Vermiform Appendix

Background
In 1886, Reginald H. Fitz, a Harvard pathologist, first described the clinical condition of
acute appendicitis.[1] He correctly pointed out the importance of its early diagnosis and timely
treatment, based on his analysis of 257 cases of perforating inflammation of the appendix and
209 cases of typhlitis or perityphlitis.[2]
A few years later, Charles McBurney described the clinical findings prior to rupture and
advocated early surgical intervention. Despite aggressive intervention, mortality and
morbidity rates remained high through the rest of the 19th century and the first half of the
20th century. The mortality rate associated with appendicitis declined with the introduction of
antibiotics and with the development of anesthesia and better perioperative care.
Currently, the diagnosis of acute appendicitis remains a challenge. Only slightly more than
half of patients present with classic signs and symptoms of acute appendicitis. Atypical
presentations often lead to a delay in diagnosis, perforation, prolonged hospitalization, and
increased morbidity.[3] Thus, all clinicians must be knowledgeable about diagnosing and
managing this disease process.
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and
Intestine Center. Also, see eMedicine's patient education articles, Appendicitis and
Abdominal Pain in Adults.

History of the Procedure

The appendix was probably first noted as early as the Egyptian civilization (3000 BC).
During the mummification process, abdominal parts were removed and placed in Coptic jars
with inscriptions describing the contents. When these jars were uncovered, inscriptions
referring to the "worm of the intestine" were discovered.[4]
Aristotle and Galen did not identify the appendix because they both dissected lower animals,
which do not have appendices. Celsus, however, probably discovered the appendix because
he was allowed to dissect criminals executed by Caesar.[4] Leonardo da Vinci first depicted
the appendix in anatomic drawings in 1492.[5] In 1521, Jacopo Beregari da Capri, a professor
of anatomy in Bologna, identified the appendix as an anatomic structure. In the 1500s,
Vesalius (1543) and Pare (1582) referred to the appendix as the caecum. Laurentine
compared the appendix to a twisted worm in 1600, and Phillipe Verheyen coined the term
appendix vermiformis in 1710.[4]

Problem
Acute appendicitis remains one of the most common surgical diseases encountered by
physicians. When appendicitis manifests in its classic form, it is easily diagnosed and treated.
Unfortunately, these classic symptoms occur in just over half of patients with acute

appendicitis; therefore, an accurate and timely diagnosis of atypical appendicitis remains

clinically challenging and one of the most commonly missed problems in the emergency
department. Furthermore, the consequence of missing appendicitis, thus leading to
perforation, significantly increases morbidity and prolongs hospitalization.[6]

Epidemiology
Frequency
In Western countries, approximately 7% of individuals develop appendicitis at some time
during their lives. Approximately 200,000 appendectomies are performed annually in the
United States.[1]
The peak incidence of acute appendicitis has gradually declined to about half of its peak
incidence in the early 20th century, with the current annual incidence of 1 per 1000 population
in the United States and 86 cases for every 100,000 persons worldwide.[7, 8]
Acute appendicitis is less common in Africa and in parts of Asia because of the high-residue
diets of the inhabitants.

Etiology
Appendicitis results from obstruction of the lumen of the appendix. Obstruction may be from
lymphoid hyperplasia (60%), fecalith or fecal stasis (35%), foreign body (4%), and tumors
(1%).[9]

Pathophysiology
The basic pathophysiology of appendicitis is obstruction of the lumen of the appendix
followed by infection. In 60% of patients, obstruction is caused by hyperplasia of the
submucosal follicles. This form of obstruction is mostly observed in children and is known as
catarrhal appendicitis. A fecalith or fecal stasis causes luminal obstruction 35% of the time
and is usually observed in adults. Obstruction may also be caused by foreign bodies (4%) and
tumors (1%).
Following obstruction, an increase in mucous production occurs, and this leads to increased
pressure. With increased pressure and stasis from obstruction, bacterial overgrowth ensues.
The mucus then turns into pus that causes a further increase in luminal pressure. This leads to
distention of the appendix and visceral pain, which is typically located in the epigastric or
periumbilical region.
As the luminal pressure continues to increase, lymphatic obstruction occurs, leading to an
edematous appendix. This stage is known as acute or focal appendicitis. The overlying
parietal peritoneum becomes irritated, and the pain now localizes to the right lower quadrant
(RLQ). This series of events results in the classic migrating abdominal pain described in
patients with appendicitis.

