INTESTINAL SURGERY II

Acute appendicitis The appendix

The vermiform appendix is a short, blind-ended outpouching
from the caecum. It is histologically similar to the neighbouring
Frances Dixon
large bowel, with an outer serosal layer of peritoneum, a
Anjana Singh muscular layer, and an inner mucosal layer with multiple mucin-
secreting goblet cells. However, there is also a large amount of
lymphoid tissue within the submucosa, which can become
Abstract inflamed in response to infection. The location of the appendix
Acute appendicitis is inflammation of the vermiform appendix. It is the base at the convergence of the taenia coli is anatomically
commonest general surgical emergency in children and young adults, consistent, but the rest of the appendix can be located anywhere
yet its diagnosis can still confound even the most skilled surgeon due from the pelvis to behind the caecum or ileum (Figure 1). The
to its highly variable presentation of appendicitis, with fewer than 50% length of the appendix is usually 7e10 cm but can be up to
of patients exhibiting classical features. Taking a detailed history and 26 cm. Blood supply is via the appendicular artery, which lies
performing a careful examination remains the cornerstone of diag- within the free edge of the mesoappendix terminating at the tip of
nosis. Urinalysis and blood tests, particularly C-reactive protein, are the appendix and is a branch of the ileocolic artery which in turn
useful adjuncts and are performed routinely. Radiological imaging, is a branch of the superior mesenteric artery. The appendix is
commonly ultrasound and computed tomography scans, also have a visible from the 8th week in-utero and is part of the midgut.
role when the diagnosis is unclear and/or other common conditions During embryological development the midgut rotates counter-
need to be excluded, such as gynaecological pathology in young fe- clockwise, leading to the final position of the caecum and ap-
males. Nevertheless 20% of appendices removed in UK are histolog- pendix in the right iliac fossa. Intestinal malrotation can cause
ically normal. Appendicitis scoring systems may further assist in the appendix to be located near the gallbladder in the right upper
stratifying risk and increasing the accuracy of diagnosis. Recently, quadrant, or even in the left upper quadrant. Very rarely there
there has been growing interest in non-surgical management of may be congenital absence of the appendix.
appendicitis, particularly during the COVID-19 pandemic. Antibiotics It was widely thought that the appendix is a vestigial organ with
alone have been used to successfully treat uncomplicated appendi- no useful function, but there is increasing evidence that it may play
citis (without perforation, abscess or gangrene) in the short-term, how- an important role in the immune modulation of the gut.1 It is
ever nearly 40% of these cases eventually require appendicectomy. postulated that it acts as a reservoir for beneficial bacteria and aids
Surgery, usually laparoscopic appendicectomy, remains the treatment re-colonization of the rest of the gut, e.g. after a diarrhoeal illness
of choice for acute appendicitis and non-operative management is such as Clostridium difficile infection. Interestingly, appendicec-
reserved for specific cases. tomy prior to diagnosis of ulcerative colitis can decrease the risk of
Keywords Appendicitis; appendicectomy; laparoscopy; negative requiring a colectomy, although potentially carries an increased
appendicectomy; right iliac fossa pain risk of colorectal cancer in this patient population.2
Appendicitis is defined as inflammation of the appendix and is
thought to usually occur due to obstruction of the lumen causing
local infection, which is unable to drain from the appendix due to
Introduction the blind-ending nature of the organ. Subsequent swelling can
Appendicitis is the most common general surgical emergency then lead to local ischaemia, necrosis, bacterial translocation, and
worldwide and is a cause of significant morbidity and mortality, potentially perforation with the development of a contained ab-
particularly in the developing world. Its presentation and man- scess or generalized peritonitis. Obstruction is most commonly
agement is not always straightforward. The signs and symptoms due to a calcified faecolith but may also be related to hyperplasia
are often non-specific and can mimic other pathology which adds of the lymphoid tissue (usually in response to viral infection),
to the complexity and challenges of making the correct diagnosis. neoplasia, parasitic infections such as worms, or even foreign
With the aid of imaging, scoring systems and a broader range of bodies. Chronic occlusion can lead to a swelling containing mucin,
treatment options, contemporary management of appendicitis is termed mucocoele of the appendix, which requires removal due to
becoming more sophisticated and precise. In this article we the small risk of underlying malignancy. Appendicitis can also
examine the background, investigations, options for treatment occur in the absence of any luminal obstruction and the reasons
and areas of controversy in the current management of acute for this are as yet unclear. Theories include genetic predisposition,
appendicitis. environmental triggers and various infective agents.

