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Acute Appendicitis & Appendectomy - A Complete Guide

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1. What is the Appendix?

• It arises from the cecum where the three taenia coli converge
• Blood supply comes from the appendiceal artery, a branch of the ileocolic artery
• Its tip can point in different directions - most commonly retrocecal (64%), subcecal (32%), pelvic (2%), or preileal/postileal positions. This is why pain location can vary between patients.

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2. What is Acute Appendicitis?

• Global incidence: 100-150 per 100,000 people per year
• Lifetime risk: 7-10%
• In the USA: ~400,000 cases per year; 16-40% are perforated at diagnosis

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3. What Causes It? (Pathophysiology)

Obstruction → Bacterial overgrowth → Mucus buildup → Distension
       ↓
Venous congestion → Arterial blockage → Ischemia → Gangrene
       ↓
                PERFORATION + ABSCESS

• Current Surgical Therapy 14e, p. 324

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4. Symptoms - What Does It Feel Like?

Key Physical Signs

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5. How Is It Diagnosed?

Blood Tests

• WBC (leukocytosis) - elevated in ~80% of cases
• CRP (C-reactive protein) - elevated, useful with WBC
• Negative urine culture (rules out UTI)
• Negative pregnancy test (rules out ectopic)

The Alvarado Score (MANTRELS)

• Score 1-4: Low risk (likely not appendicitis)
• Score 5-6: Intermediate (consider imaging)
• Score 7-10: High risk (likely appendicitis, consider surgery)

Imaging

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6. Treatment

Option A: Antibiotics Alone (Non-Operative Management / NOM)

• Recent studies show antibiotics can be effective as primary treatment
• Success rate ~70-80% at 1 year; 20-30% eventually need appendectomy
• Antibiotic of choice: piperacillin-tazobactam (IV), then oral step-down

Option B: Surgery (Appendectomy) - Definitive Treatment

• Perforated appendicitis
• Abscess formation
• Failed antibiotic therapy
• Fecalith present on imaging

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7. The Surgery - Appendectomy

A. Laparoscopic Appendectomy (Preferred, Modern Approach)

1. Anesthesia - General anesthesia (patient is fully asleep)
2. Positioning - Patient lies flat (supine); may tilt left-side-down during surgery for better view
3. Port placement - Three small cuts (~5-12 mm):
   • Port 1: At the belly button (camera/umbilical port, 12 mm)
   • Port 2: Left lower abdomen (5 mm working port)
   • Port 3: Right lower abdomen or suprapubic (5 mm working port)
4. Insufflation - CO₂ gas pumped in to inflate the abdomen (12-15 mmHg) so the surgeon can see
5. Find the appendix - Follow the cecum to where the taenia coli converge
6. Divide the mesoappendix - Using a stapler or energy device (Ligasure), the blood vessels are cut
7. Divide the appendix base - Stapler or Endoloop tie used to close and cut the appendix off
8. Remove the appendix - Placed in a bag and pulled out through the belly button port
9. Irrigate - If infected fluid is present, it is washed out
10. Close - Small cuts are sutured/stapled closed

• Smaller scars
• Less pain after surgery
• Faster recovery (home in 1-2 days typically)
• Lower wound infection rate
• Better visibility for diagnosis

B. Open Appendectomy (Traditional Approach)

• Laparoscopy not available
• Severe perforation with difficult anatomy
• Dense adhesions

1. General anesthesia
2. A 3-4 cm incision at McBurney's point (right lower quadrant) - this is called a Lanz incision or gridiron incision
3. Muscles are split (not cut) to reach the peritoneum
4. Appendix is identified and delivered into the wound
5. Mesoappendix is ligated and divided
6. Appendix base is tied and divided
7. Stump may be inverted with a purse-string suture
8. Layers closed in sequence

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8. Perforated vs. Uncomplicated Appendicitis

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9. Special Situations

Appendiceal Abscess / Phlegmon

• When the appendix perforates and the body walls it off
• Treatment: Interval approach - IV antibiotics + possible CT-guided drainage, then interval appendectomy 6-8 weeks later
• This avoids operating in a "dirty" inflamed field

Pregnancy

• Most common surgical emergency in pregnancy
• Appendix is displaced upward as the uterus grows (but less than classically taught - only moves >25% in late pregnancy)
• Ultrasound first; MRI if inconclusive; CT if needed and life is at risk
• Surgery is safe at any trimester; laparoscopy is safe in first and second trimester

Children

• Perforation is much more common in children (up to 40-70% at presentation)
• Because children cannot describe pain well and diagnosis is delayed
• Pediatric Appendicitis Score (PAS) is used alongside Alvarado

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10. Postoperative Care & Complications

Recovery (Typical)

• Laparoscopic: Home in 1-2 days; back to normal activities in 1-2 weeks
• Open: Home in 2-4 days; back to normal in 2-4 weeks
• Diet: Clear liquids first, then regular diet as tolerated
• Pain: Managed with oral medications (NSAIDs + paracetamol)

Possible Complications

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11. Summary Diagram - The Full Picture

Normal Appendix
      |
   OBSTRUCTION (fecalith/lymphoid tissue)
      |
   Bacteria multiply + mucus builds up
      |
   Distension → Periumbilical pain + nausea
      |
   Venous congestion → Ischemia
      |
   Pain moves to RLQ (McBurney's point)
      |
   NECROSIS → GANGRENE
      |
   PERFORATION → Peritonitis / Abscess / Sepsis
      |
   SURGERY (Appendectomy) or IV Antibiotics

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Quick Reference Card

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