One of the most common surgical emergencies globally is appendicitis.1 Although it appears that the incidence of appendicitis in North America has declined, this is not so in other countries. In many developing countries, appendicitis still accounts for most surgical cases.2 For general surgeons, appendicitis can be a dilemma and a nuisance because the disorder frequently presents at night and during the weekends. Fortunately, in most cases, appendicitis is uncomplicated and easily treated with a surgical procedure.
Appendicitis may occur due to obstruction of the lumen from food, adhesions, tumor or enlarged lymph nodes. The blockage of the lumen leads to an increased accumulation of mucosal secretions that tend to increase intraluminal pressure. When this pressure exceeds capillary and venous pressure, there is vascular compromise. The mucosal surface breaks down, leading to invasion by bowel flora and then to an infection.
Removal of the inflamed appendix is not a novel idea. In 1735, a surgeon in the English army named Amyan was credited with reporting the first appendectomy. At that time, there was no anesthesia and lack of antibiotics — thus removing the appendix was associated with high morbidity and mortality. Reginald Fitz, of Boston, was first to describe the pathology of the appendix and recommend early surgical intervention. Unfortunately, because he was a pathologist, most surgeons ignored his advice. Toward the end of the 19th century, English surgeon H. Hancock performed a successful appendectomy and later described the surgical technique. However, it was the American C. McBurney who finally characterized the symptoms, diagnosis and surgical approach to appendicitis. During the past 50 years, many thousands of open appendectomies have been performed worldwide. Over the years, the morbidity and mortality has decreased substantially thanks to improved antibiotics, earlier diagnosis, improvements in anesthesia and refined surgical techniques.
The appendix is a tubular structure arising from the medial aspect of the cecum. It measures 5 cm to 8 cm and may play a role in some type of immune function. The appendix tip is variable in its location on the cecum, thus causing variations in its clinical presentation when inflamed. The most common position of the appendix tip is retrocecal, followed by pelvic and paracecal locations. The blood supply to the appendix is from the ileocolic artery; however, it may also arise from the cecal artery in more than 20% of cases.3
The classic feature of appendicitis includes vague pain that starts in the periumbilical area and then settles into the right lower quadrant. The majority of people with appendicitis will present with right lower quadrant pain, mildly elevated white blood cell count (WBC) and a low-grade fever. In most cases, WBC is within normal limits. Other common symptoms include nausea, loss of appetite and diarrhea or constipation.
The physical exam
is usually the key to the diagnosis. Most patients will have localized peritonitis with signs of rebound and guarding. A physical exam may reveal pain at McBurney’s point
. Other features may be Rovsing’s sign, which is discovered by applying hand pressure to the lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of pressure on the left side indicates the presence of Rovsing’s sign. A rectal exam can be painful if the patient has an inflamed retrocecal or pelvic appendix.4
There are, however, many exceptions to this classic presentation. For example, in pregnancy, the appendix may shift and present with right upper quadrant pain. In some men, the retrocecal appendix can irritate the ureter, and cause difficult or painful discharge of urine and scrotal or urethral pain.5 (Level C)
The most common disorders in women that confuse the diagnosis of appendicitis are ovarian cysts, ectopic pregnancy, ovarian torsion, a Meckel’s diverticulum and midcycle pain.
CT scans have changed the way we manage appendicitis. This radiological imaging study can help decrease unnecessary appendectomies in women, but it has not been proven to be useful in management of men with suspected appendicitis.
Ultrasound is widely used to assess the presence of appendicitis. The basis of this technique is that the inflamed appendix cannot be compressed where a normal appendix can; however, ultrasound is limited in diagnostic ability if a retrocecal appendix is present, and perforations may be missed easily.6,7
Indications for Appendectomy
Appendicitis is a surgical disorder, and once a diagnosis is suspected, treatment is prompt surgery.3
If diagnosis is in doubt, the patient must be admitted and observed for at least for 12 to 24 hours. Today, many surgeons use ultrasound and/or CT scan to help increase the accuracy of diagnosis.7 (Level C)
Any patient with suspected appendicitis who is discharged from the ED should be told to return to the ED if symptoms continue or recur. There is no test that can reliably exclude appendicitis.
Generally, there are no reasons why an appendectomy cannot be done; one exception is when a ruptured appendix has developed a localized large collection of pus. In such a scenario, surgeons tend to observe the patient and treat the condition with IV antibiotics. Percutaneous drainage of the pus is often done, and after about four to six weeks, the appendix is removed (interval appendectomy).
Once the diagnosis is confirmed, the patient needs urgent surgery. The procedure is usually performed in the main OR theater. IV access is required for hydration, antibiotics (usually 1 g Cefazolin IV [Ancef, Kefzol]), and anesthesia administration.
Antibiotic selection is based on the patient’s weight and history of sensitivity or intolerance to antibiotics. Pre-surgical administration attempts to target the most common organisms, and the antibiotic needs to reach a therapeutic blood serum level to be effective in prophylaxis. Unnecessary broad-spectrum antibiotics are ineffective and result in future ineffectiveness in antimicrobial therapy. Impaired renal function of the patient should be addressed when deciding dosage.
Painkillers should not be administered to a patient with suspected appendicitis until the surgeon has seen the patient, as narcotics can mask pain and delay the diagnosis. Once the diagnosis is confirmed, parenteral analgesics can be administered.
An indwelling catheter is required for a laparoscopic procedure but not for an open appendectomy. This is done to avoid puncturing the bladder when the trocars are inserted into the abdomen. The catheter is usually removed at the end of the procedure.
Open Appendectomy Versus Laparoscopic Appendectomy
Traditional surgical removal of the appendix has been via a small surgical incision. A tiny skin incision made in the right lower quadrant still remains the gold standard and saves operating time and cost.
Surgical procedure (open or laparoscopic appendectomy) is determined by time of presentation, sex of the patient and past history. In women, where the diagnosis may also include gynecological pathology, many surgeons will attempt a diagnostic laparoscopy.8,9 Controversy exists as to which technique is better; in general, the choice between open versus laparoscopic is surgeon preference. Both laparoscopic and open appendectomies are performed under general anesthesia.
Advantages of using the laparoscopic approach include decreased postoperative pain, significantly improved cosmetic result, shorter recovery time, fewer wound infections, decreased incidence of hernias and faster return to normal activities of daily living. Laparoscopy also offers a distinct cosmetic advantage when compared to the open technique. If the surgeon is not hurried and has assistance, laparoscopy is the recommended procedure. Moreover, in any patient in whom the diagnosis of right lower quadrant pain remains in doubt, laparoscopic technique is far superior to the open technique for visualizing abdominal and pelvic organs.10
Laparoscopic appendectomy is slightly more expensive and requires a somewhat longer operating time interval.11,12 Even more training, operating times are still slightly longer than with the open method. Small studies indicate that there are no differences between these two techniques when it comes to development of pelvic abscess or hospital stays.13-15
Unlike an open appendectomy, a laparoscopic procedure is not suitable for all people with appendicitis.10 Those who have had prior abdominal surgery may have adhesions, making the procedure dangerous. Others who have prior radiation, heart failure, severe liver cirrhosis or coagulopathy or who have taken immunosuppressive drugs may not be suitable for a laparoscopic procedure. Pregnancy, especially during the first trimester, is another contraindication. Laparoscopic surgery is also contraindicated if cancer of the appendix is suspected. Performing a laparoscopic procedure in such a scenario may cause seeding of cancerous cells in the ports, leading to the advanced spread of the disease. Finally, the procedure should not be done if the surgeon has no expertise or cannot visualize the appendix.12