History
The appendix is named ‘vermiform’ after the Latin for “worm-
Frances Dixon MBBS BSc MRCS is a Surgical Research Fellow at like”, based on its appearance. The nomenclature is credited to
Milton Keynes University Hospital & Registrar in the Thames Valley Andreas Vesalius in 1543. The appendix also appears in 16th
Deanery, UK. Conflicts of interest: none declared. century anatomical drawings by da Vinci and Eustachius.
The first published description of acute appendicitis was in 1886
Anjana Singh BSC MRCS MD FRCS is a Consultant Laparoscopic
General and Colorectal Surgeon at Milton Keynes Hospital University by Reginald Heber Fitz, a Harvard pathologist who introduced the
Foundation Trust, Milton Keynes, UK. Conflicts of interest: none term ‘appendicitis’. However, the very first documented appen-
declared. dicectomy took place earlier in 1735 in France, performed by

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 INTESTINAL SURGERY II

visceral sensory fibres with referral to the T10 dermatome, at the

level of the umbilicus. As the inflammation worsens, local peri-
toneal irritation occurs in the RIF and somatic sensory nerve fi-
bres are stimulated, leading to radiation of pain to the right lower
quadrant. This pain tends to be constant, rather than the initial
intermittent, colicky central abdominal pain. However, the
numerous anatomical locations of the appendix mean that the
presenting symptoms can vary greatly. The retro-caecal appendix
is unlikely to directly irritate the peritoneum and patients may
complain of right loin tenderness. Similarly, a pelvic appendix
may cause groin pain or urinary symptoms including haematuria
or dysuria. A retro-ileal appendix can be challenging to diagnose
as the pain can be very difficult to localize and diarrhoea may
feature heavily. The National Institute for Health and Care
Excellence (NICE) suggest that the classic symptoms of appen-
dicitis may only be present in 50% of cases.
A thorough pain history including radiation, duration and
Figure 1 exacerbating factors is essential. Increased pain on passing over
speed bumps during the journey to hospital, likely due to exac-
erbation of local peritoneal irritation, has good sensitivity,
Claudius Amyand for a patient with a perforated appendix within though not specificity, for appendicitis.5 Pain on walking or
the sac of an inguinal hernia (Amyand’s hernia). British surgeon coughing is also similarly indicative.
Lawson Tait performed the first documented appendicectomy for Appendicitis is often associated with low-grade pyrexia but
acute appendicitis in 1880. The technique was subsequently presence of a high fever may suggest perforation and widespread
refined by Charles McBurney, who also described McBurney’s peritonitis. Anorexia is very common, sometimes alongside
point e two-thirds of the way from the umbilicus to the anterior nausea and vomiting. A full menstrual and sexual history should
superior iliac spine e theoretically the point of maximal tender- be taken in women to assess for the possibility of an underlying
ness in acute appendicitis. In the late 20th century, laparoscopic gynaecological cause for the pain. Family history of bowel dis-
surgery started increasing in its use, and in 1980 the first laparo- orders such as cancer or inflammatory bowel disease is impor-
scopic appendicectomy was performed by a German gynaecologist tant. Many symptoms are non-specific and it is important to
called Kurt Semm. This is now the standard approach for adult perform a full systems enquiry to distinguish appendicitis from
appendicectomy worldwide. other differential diagnoses (Table 1).

