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Appendectomy

  • Author: Luigi Santacroce, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Oct 26, 2015
 

Background

In recent years, the incidence of appendicitis has markedly decreased. Nevertheless, appendicitis remains one of the more common surgical emergencies, and appendectomy remains the treatment of noncomplicated appendicitis.

The first report of an appendectomy came from Amyan, a surgeon of the English army. Amyan performed an appendectomy in 1735 without anesthesia to remove a perforated appendix. Fitz, an anatomopathologist at Harvard who advocated early surgical intervention, first described appendicitis in 1886; however, because he was not a surgeon, his advice was ignored for a time. Then, at the end of the 19th century, Hancock successfully performed the first appendectomy in a patient with acute appendicitis. Some years after this, McBurney published a series of reports that constituted the basis of the subsequent diagnostic and therapeutic management of acute appendicitis.

Thousands of classic appendectomies (ie, open procedure) have been performed in the past two centuries. Mortality and morbidity have gradually decreased, especially in the past few decades, because of antibiotics, early diagnosis, and improvements in anesthesiologic and surgical techniques.

For patient education information, see the Digestive Disorders Center, as well as Appendicitis and Abdominal Pain in Adults.

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Indications

Patients with appendicitis always need urgent referral and prompt treatment. Consider an appendectomy for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present.

If the clinical picture is unclear, a short period (4-6 hours) of watchful waiting and a computed tomography (CT) scan may improve diagnostic accuracy and help hasten the diagnosis.[1] However, if a patient is discharged from the medical center without a definite diagnosis at the end of the observation period, instruct him or her to return if symptoms continue or recur; a follow-up examination in 24 hours may be beneficial.

A retrospective study by Kim et al, designed to determine whether acute nonperforated appendicitis is a surgical emergency that necessitates immediate intervention or a condition that can be treated with a semielective approach, found that delaying appendectomy for 12-24 hours was safe for patients with acute nonperforated appendicitis.[2]

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Contraindications

No contraindications to appendectomy are known for patients with suspected appendicitis, except in the case of a patient with a long history of symptoms and signs of a large phlegmon. If a periappendiceal abscess or phlegmon exists secondary to appendiceal perforation or rupture, some clinicians may choose a conservative approach with broad-spectrum antibiotics and percutaneous drainage followed by appendectomy later (interval appendectomy).

Certain contraindications exist for laparoscopic appendectomy, including extensive adhesions, radiation or immunosuppressive therapy, severe portal hypertension, and coagulopathies. Laparoscopic appendectomy is contraindicated in the first trimester of pregnancy.

Rarely, an appendiceal mucocele (ie, a collection of mucus within the appendiceal lumen) may occur. Occasionally, patients may present with a low-grade carcinoma of the appendix or the cecum. In such cases, the surgeon must avoid perforation during dissection, because it may cause seeding of the peritoneum with viable cells, leading to pseudomyxoma peritonei.

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Technical Considerations

Procedural planning

Patients with appendicitis always need urgent referral and prompt treatment. An appendectomy is generally indicated for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present (see Indications).

For reasons of time and cost, open appendectomy is the most common approach. However, an increasing number of surgeons prefer laparoscopic appendectomy, especially in female patients, because of its diagnostic ability (see Technique).

If, on open appendectomy, the surgeon finds an apparently normal appendix, he or she is faced with a dilemma: remove the appendix or leave it in place? The argument for performing appendectomy is that even if the appendix is not removed, the patient will have a scar from a right-lower-quadrant incision. In the future, this may lead those who examine the patient to assume that an appendectomy has already been performed, in which case they will not include appendicitis in the differential diagnosis.

At the opposite extreme, in the past, appendicitis sometimes was so severe that the cecum appeared necrotic. Today, this finding is fortunately very rare. In such cases, perform an ileocecectomy or right hemicolectomy with a primary anastomosis.

Laparoscopic appendectomy has now been improved and standardized.[3]  It has some advantages over open appendectomy, including decreased postoperative pain, better aesthetic result, a shorter time to return to usual activities, and lower incidence of wound infections or dehiscence. Although cost-effective, it may require more operating than the corresponding open procedure. Kouhia et al found that by 2008, operating time was only 10 minutes longer with laparoscopic appendectomy than with the open approach; in addition, patients who underwent open appendectomy returned to work later and had more complications.[4]

The reported results of laparoscopic and open appendectomies seem to overlap. In fact, the average rates of abdominal abscesses, negative appendectomies, and hospital stays are very similar, according to an overview of 17 retrospective studies.[5]  In a study comparing laparoscopic and open appendectomy for complicated appendicitis in adult patients, Taguchi et al found that the minimally invasive approach was safe and feasible in this setting, though it did not significantly reduce complications.[6]

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Outcomes

Whether appendicitis is simple or complicated (ie, with gangrene or perforation), the prognosis is excellent and outcome is good, In fact, no mortality has been reported in patients with a nonperforated appendix. Mortality is lower than 1% if appendiceal perforation exists. An exception is elderly patients, who have a mortality that approaches 5%. An intermediate mortality (1-4%) is reported in infants because of the high frequency of perforation caused by delayed diagnosis due to the difficulties in distinguishing appendicitis from other conditions in the differential diagnosis.

