Chapter 41: Appendix and Small Bowel Diverticula

HISTORY

Although appendicitis is now well recognized as a leading cause of surgically treated abdominal pain, Galen and other early anatomists overlooked the vermiform appendix for centuries.¹ The Renaissance artist, Leonardo da Vinci, became the first to document the existence of the appendix in sketches circa 1500. Subsequently, anatomists da Carpi² and Vesalius³ formally described the appendix in the mid-1500s. Soon thereafter, in 1554, Fernel described the first recorded case of disease of this organ: a 7-year-old girl with diarrhea was administered treatment with a large quince fruit, which obstructed the appendiceal lumen after it was ingested.⁴ She developed severe abdominal pain and died. Autopsy showed the quince fruit obstructing the appendiceal lumen, with resultant appendiceal necrosis and perforation, thereby resulting in the first description, postmortem, of what would later be known as “appendicitis.”

It was not until several centuries later that appendicitis was first diagnosed before autopsy and treated. Amyand is credited with performing the first appendectomy in 1736, when he operated on a child with an inguinal hernia that had been complicated by the development of an enterocutaneous fistula.⁵ On exploration of the hernia sac, he discovered the appendix, which had been perforated by a pin, resulting in an appendicocutaneous fistula. As a result of his original description, an inguinal hernia sac containing the appendix carries Amyand’s eponym.⁶ Nearly 150 years passed before Lawson Tait in London performed the first successful transabdominal appendectomy for a gangrenous appendix in 1880.⁷ Less than a decade later, in 1886, Reginald Fitz of Harvard Medical School described the natural history of the inflamed appendix and coined the term “appendicitis.”⁸ 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 doing so, 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 ilium on a straight line drawn from that process to the umbilicus.”⁹ In the 1890s, Sir Frederick Treves of London Hospital advocated conservative management of acute appendicitis followed by appendectomy after the infection had subsided¹⁰; unfortunately, his youngest daughter developed perforated appendicitis and died from such treatment. The first laparoscopic appendectomy was performed by Kurt Semm in 1980.¹¹ Refinement of the minimally invasive approach is the most recent of numerous advances in the diagnosis and treatment of appendicitis. Nonetheless, acute appendicitis continues to challenge surgeons to this day.

ANATOMY

Embryologically, the appendix and cecum develop as outpouchings of the caudal limb of the midgut loop in the sixth week of human development. By the fifth month, the appendix elongates into its vermiform shape. Containing all layers of the colonic wall, the appendix is, by definition, a true diverticulum. At ...