Further increase in pressure leads to venous obstruction, causing edema and ischemia of the
appendix. At this stage, bacterial invasion of the wall of the appendix occurs and is known as
acute suppurative appendicitis. Finally, with continued pressure increases, venous thrombosis
and arterial compromise occur, leading to gangrene and perforation.[9] If the body
successfully walls off the perforation, the pain may actually improve. However, symptoms do
not completely resolve. Patients may still have underlying right lower quadrant pain,
decreased appetite, change in bowel habits (eg, diarrhea, constipation), or intermittent lowgrade fever. If the perforation is not successfully walled off, then diffuse peritonitis will
develop.

Presentation
The classic presentation of a patient with appendicitis includes a history of initial
periumbilical or epigastric abdominal pain migrating to the RLQ. The pain is gradual in onset
and progressively worsens. Anorexia, nausea, and vomiting are typically associated with the
disease. In early appendicitis, the patient is initially afebrile or has a low-grade fever. Higher
fevers are associated with a perforated appendix.[3]
On physical examination, the patient is usually lying still, as movement worsens the pain.
Having the patient cough elicits localized pain in the RLQ. Local tenderness to palpation is
usually observed. Percussion tenderness is also noted in this area. Tenderness on the right
side during rectal examination may occur, whereas pelvic and testicular examination findings
are normal. Other signs (eg, Rovsing, psoas, obturator) are unreliable and typically occur late
in the disease process.[3]
Unfortunately, only 55% of patients with appendicitis present with classic history and
physical findings. This is because the early signs and symptoms are primarily dependent upon
the location of the tip of the appendix, which is highly variable.[9]

Indications
Indications for surgical consultation
A surgeon should evaluate any patient with classic migrating abdominal pain and RLQ
tenderness. Because only a little more than half of patients with appendicitis present with a
classic history and physical findings, acute appendicitis should be on the list of possible
diagnoses for any patient with abdominal pain. Thus, a surgeon should also evaluate patients
with focal RLQ tenderness or progressively worsening abdominal pain.
To minimize the time between presentation and appendectomy, obtain surgical consultation
prior to performing additional diagnostic studies, such as CT scan, ultrasound, and
technetium (Tc)-labeled WBC scan.[3]

Indications for operation

Any patient with suspected appendicitis who has (1) persistent pain and becomes febrile, (2)
an increasing WBC count, or (3) worsening clinical examination findings should undergo
appendectomy or at least diagnostic laparoscopy. In patients with an atypical presentation, the
most important determination for appendectomy is serial physical examinations. The WBC
count often does not increase after the patient is admitted and hydrated; therefore, any patient
sent home from the emergency department should undergo a follow-up evaluation the next
day.[3]

Relevant Anatomy
Embryologically, the appendix is a continuation of the cecum and is first delineated during
the fifth month of gestation. The appendix does not elongate as rapidly as the rest of the
colon, thus forming a wormlike structure.[1]
The appendix averages 10 cm in length but can range from 2-20 cm. The wall of the appendix
consists of 2 layers of muscle, an inner circular and outer longitudinal. The longitudinal layer
is a continuation of the taeniae coli. The appendix is lined by colonic epithelium.[1]
Few submucosal lymphoid follicles are noted at birth. These follicles enlarge, peak from 1220 years, and then decrease. This correlates with the incidence of appendicitis.
Blood supply to the appendix is mainly from the appendicular artery, a branch of the ileocolic
artery. This artery courses through the mesoappendix posterior to the terminal ileum. An
accessory appendicular artery can branch from the posterior cecal artery. This artery can lead
to significant intraoperative and postoperative hemorrhage and should be searched for
carefully and ligated once the main appendicular artery is controlled.[9]
The base of the appendix is fairly constant and is located at the posteromedial wall of the
cecum about 2.5 cm below the ileocecal valve. This is also where the taeniae converge.[9]
The base is at a constant location, whereas the position of the tip of the appendix varies. In
65% of patients, the tip is located in a retrocecal position; in 30%, it is located at the brim or
in the true pelvis; and, in 5%, it is extraperitoneal, situated behind the cecum, ascending
colon, or distal ileum. The location of the tip of the appendix determines early signs and
symptoms.

