The Appendix

Yonas A.
July, 2016

1
 Anatomy
• The relationship of the base of the appendix
to the cecum remains constant, whereas the
tip can be found in a retrocecal, pelvic,
subcecal, right pericolic, preileal, or post-ileal
position
• The appendix can vary in length from less than
1 cm to greater than 30 cm; most appendices
are 6 to 9 cm in length

2
 Physiology
• It is now well recognized that the appendix is an
immunologic organ that actively participates in the
secretion of immunoglobulins, IgA

• Although the appendix is an integral component of

the gut-associated lymphoid tissue (GALT) system,
its function is not essential and appendectomy is
not associated with any predisposition to sepsis or
any other manifestation of immune compromise
3
 Cont.
• Lymphoid tissue first appears in the appendix
approximately 2 weeks after birth
• The amount of lymphoid tissue increases
throughout puberty, remains steady for the next
decade, and then begins a steady decrease with
age
• After the age of 60 years, virtually no lymphoid
tissue remains within the appendix, and complete
obliteration of the appendiceal lumen is common

4
 Epidemiology
• Appendectomy for appendicitis is the most commonly performed
emergency operation in the world
• The lifetime rate of appendectomy is 12% for men and 25% for
women, with approximately 7% of all people undergoing
appendectomy for acute appendicitis
• There is a slight male to female predominance (M:F 1.2 to 1.3:1)
• Appendicitis is a disease of the young, with 40% of the cases
occurring in patients between the ages of 10 and 29 years
• It is assumed that there is a 15% negative appendectomy rate
• In 1886, the associated mortality rate of appendicitis was around
67% without surgical therapy
– Currently, the mortality rate for acute appendicitis is reported to be less
than 1% 5
 Cont.
• Despite an increased use of U/S, CT, and laparoscopy,
the rate of misdiagnosis of appendicitis has remained
constant (15.3%), so has the rate of appendiceal
rupture

• The percentage of misdiagnosis of appendicitis is

significantly higher among women than men (22.2 Vs
9.3%)
– The highest negative appendectomy rate is reported for
women older than 80 years of age
6
 Pathogenesis
• Obstruction of the lumen is the dominant causal
factor in acute appendicitis
– Fecaliths
• They are the usual cause of appendiceal obstruction
– They are found in 40% of cases of simple acute appendicitis, 65% of
cases of gangrenous appendicitis without rupture, and nearly 90% of
cases of gangrenous appendicitis with rupture
– Hypertrophy of lymphoid tissue
– Tumors
– Intestinal parasites
– Vegetable and fruit seeds
– Inspissated barium from previous x-ray studies 7
 Cont.
• The proximal obstruction of the appendiceal lumen produces
a closed-loop obstruction, and continuing normal secretion by
the appendiceal mucosa rapidly produces distention
– The luminal capacity of the normal appendix is only 0.1 mL
– Secretion of as little as 0.5 mL of fluid distal to an obstruction raises
the intraluminal pressure to 60 cm H2O
• Distention of the appendix stimulates nerve endings of visceral
afferent stretch fibers, producing vague, dull, diffuse pain in
the mid-abdomen or lower epigastrium
– Peristalsis is also stimulated by the rather sudden distention, so that
some cramping may be superimposed on the visceral pain early in
the course of appendicitis
– Distention of this magnitude usually causes reflex nausea and 8
 Cont..
• As pressure in the organ increases, venous pressure is
exceeded
• Capillaries and venules are occluded, but arteriolar inflow
continues, resulting in engorgement and vascular congestion
– Later the arterial flow is compromised
• The appendiceal mucosa is susceptible to impairment of
blood supply, thus its integrity is compromised early in the
process, allowing bacterial invasion
• As progressive distention encroaches upon first the venous
return and subsequently the arteriolar inflow, the area with
the poorest blood supply suffers most: ellipsoidal infarcts
develop in the antimesenteric borde
9
 Cont.
• As distention, bacterial invasion, compromise
of vascular supply, and infarction progress,
perforation occurs, usually through one of the
infarcted areas on the antimesenteric border