Epidemiology
Examination
The lifetime risk of appendicitis is approximately 7%, with
General examination may reveal flushed cheeks, coated tongue
around 35,000 appendicectomies being performed per year in the
and foetor. Patients with acute appendicitis prefer to lie still;
UK. The incidence of appendicitis is highest in older children and
children may lie with one or both hips flexed. Very young chil-
young adults, but can theoretically present at any age, with a
dren may need to be examined in their mother’s lap initially to
male to female ratio of 1.4:1. Young children tend to have a
build rapport. Palpation at McBurney’s point will elicit tender-
wider, funnel-shaped appendix, which reduces the likelihood of
ness and guarding. Rebound tenderness can be elicited by gently
occlusion and therefore of developing appendicitis. In older
tapping over the area. However, this can be distressing for chil-
people the lumen is often obliterated, with similar effect.
dren, and methods such as rocking the child’s abdomen from
Appendicitis is a global problem but there is a wide variance in
side to side while they are lying down or asking them distend and
incidence between countries, with an increase in incidence being
‘suck in’ their abdomen or to jump up and down by the bed are
recorded in newly industrialized nations. It has been hypothe-
alternative ways to assess local peritonism.
sized that a low dietary fibre intake predisposes to appendicitis,
Findings of a rigid abdomen on examination, i.e. generalized
which may explain the higher incidence in Western countries.
guarding, in the context of a typical history, indicates diffuse
Global incidence tends to be lower in winter as opposed to
peritonitis due to a perforated appendix. The appendix is perfo-
summer, for unknown reasons.3
rated in approximately 20% of patients at presentation.6 There
Mortality from acute appendicitis in developed countries is
may be associated septic shock. Other diagnoses such as
low, at 0.3%, but rises significantly to 1.7% after perforation and
pancreatitis, perforated cancer and gynaecological pathology
up to 5% following generalized peritonitis, demonstrating the
should be considered depending on patient characteristics.
importance of early diagnosis and treatment.4
Examination may reveal a palpable RIF mass, indicating an
appendiceal mass or an underlying bowel cancer, both warrant
Presentation
further investigation. Other unusual presentations of appendiceal
The typical symptom of appendicitis is gradual onset of central perforation include retroperitoneal abscess formation, liver ab-
abdominal pain which then localizes to the right iliac fossa (RIF) scess from spread of infection through the portal-venous system,
after around 24 hours. The pain is initially transmitted by entero-cutaneous fistula from abscess fistulizing to the skin,

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 INTESTINAL SURGERY II

Differential diagnoses of right iliac fossa pain according to different patient groups
Child Adult Additional considerations in females

Gastroenteritis Ureteric colic Gynaecological

Mesenteric adenitis Gastroenteritis C Ectopic pregnancy
Meckel’s diverticulitis Testicular torsion C Pelvic inflammatory disease
Intussusception Visceral perforation, e.g. peptic ulcer C Torsion/rupture of ovarian cyst
Testicular torsion Pancreatitis C Endometriosis
Diabetic ketoacidosis Inflammatory bowel disease C Mittelschmerz
Urinary tract infection Caecal diverticulitis Obstetric
Pneumonia Torted epiploic appendage C Round ligament syndrome
Sickle cell crisis Rectus sheath haematoma C Pyelonephritis
HenocheScho €nlein purpura Non-specific abdominal pain Older adults
Pneumonia Intestinal obstruction
Colon cancer
Diverticulitis
Mesenteric infarction
Leaking aortic aneurysm

