Chapter 48

### Key Points

1. Appendicitis is a very common pediatric disorder.

2. Most cases of appendicitis are secondary to appendix lumen obstruction.

3. Appendectomy, either open or laparoscopic is the treatment of choice for non-complicated (unruptured) appendicitis.

4. Complicated (perforated) appendicitis can be treated with immediate operation, or a delayed procedure if the infection is controlled with antibiotics.

### History

Leonardo da Vinci first depicted the appendix in his anatomic drawings in 1492. Unfortunately, the drawings were not published until the eighteenth century. Consequently, Berengario Da Carpi is credited for the first description of the appendix in 1521.

Although several authors had described the pathology of the appendix, surgeon Lorenz Heister was the first to recognize in 1711 that the appendix might be the location of acute primary inflammation. In 1735, Claudius Amyand incised and drained a scrotal abscess, identified, tied off, and removed a perforated appendix through the scrotal incision. He is therefore credited with the first successful appendectomy.

In 1886, Reginald Fitz presented “Perforative Inflammation of the Vermiform Appendix with Special Reference to Its Early Diagnosis and Treatment” to the Association of American Physicians. Fitz was the first to describe “appendicitis” and suggested immediate surgical intervention (less than 3 days) for spreading peritonitis or deteriorating clinical status. Three years later, Charles McBurney published the first of his papers on appendicitis. He described the most likely location of the appendix 1.5 to 2 inches toward the umbilicus from the anterior superior iliac spine.

### Pathophysiology

The association of fecalomas with perforated appendicitis had been well established since the necropsy period of the 1700s. Consequently, the concept of appendiceal luminal obstruction leading to subsequent inflammation was not new when Wangensteen and Dennis published their “Experimental Proof of the Obstructive Origin of Appendicitis in Man” in 1939.

The etiology of appendicitis in the vast majority of patients is presumed to be based on luminal obstruction of the appendix. Intact mucosa normally secretes fluid into the lumen of the appendix. In the event of obstruction at the base of the appendix, this fluid cannot escape into the cecal lumen, and the intraluminal pressure of the appendix rises. With high pressures, venous drainage is impaired. The wall of the appendix becomes edematous, and ischemia of the mucosa ensues. Concomitant with the breakdown of the mucosal barrier is bacterial invasion of the wall of the appendix, resulting in acute appendicitis, gangrene, and ultimately perforation.

However, the sequence of events described above is not a maxim. There are other scenarios with which the surgeon needs to be acquainted. Should luminal obstruction be relieved as with extrusion of an appendicolith, there will be immediate luminal decompression with relief of symptoms. The appendix will then repair the injury. Even in the event of perforation, if the inflammatory process is well isolated from the rest of the abdomen by omentum and loops ...

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