• Perforation generally occurs just beyond the

point of obstruction rather than at the tip
because of the effect of diameter on
intraluminal tension
10
 Cont.
• The above sequence is not inevitable, however,
some episodes of acute appendicitis apparently
subside spontaneously
– Many patients who are found at operation to have
acute appendicitis give a history of previous similar,
but less severe, attacks of right lower quadrant pain
– Pathologic examination of the appendices removed
from these patients often reveals thickening and
scarring, suggesting old, healed, acute inflammation

11
 Bacteriology
• The bacteriology of the normal appendix is similar to that
of the normal colon
• The appendiceal flora remains constant throughout life with the
exception of Porphyromonas gingivalis, which is seen only in adult
• The principal organisms seen in the normal appendix, in
acute appendicitis, and in perforated appendicitis are
E.coli and Bacteroides fragilis
– However, a wide variety of both facultative and anaerobic
bacteria and mycobacteria may be present
• Appendicitis is a polymicrobial infection, with some series
reporting up to 14 different organisms cultured in patients
with perforation 12
Common Organisms Seen in Patients with
Acute Appendicitis

13
 Cont.
• Broad-spectrum antibiotics are indicated
• Antibiotic coverage is limited to 24 to 48 hours
in cases of nonperforated appendicitis
– For perforated appendicitis, 3 to 7 days is
recommended
• Intravenous antibiotics are usually given until
the WBC count is normal and the patient is
afebrile for 24 hours

14
 Clinical presentation
• Abdominal pain is the prime symptom of acute
appendicitis
– Classically, pain is initially diffusely centered in the lower
epigastrium or umbilical area, is moderately severe, and is
steady, sometimes with intermittent cramping
superimposed
– After a period varying from 1 to 12 hours, but usually within
4 to 6 hours, the pain localizes to the right lower quadrant
– The classic pain sequence, although usual, is not invariable
• In some patients, the pain of appendicitis begins in the RLQ and
remains there
15
 Cont.
• Cont.
– Variations in the anatomic location of the appendix account
for many of the variations in the principal locus of the
somatic phase of the pain
– A long appendix with the inflamed tip in the LLQ causes
pain in that area
– A retrocecal appendix principally may cause flank or back
pain
– A pelvic appendix, principally suprapubic pain
– A retroileal appendix may cause testicular pain, presumably
from irritation of the spermatic artery and ureter

16
 Cont.
• Anorexia
– It nearly always accompanies appendicitis
• It is so constant that the diagnosis should be questioned
if the patient is not anorectic
• Vomiting
– Although vomiting occurs in nearly 75% of patients,
it is neither prominent nor prolonged and most
patients vomit only once or twice
– It is caused both by neural stimulation and the
presence of ileus
17
 Cont.
• The sequence of symptom appearance has
great differential diagnostic significance
– In more than 95% of patients with acute
appendicitis, anorexia is the first symptom,
followed by abdominal pain, which is followed, in
turn, by vomiting (if vomiting occurs)
– If vomiting precedes the onset of pain, the
diagnosis of appendicitis should be questioned

18
 Cont.
• Most patients give a history of obstipation
beginning prior to the onset of abdominal pain,
and many feel that defecation would relieve
their abdominal pain

• However, diarrhea occurs in some patients,

particularly children, so that the pattern of
bowel function is of little differential diagnostic
value
19
 Cont.
• G/A
– Patients with appendicitis usually prefer to lie supine, with
the thighs, particularly the right thigh, drawn up, because
any motion increases pain
• If asked to move, they do so slowly and with caution
• Vital signs
– V/S are minimally changed by uncomplicated appendicitis
• Temperature elevation is rarely more than 1°C (1.8°F) and the
pulse rate is normal or slightly elevated
– Changes of greater magnitude usually indicate that a
complication has occurred or that another diagnosis should
be considered 20
 Cont.
• The classic RLQ physical signs are present when the
inflamed appendix lies in the anterior position
– Tenderness is often maximal at or near McBurney's point
• Direct rebound tenderness is usually present
• Additionally, referred or indirect rebound tenderness is present
– Cutaneous hyperesthesia
• In the area supplied by the spinal nerves on the right at T10, T11,
and T12
• Elicited either by needle prick or by gently picking up the skin
between the forefinger and thumb
– Guarding
– Rigidity 21
 Cont.
• Rovsing's sign