Table 1

small bowel obstruction and even pylephlebitis (septic portal Blood tests including inflammatory markers and a group &
vein thrombosis) which can mimic cholangitis. screen should be taken. Normal inflammatory markers have a
There are several specific tests for appendicitis which can be good negative predictive value and serial tests improve diagnostic
worthwhile adjuncts to an abdominal examination: sensitivity. Blood amylase can rule out pancreatitis.
Ultrasound (US) is often used as first line imaging for those in
 Rovsing’s sign e palpation in the left iliac fossa causes whom the clinical signs are equivocal or alternative pathology is
pain in the RIF, due to stretching of irritated peritoneum suspected. It has the advantages of being safe and non-invasive,
 Cope’s obturator sign e flexion and internal rotation of the with no ionizing radiation exposure.7 However, it is operator
hip causes pain due to local irritation of the obturator dependent and the appendix may not be visualized due to
muscle by an inflamed pelvic appendix overlying bowel gas, making the scan non-diagnostic. Generally
 Iliopsoas sign e flexion of the thigh against resistance better views are obtained in children due to their smaller size and
causes pain due to inflammation of the psoas muscle. it can often be diagnostic. Positive US findings for appendicitis
include non-compressibility, peri-appendiceal fluid, and wall
A genital examination should always be performed in males to thickening.
exclude testicular torsion or a hernia, which can cause referred Computed tomography scanning (CT) is more diagnostically
pain to the abdomen. Digital rectal examination is sometimes accurate than US, but involves exposure to a high dose of radi-
recommended in adults if an alternative diagnosis such as bowel ation. One study showed that a single abdominal CT with
obstruction is suspected, but not in children. contrast is equivalent to 234 chest X-rays, and a 20-year old fe-
Mesenteric adenitis is an important differential diagnosis for male who undergoes an abdominal CT scan has a 1 in 470 chance
RIF pain in children and an alternative source of infection must of developing a cancer related to this scan.8 In adults over 40
be ruled out. To this end, the cervical lymph nodes, respiratory years with RIF pain, a CT scan is important to rule out an
system, ears, nose and throat must be examined. Presence of obstructing cancer or alternative diagnoses such as diverticulitis.
pathology does not rule out appendicitis but it may suggest a Routine CT scanning is used in the United States and many
more cautious approach such as serial assessment. countries in mainland Europe, but its use in the UK is limited. CT
with dose reduction may be considered in children but is
Investigation reserved for difficult cases and seldom accessible. Positive find-
A young man with typical symptoms and signs for appendicitis ings of appendicitis on CT include enlarged appendiceal diameter
can proceed straight to surgery after simple routine tests. How- (>6 mm), wall thickening (>2 mm), peri-appendiceal fat
ever, there are several groups in whom diagnosis can be complex stranding and mural hyper-enhancement.
and further investigations are required. Magnetic resonance imaging is less widely available than CT,
Routine bedside tests include urinalysis and pregnancy particularly out of hours, but lack of ionizing radiation makes it a
testing. Presence of leucocytes on urinalysis may indicate useful imaging modality in pregnant and paediatric patients.
inflammation of a pelvic appendix, or an alternative diagnosis
Scoring systems
such as a urinary tract infection. In females of childbearing age,
urinary b-human chorionic gonadotrophin levels must be There are as many as 26 scoring systems and risk prediction
checked to rule out an ectopic pregnancy. models for appendicitis but the evidence for their accuracy is