Contraindications
No contraindications to performing an appendectomy in patients with suspected appendicitis
exist; however, patients with a well-developed abscess (detected on CT scan) following
perforated appendicitis may be initially treated with percutaneous drainage and intravenous
antibiotics.
Once bowel function resumes, the patient may be discharged on oral antibiotics (total IV plus
PO antibiotics for 7-10 d) with consideration for interval appendectomy in 6 weeks.[10]

Laboratory Studies

Complete blood cell (CBC) count with manual differential

o The WBC count is often mildly elevated, and a left shift is present. When an
extremely elevated WBC count is present, either the patient has a perforated
appendix, or another process, such as a viral illness, is responsible.
o Both pediatric patients and adult patients do not always manifest an elevated
WBC count.[3] Thus, an increased percentage of bands on manual cellular
differential may be just as reliable. Because an accurate history and physical is
often more difficult to obtain, a persistently elevated percentage of bands may
be the only objective finding of appendicitis in the pediatric patient.
Urinalysis (UA): Although not mandatory, a UA is often obtained to rule out urinary
tract infections; however, pyuria (WBCs in the urine) is commonly observed in
appendicitis because the inflammatory process may lie adjacent to the right ureter.
Electrolyte and renal panel: This test is not required but may be useful to help guide
electrolyte resuscitation prior to appendectomy.

Imaging Studies

No imaging studies are needed in patients with classic appendicitis. This has been
confirmed by a retrospective study determining predictive values for appendicitis
(Alvarado score) based on history and physical findings. Prospective comparison of
the accuracy of the Alvarado score with ultrasound findings was similar.[11]
Additional imaging studies may be required in the workup of atypical appendicitis.
Controversy exists as to the most accurate, rapid, and cost-effective method of
diagnosing atypical appendicitis while avoiding delays that may increase morbidity.
Plain abdominal radiographs - Abdominal series
o For the most part, abdominal roentgenograms are not helpful in making the
diagnosis of appendicitis. Roughly 85% of radiograph findings are normal,
and 10% have nonspecific findings.[3]
o The 2 most common nonspecific findings associated with appendicitis are
ileus and small bowel obstruction. A more specific abnormality is a fecalith in
the RLQ, but this is observed in only 4-5% of radiographs.
o Rarely, free air under the diaphragm may also be present in patients with
perforated appendicitis.
Abdominal/pelvic ultrasound
o Ultrasound is an ideal noninvasive means to visualize the abdominal cavity. It
is inexpensive and portable, and it can be rapidly performed with little or no
patient preparation. Most importantly, it poses no ionizing radiation risk to the
patient; therefore, it is particularly safe to use in children and pregnant women.
On the other hand, it is operator-dependent, which means that it requires some
experience and expertise to produce consistent quality results.
o The wall elements of the appendix have a typical "target" appearance and can
be visualized using graded ultrasonography compressive technique with a high
resolution transducer, occasionally with supplement of color Doppler.
o Appendicitis is suspected when the study demonstrates wall thickening (>8-10
mm), luminal distention, and lack of compressibility. In addition, ultrasound is
useful in detecting free intraperitoneal fluid and fluid collections consistent
with abscess formation.

