Chapter 31

The first descriptions of the appendix date to the 16th century.1–3 Although sketched in the anatomic notebooks of Leonardo da Vinci around 1500, the appendix was not formally described until 1524 by da Capri4 and 1543 by Vesalius.5 Perhaps the first description of a case of appendicitis was by Fernel in 1554,6 in which a 7-year-old girl with diarrhea was treated with a large quince. Soon thereafter, she developed severe abdominal pain and died. Autopsy showed that the quince had obstructed the appendiceal lumen, resulting in appendiceal necrosis and perforation. For the next few centuries, such cases of appendicitis were typically diagnosed at autopsy.

Amyand is credited with the first appendectomy in 1736, when he operated on a boy with an enterocutaneous fistula within an inguinal hernia.7 On exploration of the hernia sac, he discovered the appendix, which had been perforated by a pin resulting in a fecal fistula. As a result of his original description, an inguinal hernia containing the appendix carries Amyand's eponym to this day.8 Nearly 150 years passed until Lawson Tait in London presented the first successful transabdominal appendectomy for gangrenous appendix in 1880.9 Less than a decade later, in 1886, Reginald Fitz of Harvard Medical School first described the natural history of the inflamed appendix, coining the term “appendicitis.”10 In 1889, Charles McBurney of the Columbia College of Physicians and Surgeons in New York presented his series of cases of surgically treated appendicitis and in so doing described the anatomic landmark that now bears his name. McBurney's point is the location of maximal tenderness “very exactly between an inch and a half and two inches from the anterior spinous process of the ileum on a straight line drawn from that process to the umbilicus.”11 In the 1890s, Sir Frederick Treves of London Hospital advocated conservative management of acute appendicitis followed by appendectomy after the infection had subsided12; unfortunately, his youngest daughter developed perforated appendicitis and died from such treatment.

Numerous advances in the diagnosis and treatment of appendicitis have emerged in the past 125 years. Nonetheless, acute appendicitis continues to challenge surgeons to this day.

Embryologically, the appendix and cecum develop as outpouchings of the caudal limb of the midgut loop in the 6th week of human development. By the 5th month, the appendix elongates into its vermiform shape. At birth, the appendix is located at the tip of the cecum, but, because of unequal elongation of the lateral wall of the cecum, the adult appendix typically originates from the posteromedial wall of the cecum, caudal to the ileocecal valve. The appendix averages 9 cm in length,3 with its outside diameter ranging from 3 to 8 mm and its lumen ranging from 1 to 3 mm. The base of the appendix is consistently found by following the teniae coli of the colon to their confluence at the base of the cecum. ...

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