• Psoas sign
– Performed by having patients lay on their left side as the
examiner slowly extends the right thigh, thus stretching
the iliopsoas muscle

• Obturator sign
– Performed by passive internal rotation of the flexed right
thigh with the patient supine
22
 Laboratory
• CBC
– Mild leukocytosis, ranging from 10,000 to 18,000/mm3, is usually present
in patients with acute, uncomplicated appendicitis and is often
accompanied by a moderate polymorphonuclear predominance
• Numbers >18,000/mm3 should raise the possibility of a perforated appendix with
or without an abscess

• U/A
– Although several white or red blood cells can be present from ureteral or
bladder irritation as a result of an inflamed appendix, bacteriuria in a
catheterized urine specimen is not generally seen with acute appendicitis

• Urine HcG
– In females
23
 Cont.
• Abdominal U/S
– The appendix 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 AP dimension
• A scan is considered positive if a noncompressible appendix
≥6 mm is demonstrated
– The presence of an appendicolith establishes the
diagnosis
– The presence of thickening of the appendiceal wall and
periappendiceal fluid is highly suggestive
24
 Cont.
• Abdominal U/S
– Sonographic demonstration of a normal appendix, which is
an easily compressible blind-ending tubular structure
measuring ≤5 mm in diameter, excludes the diagnosis of
acute appendicitis
– The study is considered inconclusive if the appendix is not
visualized and there is no pericecal fluid or mass
– The sonographic diagnosis of acute appendicitis has a
reported sensitivity of 55-96% and a specificity of 85-98%
– Sonography is similarly effective in children and pregnant
women, although its application is somewhat limited in late
pregnancy
25
 Cont.
• Cont.
– A false-positive scan can occur:
• Periappendicitis from surrounding inflammation
• A dilated fallopian tube can be mistaken for an inflamed appendix
• Inspissated stool can mimic an appendicolith
• In obese patients, the appendix may not be compressible because
of overlying fat
– False-negative sonograms can occur:
• If appendicitis is confined to the appendiceal tip
• If the appendix is retrocecal in location
• If the appendix is markedly enlarged and mistaken for small bowel
• If the appendix is perforated and therefore compressible
26
 Cont.
• Cont.
– Sonography identified appendicitis in 10% of patients
who were believed to have a low likelihood of the
disease on physical examination
– The positive and negative predictive values of
ultrasonography have impressively been reported as
91 or 92%, respectively
• However, in a recent prospective multicenter study, routine
ultrasonography did not improve the diagnostic accuracy or
rates of negative appendectomy or perforation when
compared to clinical assessment
27
 Cont.
• CT scan
– The inflamed appendix appears dilated (>5 mm) and the
wall is thickened
– There is usually evidence of inflammation, with "dirty fat,"
thickened mesoappendix, and even an obvious phlegmon
– Fecaliths can be easily visualized, but their presence is not
necessarily pathognomonic of appendicitis
– An important suggestive abnormality is the arrowhead
sign
• This is caused by thickening of the cecum, which funnels contrast
toward the orifice of the inflamed appendix

28
 Cont.
• Cont.
– A number of studies have documented improvement in
diagnostic accuracy with the liberal use of CT scanning in
the workup of suspected appendicitis
– However, despite the potential usefulness of this
technique, there are significant disadvantages:
• It is expensive
• It exposes the patients to significant radiation
• It cannot be used during pregnancy
• Although the differences are rather small, CT scanning has
consistently proven superior over U/S in establishing the
diagnosis of appendicitis
29
 Alvarado Scale for the Diagnosis of
Appendicitis
• Scores 0-4: appendicitis is unlikely
• Scores 5-6: compatible with, but not diagnostic of appendicitis
• Scores 7-8: high likelihood of appendicitis
• Scores 9-10: almost certain to have appendicitis

