Chapter 12: Appendix Surgery

Introduction

Into the 18th century, descriptions of inflammatory diseases of the appendix appeared only as solitary case reports with conflicting nomenclature and an unclear natural history.¹ Only in the mid-19th century, when nitrous oxide and chloroform anesthesia granted a degree of safety to laparotomy, did early operation for appendicitis gain favor.¹ In contrast to these humble beginnings, appendectomy is now the most common emergency operation in the United States, with more than 300,000 appendectomies performed annually.²

Acute appendicitis arises from luminal obstruction by external compression (eg, lymphadenopathy) or internal obstruction by fecalith, tumor, ingested debris, or more rarely, parasites. If untreated, mucosal and serosal ischemia develops, followed by perforation with resultant peritoneal contamination and sepsis. The rise of antibiotics as a complement to surgical management has markedly decreased the septic consequences and mortality associated with this disease.

The diagnosis and management of appendicitis have changed in recent decades. Perhaps most significant is the acceptance of the laparoscopic approach for appendectomy, which will be discussed in this chapter.³ New imaging modalities, including computed tomography and ultrasound, have improved preoperative diagnosis and reduced the traditional 20% negative appendectomy rate associated with diagnosis on the basis of physical examination alone.⁴ Increasing use of clinical scoring systems has further refined diagnostic accuracy.^5,6 Controversies persist, however, particularly regarding the utility of interval appendectomy for complex appendicitis,⁷ the use of irrigation in laparoscopic appendectomy,⁸ and guidelines for nonoperative versus operative management.⁹

Historically, patients and surgeons have been reluctant to approach appendicitis nonoperatively, and randomized clinical trials demonstrate very high dropout or crossover rates from nonoperative arms.¹⁰ As a result, most studies evaluating appendicitis are small and observational, with few randomized controlled trials. Similarly, the data on appendiceal cancers, which are rare but clinically relevant, exist primarily in the form of case series.¹¹ This chapter will review the available evidence directing the management of appendicitis and appendiceal malignancy, with the caveat that data quality is poor. Despite the paucity of rigorous studies, the importance of appendiceal disease to general surgery practice warrants careful consideration of the available data.

a. Laparoscopic versus Open Appendectomy

Laparoscopic versus open appendectomy: Outcomes comparison based on a large administrative database.

SYNOPSIS

Takeaway Point: Laparoscopic appendectomy is associated with decreased length of hospital stay, decreased in-hospital morbidity, and increased rate of routine discharge compared with open appendectomy.

Commentary: Despite numerous case series and small randomized clinical trials, for years after the introduction of laparoscopic appendectomy there was no clear consensus regarding the comparative effectiveness of the laparoscopic versus open approach. This is the first study comparing length of hospital stay, in-hospital mortality and morbidity, ...