This document outlines the anatomy, pathophysiology, diagnostic considerations, and management of appendicitis, emphasizing common presentations and risk factors. It discusses imaging studies, laboratory evaluations, and differential diagnoses, providing a detailed overview for effective diagnosis and treatment. Surgical procedures for appendectomy are described step-by-step, highlighting techniques and considerations for various patient populations.

2. Dr Nitin Jha
(MBBS,MS,FIAGES)
Consultant
Laparoscopic,MIS and Bariatric surgeon
FORTIS Hospital, Noida. INDIA
drnitinjha@yahoo.com

4. Anatomic Aspects
Blind pouch off of cecum
Contains lymphoid tissue which peaks in
adolescence, atrophies with age
Function still unclear
Appendix can be anywhere within
peritoneal cavity
One study showed 65 % retrocecal, 31 %
pelvic
Review of 70,000 cases showed 4 % in
RUQ, 0.06 % LUQ, 0.04 % LLQ

6. Pathophysiology of Appendicitis
Lymphoid hyperplasia leads to luminal obstruction
Often follows viral illness
Epithelial cells secrete mucus
Appendix distends, bacteria multiply
Visceral pain begins an average of 17 hours after
obstruction
Increased pressure compromises blood supply
Somatic pain develops
Average time to perforation = 34 hrs.

7. Classic Presentation
Seen in 60 %
Anorexia
Periumbilical pain, nausea, vomiting
RLQ pain developing over 24 hrs.
Anorexia and pain are most frequent
Usually nausea, sometimes vomiting
Diarrhea, esp. with pelvic location
Usually tender to palpation
Rebound is a later finding

9. Physical Exam
Tenderness at McBurney's point
Cutaneous hyperesthesia in T 10 to 12
dermatomes
Rovsing's sign
Psoas sign
Obturator sign

10. High Risk Patients.
Pregnancy
Most common surgical emergency in
pregnancy
Mortality rate if missed = 2 % for mother,
up to 35 % for fetus
WBC elevated in pregnancy
Appendix changes location

11. High Risk Patients, cont'd.
Pediatrics
Most common surgical disorder in kids
Accounts for 5 % of abd. pain visits
Up to 50 % initially misdiagnosed
ƒ < 2 yrs. : perforation rate approaches 100 %
ƒ 3 to 5 yrs. = 71 %
ƒ 6 to 10 yrs. = 40 %
Most common misdiagnosis is AGE
Sequence of pain and vomiting may be helpful
Localized tenderness not a feature of AGE

12. High Risk Patients, cont'd.
Elderly
Vital signs and exam may not reflect
severity
> age 60 : only 5 to 10 % diagnosed
without delay
Perforation rate = 46 to 83 %
RLQ tenderness absent in 23 %
N/V, anorexia less common
Leukocytosis less pronounced
Only 20 % classic presentation

13. High Risk Patients, cont'd.
Immunocompromised
HIV, chronic steroids, sickle cell,
chemotherapy, DM, dialysis
Increased risk of complications and
misdiagnosis
Inflammatory response decreased

14. Differential diagnostics
Gastrointestinal
•Cholecystitis
•Crohn's disease
•Duodenal ulcer
•Gastroenteritis
•Intestinal obstruction
•Meckel's diverticulitis
•Mesenteric lymphadenitis
•Necrotizing enterocolitis
•Neoplasm (carcinoid,
carcinoma, lymphoma)
Gynecologic
•Ectopic pregnancy
•Endometriosis
•Ovarian torsion
•Pelvic inflammatory
disease
•Ruptured ovarian cyst
•Tubo-ovarian abscess

15. Systemic
 Diabetic ketoacidosis
 Henoch-Schonlein
purpura
Pulmonary
 Pleuritis
 Pneumonia (basilar)
 Pulmonary infarction
Genitourinary
 Kidney stone
 Pyelonephritis
 Wilms' tumor
Other
 Parasitic infection
 Psoas abscess
 Rectus sheath hematoma

16. Laboratory Studies
CBC
75 to 85 % have elevated WBC, but it is
nonspecific
WBC normal in 80 % in the first 24 hrs.
Can see elevated ANC in up to 89 %
WBC usually 12 to 18,000 in appendicitis
Chemistry panel
May help with diagnosis of dehydration

17. Laboratory Studies, cont'd.
Urinalysis
Specific gravity, ketones
Can see WBC’s, RBC’s, bacteria if inflamed
appendix close to ureter
> 30 WBC’s = probable UTI
HCG
Essential in women of child-bearing age
CRP
Acute phase reactant

18. Imaging Studies
Plain films
Low sensitivity and specificity
Appendicolith specific, but seen in only 2 %
May see local air-fluid levels, psoas
obliteration, soft tissue mass, gas in
appendix : all nonspecific

19. Imaging Studies, cont'd.
Ultrasound
75 to 90 % sensitive, 86 to 100 % specific
Noninvasive, low cost, but operator-
dependent
Good for diagnosing GYN disorders
3 criteria for diagnosis
ƒ Tender, noncompressible appendix
ƒ No peristalsis of appendix
ƒ Overall diameter > 6 mm