30
 Appendiceal Rupture
• The overall rate of perforated appendicitis is 25.8%
• Children younger than age 5 years and patients older than
age 65 years have the highest rate of perforation (45 and
51% respectively)
• It has been suggested that delays in presentation are
responsible for the majority of perforated appendices
• Although it has been suggested that observation and
antibiotic therapy alone may be an appropriate treatment
for acute appendicitis, nonoperative treatment exposes
the patient to the increased morbidity and mortality
associated with a ruptured appendix
31
 Cont.
• Appendiceal rupture occurs most frequently distal
to the point of luminal obstruction along the
antimesenteric border of the appendix
• Rupture should be suspected in the presence of
fever greater than 39°C and a WBC count
>18,000/mm3
• In the majority of cases, rupture is contained and
patients display localized rebound tenderness
– Generalized peritonitis will be present if the walling-off
process is ineffective in containing the rupture
32
 Cont.
• In 2 to 6% of cases, an ill-defined mass will be
detected on physical examination
– This could represent a phlegmon, which consists
of matted loops of bowel adherent to the adjacent
inflamed appendix, or a periappendiceal abscess
• Patients who present with a mass have a
longer duration of symptoms, usually at least
5 to 7 days

33
 Cont.
• Treatment
– Phlegmons and small abscesses can be treated
conservatively with intravenous antibiotics
• Interval appendectomy performed after at least 6 weeks
– Well-localized abscesses can be managed with
percutaneous drainage
– Complex abscesses should be considered for surgical
drainage
• It should be performed by using an extraperitoneal
approach, with appendectomy reserved for cases in which
the appendix is easily accessible
34
 DDX
• The accuracy of preoperative diagnosis of acute
appendicitis should be approximately 85%
• The most common erroneous preoperative
diagnoses—accounting for more than 75%—in
descending order of frequency are:
– Acute mesenteric lymphadenitis
– No organic pathologic conditions
– Acute pelvic inflammatory disease
– Twisted ovarian cyst or ruptured graafian follicle
– Acute gastroenteritis
35
 Cont.
• The differential diagnosis of acute appendicitis
depends upon four major factors:
– The anatomic location of the inflamed appendix
– The stage of the process (i.e., simple or ruptured)
– The patient's age
– The patient's sex

36
 Common DDX
• PUD perforation
• Regional enteritis (TB, Typhoid, Crohn’s)
• Colonic causes (diverticulitis, perforated colonic cancer)
• Right ureteric stone
• Right pyelonephritis
• Closed-loop intestinal obstruction
• Mesenteric vascular occlusion
• Pleuritis of the right lower chest
• Acute cholecystitis
• Acute pancreatitis
37
 DDX in pediatrics
• Acute gastroenteritis
• Meckel's Diverticulitis
• Acute mesenteric lymphadenitis
• Intussusception
• HSP

38
 DDX in females
• Pelvic inflammatory disease
• Ruptured graafian follicle (Mittelschmerz)
• Twisted ovarian cyst or tumor
• Endometriosis
• Ruptured ectopic pregnancy

39
 DDX in males
• Torsion of the testis
• Acute epididymitis
• Seminal vesiculitis

40
 Acute Appendicitis in the Young
• Children younger than 5 years of age have a negative
appendectomy rate of 25% and an appendiceal
perforation rate of 45%
• The establishment of a diagnosis of acute appendicitis in
young children is more difficult than in the adult
– The inability of young children to give an accurate history
– Diagnostic delays by both parents and physicians
– The frequency of gastrointestinal upset in children
• The more rapid progression to rupture and the inability
of the underdeveloped greater omentum to contain a
rupture lead to significant morbidity rates in children41
 Acute Appendicitis in the Elderly
• In patients older than age 80 years, perforation rates of 49%
and mortality rates of 21% have been reported
• Although the incidence of appendicitis in the elderly is lower
than in younger patients, the morbidity and mortality are
significantly increased in this patient population
– Delays in diagnosis
– A more rapid progression to perforation
– Comorbid disease
• The diagnosis of appendicitis may be subtler and less typical
than in younger individuals, and a high index of suspicion
should be maintained
42
 Acute Appendicitis During Pregnancy
• Appendicitis is the most frequently encountered
extrauterine disease requiring surgical treatment during
pregnancy
– The incidence is approximately 1 in 2000 pregnancies
• Acute appendicitis can occur at any time during pregnancy,
but is more frequent during the first two trimesters
• As fetal gestation progresses, the diagnosis of appendicitis
becomes more difficult as the appendix is displaced
laterally and superiorly
• The suspicion of appendicitis during pregnancy should
prompt rapid diagnosis and surgical intervention
43
 Cont.
• Diagnosis
– Nausea and vomiting after the first trimester or new-onset
nausea and vomiting
– Abdominal pain and tenderness
• Rebound and guarding are less frequent because of laxity of the
abdominal wall
– Elevation of the WBC count above the normal pregnancy
levels of 15,000 to 20,000/L, with a predominance of
polymorphonuclear cells
– When the diagnosis is in doubt, abdominal ultrasound may
be beneficial
– Laparoscopy may be indicated in equivocal cases
44
 Cont.
• The performance of any operation during
pregnancy carries a risk of premature labor of
10 to 15%
• The most significant factor associated with
both fetal and maternal death is appendiceal
perforation
– Fetal mortality increases from 3 to 5% in early
appendicitis to 20% with perforation