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 INTESTINAL SURGERY II

limited. They often use a combination of clinical signs, safety-netting. They should be reviewed the following day in an
biochemical markers, and imaging findings. The most widely ambulatory clinic, either for imaging such as US or for serial
used is the Alvarado score, which was initially designed for use examination and repeat blood tests. This “active observation”
in pregnant women but has been extensively validated for the approach is recommended by the Royal College of Surgeons of
general population. A further example is the Appendicitis In- England (RCS) for suitable patients, and is also supported by the
flammatory Response score, which places a larger emphasis on National Institute for Health & Care Excellence (NICE).7
biochemical markers (Table 2). A recent study of UK patients There is emerging interest in determining whether antibiotics
presenting with RIF pain identified the Adult Appendicitis Score alone are an appropriate alternative treatment for uncomplicated
as having the best negative predictive value for identifying those appendicitis. The regimen typically involves intravenous antibi-
at low risk of having appendicitis.9 otics administered for 1e3 days followed by oral antibiotics for
up to 10 days with prompt surgical intervention in case of clinical
deterioration. Antibiotics alone are reported to be successful in
Management
treating 44%e85% of patients in the short-term, with a lower
Patients with a diagnosis of acute appendicitis should be complications rate than the surgical group.4 However, there was
admitted and receive analgesia, appropriate fluid resuscitation a 20% readmission rate and all eventually required appendi-
and intravenous antibiotics whilst awaiting surgery. The time to cectomy. A meta-analysis from 2019 showed no difference in
progression from acute appendicitis to perforation is variable. A length of stay or complication-free treatment between the anti-
short in-hospital delay of 12e24 hours prior to surgery does not biotic and appendicectomy group.10 Absence from work was
appear to increase the risk of perforation. However, patients shorter in the former, but again, a significant proportion (37.4%)
should be monitored for signs of sepsis as systemic infection can required appendicectomy within one year following conservative
quickly become life-threatening if not treated promptly. Delay management. There are also concerns regarding missed neo-
beyond 48 hours increases risk of surgical site infections and plasms. The need for ‘rescue appendicectomy’ was elegantly
other complications.7 For unstable patients with generalized demonstrated by the famous case of Leonid Rogozov, the sole
peritonitis, immediate resuscitation followed by emergency ap- physician posted to an Antarctic base. He developed appendicitis
pendicectomy is required. that was unresponsive to antibiotics, and eventually ended up
In equivocal cases, in the absence of sepsis, antibiotics should removing his own appendix with the help of a mirror and 2
not be administered as they may mask diagnosis by partial untrained assistants (Figure 2). Current NICE as well as Euro-
treatment of any intra-abdominal pathology. Also if the symp- pean and American guidance continues to advocate appendi-
toms resolve, it is unclear whether this is attributable to the cectomy as the treatment of choice for uncomplicated
antibiotics or due to natural improvement of the underlying appendicitis.7 Patients who elect for non-surgical management
condition. In these cases, a “watch & wait” policy can be must be clearly counselled on the risks and benefits. This is an
employed. If the patient is systemically well and has a good area of ongoing research and controversy but may be useful for
support system at home, they may be suitable for ambulatory patients who are high risk for surgery, e.g. those with multiple
management, and can often be discharged with appropriate comorbidities, or for situations when surgery is unavailable.

Three widely known and validated appendicitis scoring systems and their scoring methods
Alvaradob Appendicitis Inflammatory Response Scoreb Adult Appendicitis Score

Symptoms Gender 1
Time from onset 1
Anorexia 1
Nausea/vomiting 1 1
RIF pain 1 2
Migratory pain 1 2
Signs RIF tenderness 2 2e4
Guarding/rebound 1 1e3 2e4
Vitals Pyrexia 1 1
Bloods White cell count (x 109) 2 1e2 (>15)a 1e3 (>14)a
Proportion of neutrophils (%) 1 1e2 (>85%)a 2e4 (>83)a
CRP (mg/l) 1e2 (>50)a 1e5 (25e83)a
CRP (mg/ml) (symptoms >24 h) 1e2 (12e152)a
Appendicitis risk Low risk (total score) 0e4 0e4 0e10
High risk (total score) 7e10 9e12 >16

CRP, C-reactive protein; RIF, right iliac fossa.

a
Numbers in brackets indicate values required to achieve the highest score.
b
Score can be used in children or adults with suspected appendicitis.

