvic organs and large bowel
should be performed. It may be necessary to convert to a midline
Procedure laparotomy to improve visualization and access.
A finger is used to identify the appendix, bluntly dividing any
Laparoscopic appendicectomy is now more common than an
adhesions. The taenia coli on the caecum can be traced to locate
open approach in the UK.1 It is a better diagnostic procedure and
the base of the appendix. Once mobile, the appendix and caecum
other advantages include earlier return to work and fewer sur-
can be delivered through the wound. The tip of the appendix may
gical site infections. The open appendicectomy is safe and re-
be difficult to mobilize, particularly with a retrocaecal appendix,
mains widely used, particularly in small children, pregnancy,
in which case a retrograde appendicectomy can be performed,
patients with severe cardiorespiratory disease unable to tolerate
tying off the base of the appendix and mesoappendix first then
the pneumoperitoneum or patients with multiple previous sur-
working distally to free the appendix.
geries where port access may be risky due to adhesions tethering
To remove the appendix a window is made in the meso-
bowel to the abdominal wall.
appendix adjacent to the base. Two clips are placed across the
Experimental approaches to the appendicectomy include sin-
base of the mesoappendix, which is then divided and Vicryl ties
gle incision laparoscopic appendicectomy (SILA) and natural
applied to ligate the vessels (contains appendicular artery).
orifice transluminal endoscopic surgery (NOTES) performed by
Haemostasis is checked following removal of the clips. The
trans-vaginal or trans-gastric routes but neither have demon-
base of the appendix is crushed with a heavy clip then released
strated superiority so far and involve increased complexity.
and placed 1 cm higher. The appendix is transfixed at the
Open appendicectomy crushed base and divided just above. Burying the appendicular
The patient is prepared supine. Palpating the abdomen under stump using a purse-string suture is still common but the evi-
anaesthesia can be helpful, sometimes revealing an appendicular dence suggests this does not provide any additional benefit.14
mass or localizing the caecum to guide the incision. The Lanz Neither does leaving a drain unless there is a significant ab-
incision is performed over McBurney’s point but relatively scess cavity. In the presence of free fluid most surgeons will

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 INTESTINAL SURGERY II

perform an intra-peritoneal washout with warm saline and the particularly the appendicular artery can be cauterized or clipped
wound is closed in layers. when encountered. When the mesoappendix is dissected off at
the base of the appendix an endoloop (loop of suture with a pre-
Laparoscopic appendectomy tied knot) is placed over the tip and tightened at the appendix
The patient is prepared supine, the surgeon and assistant typi- base. A second is positioned just above the first, allowing enough
cally stand on the left side of the patient with the stack including space between the loops to divide the appendix; alternatively
the screen on the opposite side. Ports are commonly placed using stapling devices can be used.
the Hassan technique, emptying the bladder reduces the risk of To limit contamination, the appendix is placed in a retrieval
injury during placement. A supra- or infra-umbilical incision is bag prior to removal through the umbilical 10 mm port and
made and the umbilical stalk traced down to the fascia (linea washout performed if there is contamination. Intraperitoneal gas
alba). At the stalk fascial junction the peritoneum is tethered, a should be allowed to escape from the abdomen as it contributes
superficial incision is made and a blunt instrument is gently to shoulder tip pain on emergence from anaesthetic. At the um-
pushed through the peritoneum. A 10 mm port is inserted and bilicus the fascia is usually closed with a J-stitch to reduce the
the pneumoperitoneum is established at 12 mmHg. Additional risk of port site hernias prior to skin closure.
ports are introduced; a common approach is 5 mm ports supra-
pubically and in the left iliac fossa allowing triangulation of the Outcomes
instruments to manipulate the appendix (Figure 3). They are
placed under direct vision to avoid injury to the viscera and Postoperative complications occur in approximately 12e13% of
epigastric vessels. cases. Surgical site infection is the most common complica-
Examination of the abdominal cavity is performed to confirm tion, occurring in approximately 3.5% of appendicectomies.
the diagnosis. The appendix is then mobilized and manipulated Increasing abdominal or pelvic pain, intermittent pyrexia and
with an atraumatic grasper, tilting the table head and left side diarrhoea should raise suspicion of an intra-abdominal abscess,
down can assist in removing small bowel from the right iliac occurring in 3% of appendicectomies.15 Ultrasound or CT scans
fossa isolating the appendix. Dissection of the mesoappendix are used to detect postoperative collections and they are most
from the appendix is performed using diathermy, vessels frequently found in the pelvis or subphrenic space. Depending on
size and location they may be treated with intravenous antibi-
otics alone or in combination with percutaneous drainage under
radiological guidance or surgical drainage.
Less frequent complications include bleeding, ileus, iatrogenic
bowel or bladder injury, incisional or port site hernias and ad-
hesions causing small bowel obstruction. Rare complications
include stump appendicitis, the inflammation of a long residual
appendicular stump that has been left in situ following appen-
dicectomy. Another is a faecal fistula, it occurs when the stump
reopens resulting in the leakage of faecal material which dis-
charges through the wound. Most faecal fistulae will resolve with
non-operative management.