45
Location of the appendix during pregnancy

46
 Appendicitis in Patients with AIDS or HIV
Infection
• The incidence of acute appendicitis in HIV-infected
patients is reported to be 0.5%
– This is higher than the 0.1 to 0.2% incidence reported for
the general population

• The presentation of acute appendicitis in HIV-infected

patients is similar to that of noninfected patients
– But HIV-infected patients will not manifest an absolute
leukocytosis
• However, if a baseline leukocyte count is available, nearly all HIV-
infected patients with appendicitis will demonstrate a relative
leukocytosis 47
 Cont.
• There appears to be an increased risk of
appendiceal rupture in HIV-infected patients
– Contributing factors:
• Delay in presentation seen in this patient population
• A significant hospital delay
• A low CD4 count

48
 Cont.
• The DDX of RLQ pain is expanded in HIV-infected
patients when compared to the general
population
– In addition to the conditions in uninfected
population, OIs should be considered as possible
causes of RLQ pain
• CMV, TB, Cryptococcus neoformans, and strongyloides,
Kaposi's sarcoma, lymphoma, and other causes of
infectious colitis
• Neutropenic enterocolitis (typhlitis) should also be
considered
49
 Cont.
• In the HIV-infected patient with classic signs and
symptoms of appendicitis, immediate
appendectomy is indicated
– The negative appendectomy rate is 5 to 10%

• In those patients with diarrhea as a prominent

symptom, colonoscopy may be warranted

• In patients with equivocal findings, CT scan is

usually helpful 50
 Cont.
• Post-op outcome
– Morbidity rates for HIV-infected patients with
nonperforated appendicitis are similar to those seen
in the general population
• Postoperative morbidity rates appear to be higher in HIV-
infected patients with perforated appendicitis

– The length of hospital stay for HIV-infected patients

undergoing appendectomy is twice that of the
general population
51
 Treatment
• Resuscitation
• Pre-op antibiotics
– Routinely administered to lower the infectious complications in
appendicitis
– If simple acute appendicitis is encountered, there is no benefit in
extending antibiotic coverage beyond 24 hours
– If perforated or gangrenous appendicitis is found, antibiotics are
continued until the patient is afebrile and has a normal WBC
count
• Appendectomy
– Open
– Laparascopic
52
 Open Appendectomy
• Choice of incision
– Usually either a McBurney (oblique) or Rocky-Davis
(transverse) RLQ muscle-splitting incision is used
• The incision should be centered over either the point of
maximal tenderness or a palpable mass
– If an abscess is suspected, a laterally placed incision is
imperative to allow retroperitoneal drainage and to
avoid generalized contamination of the peritoneal cavity
– If the diagnosis is in doubt, a lower midline incision is
recommended to allow a more extensive examination of
the peritoneal cavity
53
 Interval Appendectomy
• The accepted algorithm for the treatment of appendicitis
associated with a palpable or radiographically
documented mass (abscess or phlegmon) is conservative
therapy with interval appendectomy 6 to 10 weeks later
• The initial treatment consists of IV antibiotics and bowel
rest
• While generally effective, there is a 9 to 15% failure rate,
with operative intervention required at 3 to 5 days after
presentation
– Percutaneous or operative drainage of abscesses is not
considered a failure of conservative therapy
54
 Cont.
• While the second stage of this treatment plan, interval
appendectomy, has usually been performed, the need for
subsequent operation has been questioned
– The major argument against interval appendectomy is that approximately
50% of patients treated conservatively never develop manifestations of
appendicitis, and those who do, can generally be treated nonoperatively