20. Imaging Studies, cont'd.
CT
Early studies showed low yield, but helical
CT much more accurate
Sensitivity 97 to 100 %, specificity 95 %
(similar no matter what type or whether
contrast is used)
Often shows alternative diagnosis
More expensive, radiation exposure

21. Imaging Studies, cont'd.
CT
Criteria for appendicitis :
ƒ Diameter > 6 mm
ƒ Failure to completely fill with contrast or
air
ƒ Appendicolith
ƒ Wall thickening or enhancement
Other contributory signs include fat
stranding, fluid, inflammatory mass,
adenopathy

22. Imaging Studies, cont'd.
CT
One study showed negative laparotomy
rates of 4 % in men, 8 % in ovulating
women with CT (typical is 20 % and 45 %
respectively), but no change in perforation
rate
Another study showed increase in CT use
led to earlier diagnosis, less severe
pathologic findings, and decreased length
of stay

23. Do We Need Imaging Studies?
Literature conflicting
Pediatric Imaging -Evidence-Based
Guidelines
Imaging most useful in clinically equivocal
cases
Costs of imaging minor compared to cost
of unnecessary surgery or delayed
diagnosis
US and CT both specific enough to rule in
appendicitis, but only CT sensitive enough
to rule it out

24. Risk Management
Misdiagnosis of appendicitis = 5th
leading cause of successful litigation
against EPs
7 features of misdiagnosed cases :
No nausea / vomiting
Lack of distress
No rebound
No guarding
No rectal exam (controversial)
Narcotic pain meds given
Diagnosis of acute gastroenteritis

25. Risk Management, cont'd.
When discharging, stress unclear
diagnosis, what to watch for
Follow up in 12 hours (PMD or E.D.)
Can always observe if unsure
"When in doubt, don't send them out."

26. TREATMENT
 1. OPEN APPENDECTOMY
2. Standard LAP APPENDECTOMY
3. SILS APPENDECTOMY

33.  Patient is supine,
laying flat
 Surgeon and
assistant
positioned on
patient’s left
 Monitors on
patient’s right,
facing surgeons
 Anesthesiologist
conventionally
stationed at
patient’s head
(not shown)

34.  10-mm trocar
placed through
umbilicus (this
port holds camera)
 5-mm trocar
placed at
suprapubic region
 5-mm trocar
placed at LLQ
 *A fourth port containing
extraction tube may be
placed closer to McBurney’s
point later in procedure.

35. Step 1: Port placement A 10-mm trocar is placed
at the umbilicus, and the abdominal cavity is
insufflated to a pressure of 15 mmHg. The
camera is also inserted through this larger trocar.
A 5-mm trocar is placed at the suprapubis, and a
second 5-mm trocar is placed at the LLQ.
(Placement of the third port may vary by surgeon
preference or as case dictates but LLQ is standard
placement)
Step 2: Inspect abdominal cavity The area is
inspected to orient the surgeon to the position of
the appendix. Inspection will also alert surgeon to
any anatomic variation or pathological conditions
that may be relevant (e.g. peritonitis).

36. Step 3: Expose appendix The bowel is
gently retracted rostrally using
atraumatic graspers to allow access to
appendix.
Step 4: Locate and separate appendicular
artery The mesoappendix is separated
from the body of the appendix, and the
mesenteric fat is separated to reveal the
appendicular artery. This is best done
using the “spreader” action of a
dissector.

37. Step 5: Divide appendix from cecum
Using an endoloop, two loops are placed
proximal to the cecum, and a third loop is
placed 1-2 cm distally to these. The
appendix is then divided between the
two proximal and 3rd distal loops using
scissors or cautery. Staples may be
substituted for loops.
UK surgeons tend to use the Endo GIA
tool, which simultaneously seals and
cuts, eliminating the need for loops or
staples.
Step 6: Divide appendicular artery The
artery is divided using the Endo GIA or
the endoloop method described above
(two ligatures proximally, one distally).

38. Step 7: Extract appendix A fourth
port (10 mm) may be placed
containing the extraction tube.
Alternately, the camera may be
withdrawn and the existing 10 mm
port used for extraction (a 5 mm
camera is inserted into one of the
smaller ports in these cases).
In either case, an extraction tube is
placed through the appropriate 10
mm port, and the extraction
bag tool is placed through the extraction tube. The appendix is placed in the
capture bag, and removed from the abdomen through the extraction tube.
*(It should be noted that in the accompanying video, a non-conventional extraction technique is used,
probably because the appendix had already ruptured and the extraction bag was deemed unnecessary. The
image above comes from a different case.)

39. Step 8: Irrigate The abdominal
cavity should be irrigated
thoroughly with sterile saline and
suctioned clean several times. In the
event of a rupture, great care should
be taken to ensure all pus or other
infectious fluids have been
removed.
Step 9: Final inspection The
abdominal and pelvic cavities are
inspected one final time for any signs
of infection, errors, or other potential
complications of which the surgeon
might need to be aware. This can
often be done simultaneously with
irrigation.

40.  VIDEO