Conclusion
The classic case is an adolescent or young adult diagnosed based
on a typical history, examination and laboratory findings. The
mainstay of treatment is either laparoscopic or open appendi-
cectomy. In reality appendicitis can be a challenge to diagnose
and manage. Appreciating this and maintaining a level of sus-
picion is crucial, particularly for those atypical groups at risk of
poor outcomes. A

REFERENCES
1 van Rossem CC, Bolmers MDM, Schreinemacher MHF, et al.
Diagnosing acute appendicitis: surgery or imaging? Colorectal Dis
2016; 18: 1129e32.
2 Faiz O, Clark J, Brown T, et al. Traditional and laparoscopic ap-
pendectomy in adults. Outcomes in English NHS hospitals be-
tween 1996 and 2006. Ann Surg 2008; 248: 800e6.
3 McCarty AC. History of appendicitis vermiformis its diseases and
treatment. University of Louisville 1927. Presented to the Innom-
Figure 3 Common laparoscopic set up and port site placement for an inate Society. www.innominatesociety.com/Articles/History%20of
appendicectomy %20Appendicitis.htm.

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 INTESTINAL SURGERY II

4 Machado NN, Machado NO. Neurogenic appendicopathy: a histor- pregnant and nonpregnant women. Obstet Gynecol 2011; 118:
ical and contemporary review. World J Colorectal Surg 2014; 4. Art 1. 1261e70.
5 Kooij IA, Sahami S, Meijer SL, et al. The immunology of the ver- 11 Thompson MM, Underwood MJ, Dookeran KA, et al. Role of
miform appendix: a review of the literature. Clin Exp Immunol sequential leucocyte counts and C-reactive protein measure-
2016; 186: 1e9. ments in acute appendicitis. Br J Surg 1992; 79: 822e4.
6 Bhangu A, Søreide K, Di Saverio S, et al. Acute appendicitis: 12 Strong S, Blencowe N, Bhangu A. National Surgical Research
modern understanding of pathogenesis, diagnosis, and manage- Collaborative. How good are surgeons at identifying appendicitis?
ment. Lancet 2015; 386: 1278e87. Results from a multi-centre cohort study. Int J Surg 2015; 15:
7 Drake F, Mottey NE, Farrokhi ET, et al. Time to appendectomy and 107e12.
risk of perforation in acute appendicitis. JAMA Surg 2014; 149: 13 Connor SJ, Hanna GB, Frizelle FA. Appendiceal tumors: retro-
837e44. spective clinicopathologic analysis of appendiceal tumors from
8 Ashdown H, D’Souza N, Karim D, et al. Pain over speed bumps in 7,970 appendectomies. Dis Colon Rectum 1998; 41: 75e80.
diagnosis of acute appendicitis: diagnostic accuracy study. BMJ 14 Blake L, Som R. Best evidence topic: what is the best manage-
2012; 345: e8012. ment of the appendix-stump in acute appendicitis: simple ligation
9 Abbasi N, Patenaude V, Abenhaim H. Management and outcomes or stump invagination? Int J Surg 2015; 24: 20e3.
of acute appendicitis in pregnancy-population-based study of 15 Bhangu A, Richardson C, Torrance A, et al. National Surgical
over 7000 cases. BJOG 2014; 121: 1509e14. Research Collaborative. Multicentre observational study of per-
10 Silvestri M, Pettker C, Brousseau E, Dick M, Ciarleglio M, formance variation in provision and outcome of emergency ap-
Erekson E. Morbidity of appendectomy and cholecystectomy in pendicectomy. Br J Surg 2013; 100: 1240e52.

SURGERY --:- 7 Ó 2017 Published by Elsevier Ltd.

Please cite this article in press as: Sellars H, Boorman P, Acute appendicitis, Surgery (2017), http://dx.doi.org/10.1016/j.mpsur.2017.06.002