• On the other hand, the data clearly support the need for interval
appendectomy
– After conservative trt a significant percentage of patients either continue
to have, or redevelop RLQ pain
– While the appendix may occasionally be pathologically normal, persistent
periappendiceal abscesses and adhesions are found in 80% of patients

55
 Cont.
• The timing of interval appendectomy is
somewhat controversial
– Appendectomy may be required as early as 3
weeks following conservative therapy
– Two thirds of the cases of recurrent appendicitis
occur within 2 years

56
 Post-op complications
• Most of the serious early complications are
septic and include abscess and wound
infection

57
 Cont.
• Wound infection
– It is common, but is nearly always confined to the
subcutaneous tissues and promptly responds to
wound drainage, which is accomplished by
reopening the skin incision
– Wound infection predisposes the patient to
wound dehiscence
• The type of incision is relevant
– Complete dehiscence rarely occurs in a McBurney incision

58
 Cont.
• Intra-abdominal abscess
– The sites of predilection for abscesses are the
appendiceal fossa, pouch of Douglas, subhepatic
space, and between loops of intestine
– Transrectal drainage is preferred for an abscess
that bulges into the rectum

59
 Cont.
• Fecal fistula
– It is an annoying, but not particularly dangerous,
complication of appendectomy
– May be caused by:
• Sloughing of that portion of the cecum inside a
constricting purse-string suture
• The ligature's slipping off a tied, but not inverted,
appendiceal stump
• Necrosis from an abscess encroaching on the cecum

60
 Cont.
• Intestinal obstruction
– Initially paralytic but sometimes progressing to
mechanical obstruction, may occur with slowly
resolving peritonitis with loculated abscesses and
exuberant adhesion formation
– Late adhesive band intestinal obstruction after
appendectomy does occur, but much less
frequently than after pelvic surgical therapy

61
 Cont.
• Hernia
– The incidence of inguinal hernia is 3 times greater
in patients who have had an appendectomy
– Incisional hernia is like wound dehiscence in that
infection predisposes to it, it rarely occurs in a
McBurney incision, and it is not uncommon in a
lower right paramedian incision

62
 Prognosis
• Principal factors in morbidity and mortality are whether
rupture occurs before surgical treatment and the age of the
patient
– The overall mortality rate for a general anesthetic is 0.06%
– The overall mortality rate in ruptured acute appendicitis is about
3%—a 50-fold increase
– The mortality rate of ruptured appendicitis in the elderly is
approximately 15%—a 5-fold increase from the overall rate

• Death is usually attributable to uncontrolled sepsis—

peritonitis, intra-abdominal abscesses, or gram-negative
septicemia
63
 Appendiceal Parasites
• A number of intestinal parasites cause appendicitis
• The live parasites occlude the appendiceal lumen, causing
obstruction
• Examples
– Ascaris lumbricoides (the most common)
– Enterobius vermicularis
– Strongyloides stercoralis
– Echinococcus granulosis
• Amebiasis can also cause appendicitis
• Once appendectomy has been performed and the patient
recovered, therapy with helminthicide is necessary to clear the
remainder of the GIT
64
 Chronic/recurrent appendicitis
• Characteristically, the pain lasts longer and is less
intense than that of acute appendicitis, but is in
the same location
– There is a much lower incidence of vomiting, but
anorexia and occasionally nausea, pain with motion,
and malaise are characteristic

• Leukocyte counts are predictably normal and CT

scans are generally nondiagnostic
65
 Stump appendicitis
• An uncommon complication after surgery

• It refers to the development of appendicitis in an incompletely

excised appendiceal stump (>0.5 cm stump length)

• Diagnosis can be difficult and requires careful assessment of the

patient’s history, physical exam, and imaging studies

• Optimal management requires reexcision of the appendiceal base

• Prior appendectomy should not be an absolute criterion in ruling

out acute appendicitis!
66
 Cont.
• Appendectomy is curative
– Symptoms resolve postoperatively in 82 to 93% of
patients
– Many of those whose symptoms are not cured or
recur are ultimately diagnosed with Crohn's
disease