Prospective studies have shown excellent results, with an average sensitivity

of 86% and a specificity of 94% under the conditions of well-controlled
clinical trials, namely in the hands of experienced examiners.[12] In addition,
many reported studies included patients with classic appendicitis instead of
patients with equivocal clinical histories and physical findings. Such good
results reported in prospective clinical trials were not frequently duplicated in
routine clinical conditions. In fact, the accuracy of ultrasonography was no
better than that based on clinical evaluation by the surgeons, and low
sensitivity and high false-negative rates have been reported.[3, 13, 14]
o Ultrasound is most useful for excluding other diagnoses. In women, pelvic
pathology, such as pelvic inflammatory disease, ruptured Graafian follicle,
twisted ovarian cyst or tumor, endometriosis, and ruptured ectopic pregnancy,
can be readily detected by ultrasonography.
Contrast-enhanced CT scans
o CT scan findings become more prominent with enhanced disease. Specific
findings include an edematous, thick-walled appendix, inflammatory streaking
of surrounding fat, and the presence of an appendicolith. Abscess formation, a
small amount of free air in the RLQ, and a pericecal phlegmon suggest a
perforated appendix.
o In most clinical trials, CT appears superior to ultrasonography in the
evaluation of the acute abdomen. Since CT scans have shown to yield precise
information, it has increasingly become a screening tool for acute appendicitis
in the emergency department. In well-conducted clinical trials, CT scans have
excellent sensitivity and specificity, in the range of 87-100% and 91-97%,
respectively.[15, 16, 17] Again, such good results reported in prospective clinical
trials were not frequently duplicated in routine clinical conditions. Use of CT
scans in patients who have acute appendicitis had risen from 25% to 68% over
a 5-year period and yet the rate of negative appendectomy remained largely
unchanged, suggesting the information obtained from the imaging studies may
not have much influence on the clinical decision-making process.[18]
o One of the potential clinical dilemmas involves the failure of CT scan to
identify a normal appendix. The difficulty in identifying the normal appendix
by CT scan ranges from 44-51% in asymptomatic patients.[19, 20] It is probably
unsafe to assume that nonvisualization of the appendix excludes the diagnosis
of acute appendicitis unless there is a collaborating history or physical
findings. In a patient who has no evidence of inflammation in the ileocecal
region and the appendix is not visualized, there is a chance that the patient
indeed still has acute appendicitis.
Tc-labeled WBC scan: Despite a reported sensitivity of 98% and specificity of 95%,
the time required for performing the scan and its lack of around-the-clock availability
make this a less-than-ideal diagnostic test for appendicitis.[21]
Barium contrast studies
o Historically, a single-contrast barium enema was used to diagnose patients
with atypical signs and symptoms. The goal was to assess the patency of the
appendiceal lumen. In addition, the colonic wall could be examined for
extrinsic mass effects caused by appendicitis.
o Although this remains a simple, inexpensive, and safe study, it has been
largely replaced by ultrasound and CT scanning and is rarely used today.

Diagnostic Procedures

The only diagnostic procedure for acute appendicitis short of open exploration is
diagnostic laparoscopy.

Histologic Findings
A small percentage of normal-appearing appendices have focal appendicitis on microscopic
examination. In addition, early appendicitis may be encountered in the form of increased
interleukin (IL)-2 and tumor necrosis factor (TNF)-alpha secretion, which may not be
detected on gross examination. Approximately 1% of patients have appendicitis from
carcinoid or adenocarcinoma.[3]

Staging
Appendicitis progresses through the following stages: acute or focal appendicitis, suppurative
appendicitis, gangrenous appendicitis, and perforated appendicitis.[9]

Medical Therapy
No medical treatment exists for acute appendicitis.

Surgical Therapy
A total of 17 prospective randomized trials have compared laparoscopic versus open
appendectomy. The two techniques are similar with respect to the negative appendectomy
rate (lap = 14.4% vs open = 14.5%), length of hospital stay (lap = 3 d vs open = 3.7 d), and
intra-abdominal abscess (lap = 1.9% vs open = 0.8%).
Laparoscopic appendectomy appears to have a slightly lower wound infection rate (2.9%)
compared to open appendectomy (7.4%).[5]
The benefits of a laparoscopic approach seem to be more pronounced among obese patients,
where a recent study found a significantly shorter length of hospital stay (lap = 3.4 d vs open
= 5.5 d) and a higher wound closure rate (lap = 90% vs open = 68%).[22]