Table 2

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 INTESTINAL SURGERY II

During the COVID-19 pandemic the use of conservative treat- histology, and non-removal could lead to non-resolution of
ment with antibiotics increased in both adults and children with symptoms13 and in the case of open appendicectomy, cause
appendicitis worldwide, likely as part of the global trend to reduce confusion due to the presence of an appendicectomy scar.
surgery and reserve hospital space for those with COVID.11 Inter- All appendiceal specimens should be sent for histology as
estingly, there was a reduction in the number of adult appendicitis underlying malignancy can be a cause of appendicitis. Neo-
cases presenting to hospitals during this time, but higher rates of plasms such as neuroendocrine tumour, adenocarcinoma and
complicated appendicitis, perhaps indicating late presentation or a mucinous cystadenomas occur in less than 1% of routine ap-
reluctance to attend hospital, a trend which has been reflected in pendicectomies and 10%e29% of interval appendicectomies for
numerous other diseases during the pandemic. A further impact of perforated appendicitis.14 These patients may require further
COVID on appendicitis treatment can be seen in a case series of investigation, monitoring or even more extensive surgery.
open appendicectomy performed under spinal anaesthesia. Management of patients who present with an appendiceal
Although this technique is used in the developing world it is rarely mass or abscess is different to uncomplicated appendicitis. Often
used in the United Kingdom, but was adopted as a mechanism to these patients will have a longer duration of symptoms and may
reduce aerosolization from both intubation and laparoscopy. This even find that their pain has improved over time. This is
technique was shown to be safe and feasible but has not been more generally due to omental wrapping of a contained perforation,
widely adopted post-pandemic.12 leading to a mass in the RIF. Operating on this population carries
The majority of appendicectomies in the UK are now per- a high risk of conversion to right hemicolectomy. Therefore, the
formed laparoscopically. Laparoscopic surgery confers benefits preferred option is to confirm the diagnosis on imaging and to
of shorter length of stay, fewer wound complications and quicker treat conservatively with intravenous antibiotics for 48e72 hours
return to normal function than open surgery. Further advantages followed by oral antibiotics for 7 days. It can be useful to mark
are a lower risk of both short- and long-term adhesive small the outline of the mass and perform serial examinations to ensure
bowel obstruction. Intra-abdominal abscess is slightly more response to antibiotics. If there are signs of sepsis and drainable
common after laparoscopic appendicectomy in adults, although collection on imaging then image-guided drainage is an option.
this effect is not seen in children.4 Laparoscopic surgery histor- Repeat imaging is often required to follow the progress of the
ically takes longer than open but this difference is reducing as phlegmon. The patient should be reviewed in an outpatient clinic
surgeons become more skilled at it. In fact, many surgeons now and an interval appendicectomy planned for approximately
believe there are very few situations when open appendicectomy 6 weeks later. Those over 40 years of age should be offered a
is preferable; surgical expertise, local resources and stability of colonoscopy prior to interval appendicectomy.14 A proportion of
the patient are the primary determinants. patients will re-present in the intervening period and require
Laparoscopy can be diagnostic as well as therapeutic and is acute intervention. Indications for acute intervention include
therefore useful in equivocal cases. It enables examination of the increasing abdominal pain, increasing size of mass, and any
intra-abdominal organs and can aid diagnosis of alternative symptoms of systemic infection such as tachycardia or pyrexia.
causes for presenting symptoms, such as ovarian pathology or
Meckel’s diverticulum. All organs should be examined system- Appendicectomy
atically and the findings recorded with intraoperative photo-
Patients must be counselled regarding the risks, benefits and
graphs, particularly if the appendix appears grossly normal.
alternatives of appendicectomy and consented preoperatively.
When no alternative pathology is identified, the general
The most common complication following appendicectomy is
consensus amongst UK surgeons is to remove a normal-looking
wound infection and can occur in 5%e10% of cases. Other
appendix. Up to 30% have microscopic inflammation on
complications include bleeding, damage to surrounding struc-
tures, postoperative ileus, abscess or collection, and incisional
hernias. Some surgeons also consent for bowel resection, anas-
tomotic leak and stoma. It was thought that perforated appen-
dicitis could have a detrimental effect on fertility in females but
this has not been borne out in studies.4
Both open and laparoscopic appendicectomy are performed
under general anaesthesia with the patient in supine position.
Prophylactic antibiotics are administered to prevent wound
infection and intra-abdominal abscess. Once intra-abdominal
access is achieved, the patient is placed in the Trendelenburg
position (head down) with a tilt to the left. This allows access to
the caecum and appendix without overlying small bowel loops.

Surgical technique e open appendicectomy

There are several possible incisions for an open appendicectomy
(Figure 3). The Lanz incision is most commonly used e a
Figure 2 Leonid Rogozov performing an auto-appendicectomy in
1961. (From Rogozov L. Auto-appendectomy in the Antarctic, a case transverse incision centred on McBurney’s point. It allows good
report. Rogozov, Brit Med J 2009; 339: 1421e2. With permission from access to the caecal pole and appendix, and gives an aesthetically
BMJ Publishing Group Limited.). pleasing scar as it lies within Langer’s lines of skin tension. It can