• In the absence of imaging abnormalities,

prophylactic appendectomy is not encouraged
67
 Negative exploration
• Upon performing a laparoscopy or laparotomy
for suspected appendicitis, if one finds no
evidence of appendicitis, a thorough
exploration of the peritoneum must be
performed to rule out contributing pathology

• A normal appendix is often removed to reduce

future diagnostic dilemma

68
 Incidental appendectomy
• While incidental appendectomy is generally neither clinically
nor economically appropriate, there are some special
circumstances during laparotomy or laparoscopy for other
indications in which it is routinely performed
– Crohn's disease patients in whom the cecum is free of macroscopic
disease
– Patients undergoing cytoreductive operations for ovarian
malignancies
– Children undergoing chemotherapy
– Individuals who are about to travel to remote places where there is
no access to medical/surgical care
– The disabled who cannot describe symptoms or react normally to
abdominal pain
69
 Cont.
• While there is no evidence clearly evaluating
long-term outcomes of patients undergoing
incidental appendectomy with an asymptomatic
appendix, the risk of adhesions and future
complications after an appendectomy has been
suggested to be higher than the risk of future
appendicitis and increased economic costs
– For these reasons, an incidental appendectomy
is currently not advocated

70
 Appendiceal tumors
• Appendiceal malignancies are extremely rare
– Primary appendiceal cancer is diagnosed in about
1% of appendectomy specimens

• These tumors are only rarely suspected

preoperatively
– Almost one-third of the neoplasms of the appendix
present with acute appendicitis, while the others
are often incidentally detected or are detected after
regional spread of disease
71
 Gastroenteropancreatic neuroendocrine
tumors (carcinoid)
• The finding of a firm, yellow, bulbar mass in the appendix
should raise the suspicion of an appendiceal carcinoid

• They are relatively indolent but can develop nodal or

hepatic metastases

• The appendix is the most common site of GI-carcinoid,

followed by the small bowel and then rectum

• The majority of carcinoids are located in the tip of the

appendix
72
 Cont.
• Symptoms attributable directly to the carcinoid are
rare, although the tumor can occasionally obstruct the
appendiceal lumen and result in acute appendicitis

• Infrequently, there can be associated with a carcinoid

syndrome if there are hepatic metastases (2.9%)

• Malignant potential is related to size, with tumors

less than 1 cm rarely resulting in extension outside of
the appendix or adjacent to the mass
73
 Cont.
• Treatment
– For lesions that are <1 cm (95% of all lesions), a
negative margin appendectomy is adequate
– For tumors 2 cm or larger, a right hemicolectomy is
recommended
– For lesions 1 to 2 cm in size, there is no consensus on
a completion colectomy
• A right hemicolectomy is often performed for:
– Mesenteric invasion
– Positive or unclear margins
– Enlarged nodes
74
 Adenocarcinoma
• Primary adenocarcinoma of the appendix is a rare neoplasm
of 3 major histologic subtypes: mucinous adenocarcinoma,
colonic adenocarcinoma, and adenocarcinoid

• The most common mode of presentation for appendiceal

carcinoma is that of acute appendicitis

• The recommended treatment for all patients with

adenocarcinoma of the appendix is a formal right
hemicolectomy

75
 Lymphoma
• Lymphoma of the appendix is extremely
uncommon

• The frequency of primary lymphoma of the

appendix ranges from 1 to 3% of gastrointestinal
lymphomas

• Appendiceal lymphoma usually presents as acute

appendicitis and is rarely suspected preoperatively
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 Cont.
• The management of appendiceal lymphoma
confined to the appendix is appendectomy
– Right hemicolectomy is indicated if there is
extension of tumor beyond the appendix onto the
cecum or mesentery
– Adjuvant therapy is not indicated for lymphoma
confined to the appendix

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 Pseudomyxoma Peritonei Syndrome
• Result from peritoneal dissemination from appendiceal
mucinous neoplasms

• It can occur in gastric, pancreatic, colorectal, and ovarian

primary tumors as well

• Cytoreductive surgery and hyperthermic

intraperitoneal chemotherapy (HIPEC) are considered
the standard of care for patients with PMP syndrome
from appendiceal primaries
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The end!

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