Preoperative Details
All patients diagnosed with appendicitis should be adequately hydrated with isotonic
intravenous fluids. In addition, broad-spectrum intravenous antibiotics (ampicillin,
gentamicin, and metronidazole or a third-generation cephalosporin and metronidazole) should
be started prior to the operation. Newer single agent, broad-spectrum antibiotics may also be
used, and they are at least as effective as the traditional triple therapy.[23]
Antibiotics, analgesics, or antipyretics should not be administered to patients admitted for
serial examination because these medications may mask the underlying disease process.

To minimize the time from presentation to the time of appendectomy, surgical consultation
should be obtained prior to obtaining additional diagnostic studies, as these tests are often
unnecessary.[3]

Intraoperative Details
The basic technique for open and laparoscopic appendectomy is described below and is
individualized to the authors' preference.[5] Other approaches, suture materials, or techniques
may be used with equal success.

Open appendectomy
Incision: Most surgeons perform appendectomy through a RLQ incision over the McBurney
point (two thirds of the distance between the umbilicus and the anterior superior iliac spine).
The subcutaneous tissue and Scarpa fascia are dissected until the external oblique
aponeurosis is identified. This aponeurosis is divided sharply along the direction of its fibers.
A muscle-splitting technique is then used to gain access to the peritoneum. Once the
peritoneum is entered, any purulent fluid should be cultured.
Delivering the appendix: Small Richardson retractors are placed into the peritoneum, and the
cecum is identified and partially exteriorized using a moist gauze pad or Babcock clamp. The
taenia coli is followed to the point where it converges with the other taenia, leading to the
base of the appendix. The rest of the appendix is then brought into the field of vision. Gentle
manipulation may be required to bluntly dissect any inflammatory adhesions.
Division of the mesoappendix and ligation of the appendix: Once the appendix is
exteriorized, the mesoappendix is divided between clamps, divided, and ligated. The base of
the appendix is clamped after milking potential fecaliths into the lumen of the appendix. The
appendix is then tied off with a 0-polyglycolic (PG) acid suture. The appendix is amputated
and passed off the field as a specimen.
The mucosa of the appendiceal stump may be cauterized to avoid future mucous production.
Inverting the appendiceal stump is not necessary. The cecum and appendiceal stump are then
placed back into the abdomen. The pelvis and the right pericolic gutter are suctioned to
remove any fluid. If no evidence of free perforation exists, further peritoneal lavage is not
necessary and may potentially be harmful; however, if free perforation is encountered, the
authors prefer to thoroughly irrigate the abdomen with warm saline solution. A drain is not
required unless an obvious cavity is present following drainage of a well-developed abscess.
Closure of the incision: The peritoneum is identified, and hemostats are placed on the cut
ends at both apices and the midpoint of the superior and inferior sides. The peritoneum is
closed with a continuous 3-0 PG suture. The inferior oblique muscles are reapproximated
with a figure-of-eight 3-0 PG suture, and the external oblique fascia is closed with a
continuous 2-0 PG suture. The skin may be closed with staples or subcutaneous sutures. Use
of staples is recommended if the appendix was perforated and skin closure is to be performed.
Some authors believe that the skin should be left open in cases of perforated appendicitis,
with delayed primary closure performed on postoperative day 4 or 5.

Laparoscopic appendectomy
A urinary bladder catheter is placed, and the surgeon typically stands on the left side of the
patient. Video monitors are placed at the patient's feet.
A 6-mm infraumbilical incision is made, followed by placement of the Veress needle. After
confirmation of intraperitoneal placement, a pneumoperitoneum (14 mm Hg) is established
and maintained using a carbon dioxide insufflator. The Veress needle is replaced with a 5mm trocar, and a 5-mm, 30-degree laparoscope is used. Alternatively, the 5-mm trocar can be
placed directly into the abdominal cavity using an open cutdown approach.
Under direct visualization, a 12-mm trocar is inserted into the left lower quadrant (LLQ) and
another 5-mm trocar in the right periumbilical region. Through the right periumbilical trocar,
a grasper is used to gain control of the appendix. A small hole in the mesoappendix is made
using a dissector placed through the LLQ port at the base of the appendix. An endogastrointestinal assistant stapler is then used to staple the base of the appendix, and a vascular
reload is used to staple across the mesoappendix.
Once the appendix is free, it is removed through the LLQ port. Appropriate peritoneal
irrigation is then performed. The fascia of the LLQ and infraumbilical port sites are closed
with 0-PG suture, and the skin incisions are closed with subcuticular sutures.