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 INTESTINAL SURGERY II

Incisions used for open and laparoscopic appendicectomy

Lower midline

Laparoscopic
– umbilical
– supra-pubic
– left iliac fossa

Lanz
(transverse, in Langer’s lines,
centred on McBurney’s point)
(extension of Lanz into
Rutherford Morison/
hockey stick)
Gridiron
(oblique, centred on
McBurney’s point)

Figure 3

be converted to the longer muscle-cutting Rutherford Morison/ established at 10e12 mmHg. A typical arrangement would be to
hockey stick incision if improved access is required. Occasionally use the umbilical port for the camera and place two further 5 mm
a lower midline laparotomy is used if access is likely to be ports, one in the left iliac fossa and one supra-pubically, as per
difficult, e.g. an obese patient. Figure 3. This placement allows triangulation to the right iliac
Once the skin is divided, the external oblique aponeuroses is fossa and minimizes instrument clashing. Ports should be
incised, followed by blunt dissection of the internal oblique and inserted under direct vision to avoid damage to vessels or intra-
transversus abdominis. The exposed transversalis fascia and abdominal structures. The patient’s bladder must be empty to
peritoneum is then lifted between clips to exclude any underlying reduce the possibility of bladder injury during suprapubic port
bowel prior to dividing and entering the abdominal cavity. The insertion. The patient should void immediately preoperatively, or
appendix can be identified by following the taenia coli to its base. alternatively a urinary catheter can be inserted.
Blunt dissection is often necessary to free local adhesions and the Once the set-up is complete, a diagnostic laparoscopy is per-
appendix can then be delivered into the wound. The meso- formed. If the appendix is adherent locally or is retro-caecal,
appendix is clamped, divided and ligated. The base of the ap- additional dissection may be required to free it. The appendix
pendix is crushed in artery forceps, which are then reapplied is then lifted using forceps, exposing the mesoappendix. As with
slightly distal to the crushed base, and a suture tied around the open surgery, a window can be made near the appendix base and
crushed portion to ligate the base. The appendix can now be the mesoappendix divided and removed alongside the appendix.
divided. The stump may be buried with a purse-string suture in The mesoappendix can alternatively be dissected off the appen-
the caecum but this does not appear to confer any benefit and dix from tip to base and left behind intra-abdominally, but this
many surgeons now consider it superfluous.15 can be difficult if the mesoappendix is grossly inflamed. It is
Next the right iliac fossa and pelvis is inspected and washed generally desirable to remove the mesoappendix with the ap-
out if there is contamination. Alternatively, a swab on a stick pendix in case of incidental finding of a tumour, as sampling the
may be used to ‘mop’ the peritoneal cavity clean of any residual nodes in the mesoappendix can be prognostically important.
pus after suctioning. This has the advantage of not spilling pus Once the appendix is free the base is ligated, using two loop
into clean areas, which might occur when washing through a ligatures, and the appendix divided between them. If there is a
small incision. An abdominal drain may be used if there is an perforation close to the base of the appendix a stapler may be
abscess cavity. The abdominal wall is then closed in layers. preferred as a looped suture may cut through oedematous tissue.
To reduce contamination, the appendix is removed using a
Surgical technique e laparoscopic appendicectomy
retrieval bag, via the umbilical port. Washout is performed as
Pneumoperitoneum is usually established via a port placed just necessary and then working ports are removed under direct
below the umbilicus, using an open Hasson’s technique. This vision. The larger umbilical port site should be closed primarily
involves incision of the skin followed by dissection along the to reduce the incidence of incisional hernias, and the skin closed
umbilical stalk (cicatrix) to its base where it meets the fascia at all port sites.
which is then incised and access to the peritoneal cavity ob- Other surgical techniques for appendicectomy include single
tained. A 10 mm port is inserted and pneumoperitoneum incision laparoscopic surgery (SILS) and the more experimental