Overall, patients may return to their activities soon after the operation. Once the patient has recovered, no changes in lifestyle (eg, diet, exercise) are required after appendectomy.

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Contributor Information and Disclosures
Author

Luigi Santacroce, MD Assistant Professor, Medical School, State University at Bari, Italy

Disclosure: Nothing to disclose.

Coauthor(s)

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh School of Medicine; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Oscar Joe Hines, MD Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine

Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Tommaso Loasacco, MD, to the development and writing of this article.

References
  1. Bachar I, Perry ZH, Dukhno L, Mizrahi S, Kirshtein B. Diagnostic Value of Laparoscopy, Abdominal Computed Tomography, and Ultrasonography in Acute Appendicitis. J Laparoendosc Adv Surg Tech A. 2013 Oct 17. [Medline].

  2. Kim SH, Park SJ, Park YY, Choi SI. Delayed Appendectomy Is Safe in Patients With Acute Nonperforated Appendicitis. Int Surg. 2015 Jun. 100 (6):1004-10. [Medline].

  3. Pham VA, Pham HN, Ho TH. Laparoscopic appendectomy: an efficacious alternative for complicated appendicitis in children. Eur J Pediatr Surg. 2009 Jun. 19(3):157-9. [Medline].

  4. Kouhia ST, Heiskanen JT, Huttunen R, Ahtola HI, Kiviniemi VV, Hakala T. Long-term follow-up of a randomized clinical trial of open versus laparoscopic appendicectomy. Br J Surg. 2010 Sep. 97(9):1395-400. [Medline].

  5. Chung RS, Rowland DY, Li P, Diaz J. A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg. 1999 Mar. 177(3):250-6. [Medline].

  6. Taguchi Y, Komatsu S, Sakamoto E, Norimizu S, Shingu Y, Hasegawa H. Laparoscopic versus open surgery for complicated appendicitis in adults: a randomized controlled trial. Surg Endosc. 2015 Aug 15. [Medline].

  7. Karamanakos SN, Sdralis E, Panagiotopoulos S, Kehagias I. Laparoscopy in the emergency setting: a retrospective review of 540 patients with acute abdominal pain. Surg Laparosc Endosc Percutan Tech. 2010 Apr. 20(2):119-24. [Medline].

  8. Cho J, Park I, Lee D, Sung K, Baek J, Lee J. Risk Factors for Postoperative Intra-Abdominal Abscess after Laparoscopic Appendectomy: Analysis for Consecutive 1,817 Experiences. Dig Surg. 2015. 32 (5):375-81. [Medline].

  9. Kim HJ, Lee JI, Lee YS, Lee IK, Park JH, Lee SK, et al. Single-port transumbilical laparoscopic appendectomy: 43 consecutive cases. Surg Endosc. 2010 Nov. 24(11):2765-9. [Medline].

  10. Kössi J, Luostarinen M. Initial experience of the feasibility of single-incision laparoscopic appendectomy in different clinical conditions. Diagn Ther Endosc. 2010. 2010:240260. [Medline]. [Full Text].

  11. Golebiewski A, Losin M, Murawski M, Wiejek A, Lubacka D, Czauderna P. One, two or three port appendectomy - a rational approach. Wideochir Inne Tech Malo Inwazyjne. 2013 Sep. 8(3):226-31. [Medline]. [Full Text].

  12. Lee J, Baek J, Kim W. Laparoscopic transumbilical single-port appendectomy: initial experience and comparison with three-port appendectomy. Surg Laparosc Endosc Percutan Tech. 2010 Apr. 20(2):100-3. [Medline].

  13. Zilbert NR, Stamell EF, Ezon I, Schlager A, Ginsburg HB, Nadler EP. Management and outcomes for children with acute appendicitis differ by hospital type: areas for improvement at public hospitals. Clin Pediatr (Phila). 2009 Jun. 48(5):499-504. [Medline].

  14. Uludag M, Isgor A, Basak M. Stump appendicitis is a rare delayed complication of appendectomy: A case report. World J Gastroenterol. 2006 Sep 7. 12(33):5401-3. [Medline].

 
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Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.
Computed tomography scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.
Computed tomography (CT) study of appendicitis. Intravenous (IV) contrast was administered to the patient, who had gram-negative sepsis but no abdominal pain on examination. Left, an inconclusive CT scan after administration of oral contrast but no IV contrast. Right, a repeat CT scan study following administration of IV contrast demonstrates the thickened, enhanced appendiceal wall and periappendiceal changes. The retrocecal location of the appendix may have attenuated abdominal symptoms.
Suppurative appendicitis; transverse view, color Doppler ultrasound image. Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strong indicator of acute appendicitis.
Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled white blood cells in the right lower quadrant, a finding that is consistent with acute appendicitis.
Sagittal graded compression transabdominal ultrasonogram shows an acutely inflamed appendix. The tubular structure is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.
Transverse graded compression transabdominal ultrasonogram of an acutely inflamed appendix. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection.
Perforated Appendicitis
 
 
 
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