Treatment of perforated appendicitis with abscess

Patients with perforated appendicitis and abscess formation or phlegmon may be treated with
either immediate operative intervention or initial nonoperative management. Although there
are some proponents of immediate surgical intervention, it has been associated with
significantly higher morbidity (odds ratio 3.3) than nonsurgical treatment in a meta-analysis
of 19 studies by Andersson et al.[24]
With nonoperative management, patients are initially treated with broad-spectrum,
intravenous antibiotics alone or in combination with percutaneous aspiration of the abscess
and/or drain placement.[25] Intravenous antibiotics are continued until the patient is afebrile
for 24 hours, has a return of normal gastrointestinal function, and has a normal WBC count
with a normal differential. At this time, patients are switched to oral antibiotics for a total
antibiotic course of 10-14 days.
Traditionally, interval appendectomy is performed 6-8 weeks later. The need for routine
interval appendectomy has recently been challenged given the low incidence of recurrent
appendicitis.[10, 26]

Postoperative Details
If acute appendicitis is encountered, perioperative antibiotics covering skin flora should be
continued for 24 hours. If suppurative appendicitis is encountered, intravenous antibiotics
covering enteric flora should be continued for 48-72 hours and can be safely discontinued
once the patient remains afebrile for 24 hours. In both instances, clear liquids can be started
once the patient is stable from anesthesia, and diet can be advanced as tolerated.
If gangrenous or perforated appendicitis is encountered, continue intravenous antibiotics until
the patient is afebrile and has return of bowel function and a normal WBC count with a
normal differential. Once bowel function returns, clear liquids can be started and the diet
advanced as tolerated. In most patients, a nasogastric tube is not needed.[27]

Follow-up
The patient should return to the clinic 1-2 weeks following discharge for wound evaluation
and discussion of the pathology.
Full activity may resume in 2 weeks following appendectomy if performed through an RLQ
incision. If a midline incision was used, activity should be limited for 6 weeks.

Complications
The overall morbidity rate of appendicitis is approximately 10%. Most perioperative
morbidity is caused by infectious complications. Wound infections occur in approximately
5% of all appendectomies; however, incidence of this complication is related to the stage of
appendicitis. The wound infection rate is 1.4% for nonacute appendicitis, 3% for acute
appendicitis, and 10-15% for perforated or gangrenous appendicitis. Formation of intraabdominal or pelvic abscess following appendectomy occurs in 2-5% of patients. The
incidence is higher for gangrenous or perforated appendicitis (6-8%) compared to early or
suppurative appendicitis (1-2%).[3]
Other complications include persistent ileus, small bowel obstruction, and pulmonary
complications, such as atelectasis and pneumonia. Deep venous thrombosis, pulmonary
embolism, and myocardial infarction have also occurred in the early postoperative period.

Outcome and Prognosis

The outcome following appendectomy for acute or suppurative appendicitis is excellent.
Most patients return to full activity within 2 weeks; however, when perforated appendicitis is
encountered, prolonged hospitalization and additional diagnostic and therapeutic procedures
may be required.
The prognosis for all stages of appendicitis is excellent, with a mortality rate of less than 1%.
This low mortality rate is largely the result of early diagnosis and treatment, antibiotics, and
improved anesthesia care.

Future and Controversies

Controversy continues over the most accurate, cost-effective, and rapid method of making the
diagnosis of atypical appendicitis. Surgical consultation remains the most effective method of
determining what additional diagnostic tools are needed.