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 INTESTINAL SURGERY II

natural orifice transluminal endoscopic surgery (NOTES). Both low to minimize risks. From the second trimester patients
increase the complexity of the procedure and currently offer no should be positioned in a slight left lateral position during the
advantage over the standard techniques. operation.
Postoperative recovery is generally rapid, particularly with
laparoscopic appendicectomy, and discharge within 24 hours Children often present later and are more likely to have a
postoperatively is the usual target for uncomplicated cases. Upon perforated appendicitis. In young children particularly, the
discharge, patients should be counselled to seek medical advice if omentum is less effective at containing the inflammation, so
they are not feeling back to normal within a few days. Patients increasing the likelihood of generalized peritonitis following
with perforated appendicitis should receive intravenous antibi- perforation of appendix.17
otics for 2e3 days followed by oral antibiotics.
Commonest postoperative complications include wound Older adults tend to have diminished inflammatory response
infection, intra-abdominal collection, and postoperative ileus, resulting in less marked findings on history and clinical exami-
with overall rates of 10%, 5% and 2%, respectively.15 Radio- nation. They may delay seeking medical care and have higher
logical imaging is useful in diagnosing postoperative collections rate of perforation and mortality. Because of the higher incidence
and the latter may be treated with percutaneous drainage or of colonic neoplasms, patients over 40 should have a CT scan or
surgical washout as appropriate. Stump appendicitis is related to alternatively a colonoscopy post-discharge.
incomplete appendicectomy that leaves an excessively long
stump after surgery and is a rare complication. To minimize this, Immunocompromised people: This population is increasingly
the surgeon should ensure that the base of the appendix is seen in surgical practice. They are susceptible to infection and
identified at its junction with the caecum and ligated. Treatment their immune response is attenuated due to immunosuppression
is resection of the stump. Faecal fistulae are rare and usually either from the underlying condition or medication. They may
respond to conservative management. not exhibit typical symptoms and signs of appendicitis which can
complicate and delay diagnosis. CT can be helpful to differen-
Negative appendicectomy tiate. A broader range of differential diagnosis includes oppor-
tunistic bacterial, viral and fungal infections, secondary
This is defined as the removal of a normal appendix. The UK has
malignancies (lymphoma and Kaposi’s sarcoma) and typhlitis
a much higher negative appendicectomy rate than most countries
(inflammation of the caecum). There are no specific contraindi-
e 20% compared to 6.2%.9 This may in part be attributable to
cations to operation.
low rates of CT scanning in the UK.7 Laparoscopy provides a
higher probability of making a specific diagnosis when compared
Obese: Diagnosis and surgery may be a challenge due to high
to open surgery, and a lower rate of removal of normal appen-
BMI. Laparoscopic appendicectomy is the preferred approach in
dices. However, there is still a high rate of removal of normal
obese patients to avoid large morbidity prone incisions of open
appendices with either type of surgery especially in women.16
surgery. It also affords better views and the other advantages
Since surgery has associated risks, removal of an entirely
mentioned earlier.
normal-looking appendix is becoming increasingly controversial.
There is a 10% complication rate following negative appendi-
Conclusion
cectomy and patients should be fully counselled prior to surgery.
It has been proposed that increasing the use of scoring systems to The diagnosis of appendicitis is a challenge for surgeons; how-
identify patients at low risk for appendicitis can prevent this ever, recognizing the condition early is important to minimize
population from ever progressing to surgery.9 the risks of complications and avoid mortality. A high index of
suspicion should be maintained particularly in the atypical cases
Special groups until a diagnosis is reached. Associated sepsis must be managed
according to standard sepsis protocols. The definitive treatment
Pregnancy: Acute appendicitis is the most common general
for appendicitis is appendicectomy, which is often performed
surgical problem encountered during pregnancy. The pregnant
laparoscopically and when uncomplicated can be managed as a
uterus causes displacement of other intra-abdominal organs,
day case procedure. A
leading to atypical presentations. In the third trimester the pain
may localize to right lumbar region or even right upper quad-
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SURGERY 41:7 424 Ó 2023 Published by Elsevier Ltd.

Descargado para Lucia Angulo (lu.maru26@gmail.com) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en julio 19, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 INTESTINAL SURGERY II

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SURGERY 41:7 425 Ó 2023 Published by Elsevier Ltd.

Descargado para Lucia Angulo (lu.maru26@gmail.com) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en julio 19, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.