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54
Appendicitis
Kurosh Paya
Although Leonardo da Vinci has already illustrated
the appendix in his anatomic drawings in 1492, a first
anatomic description of a vermiform appendix was
not done before 1521 by Berengario DaCarpi.1
Certainly much more older are descriptions of an
appendicitis of an Egyptian mummy from Byzanz.
Reports on an appendicitis were first published by Jean
Fernel 1544 and von Hilden 1652. These were followed
by impressive reports on perforations of the appendix
by L Heister, Mestivier and J Hunter in the 18th
century. The first appendectomy was performed 1735
by C Amyand on an eleven-year old boy who
developed appendicitis in the region of a scrotal
hernia. In 1827, F Melier proposed the surgical
treatment of appendicitis as standard therapy but was
stubbornly ignored. For a long time the treatment of
appendicitis remained a domain of internists who
treated the patients with opium and bed rest as well
as with drainage in case of abscesses. In 1886, Reginald
Heber Fitz from Boston, for a short period a scholar
also of the famous R Virchow in Vienna, imprinted
the term “appendicitis” and also demanded an early
surgical treatment and resection of the appendix,
respectively. At that time chloroformism as well as
Lister’s principles of asepsis have met with approval.
Since it was clear at the end of the 19th century
that vermiform appendix was responsible for two-
thirds of all cases of fatal peritonitis, a basis for
diagnosis and treatment of this disease was rapidly
found. Already in 1889, numerous reports on the
surgical therapy of appendicitis were published
among others also by McBurney. In 1894, he reported
on a new surgical method which he had taken over
from his colleague JB Murphy and published for the
first time, the gridiron.2 This method made it’s way
worldwide and is now accepted as standard. Already
ten years later Murphy was able to report on 2,000
accomplished appendectomies in the American
Journal of Medical Sciences.3 But not till the era of
antibiotics in the fifties of our century appendicitis
could loose the nimbus of an extremely dangerous
disease. In 1910 the operative mortality, for a country
like Switzerland, lay in the range of 6.2% compared to
a cumulative mortality of 5.7 %.4 Appendectomy now
represents one of the most important abdominal
teaching operations for young surgeons.1,5 Today
appendicitis is the most frequent indication for
operation in the childhood and in general
appendectomy presents the third-most operation
worldwide.
EPIDEMIOLOGICAL FACTS
In the USA, about half a million appendectomies are
performed every year which accords with an incidence
of 260/100,000 inhabitants. There are similar numbers
in Europe. For instance, in Austria approximately
20,000 in 1998 and in France about 200,000
appendectomies were performed in 1996 (Table 54.1).
Table 54.2 outlines the morbidity and mortality in
India.
ANATOMIC AND HISTOLOGIC BASICS
The vermiform appendix develops from a common
gemma with the cecum in the distal part of the
primitive intestinal loop between the 6th and 8th
embryonic week, and exists in this type only in
primates. It becomes visible from the 8th week of
development; at this time in the child, the appendix
has a length of about 10 cm. The appendix is an about
Diagnostic Laparoscopy 597
Appendicitis 597
Table 54.1: Appendectomies/100,000 inhabitants in different countries6
• Less than the half of these patients do really have appendicitis (110/100,000). Therefore, nearly 50% are so-called “negative”
appendectomies - appendectomies without an inflamed vermiform appendix. Especially in young women this rate can be
2.5 times higher than in the respective male population. This can be explained by the insecure diagnostic demarcation to
other causes of pain in the right hypogastric zone in women, and by the known increased morbidity and mortality in cases of
an overlooked appendicitis. In general the incidence of newly diagnosed appendicitis is slightly but steadily retrograde. This
process cannot be explained by now but in the last decades, for some regions there is reported upon a decrease of up to
46%.7 Apparently also genetic factors seem to play an important role in the disease process. The highest rate of appendicitis
is found within the white population, while Black Africans and Asians only suffer half as much from appendicitis. In Africa the
incidence of appendicitis is particularly low. To what extent only predisposition or other habits of life are responsible for that
cannot be answered yet. A higher frequency of appendicitis has also been described within families. Children whose parents
have been appendectomized early during childhood, are also frequently appendectomized early. Whether this is caused by
an increased sensibility of parents or by genetic factors is still unclear.8 There exists a sex-specific distribution, in consequence
of, males do have a 1.1-1.7 times higher risk to develop appendicitis. These data comply with a whole life-span risk for men
of 8.6-6.7% for women to suffer from appendicitis. On the other hand, women do have a much higher risk to get
appendectomized (23.1% of women, 12% of men).
Age shows a distribution with a peak in the age group of 14-19 years. In this group there is a relative disease frequency
of 230/100,000 whereas frequency is decreasing to 50/100,000 at the age of 45 and to about 13/1000,000 at the age of
80.9,10,11 These data underline the enormous importance of this disease, especially for pediatric surgery.
Table 54.2: Morbidity and mortality in developing contries
Incidence: 110/100 ,000 year
Maximum in the age group of 14-19 years: 230/100,000/year
Whole lifespan risk to
suffer from appendicitis: Men 8.6%
Women 6.7%
Incidence for surgical interventions is 2.5 times higher in
women
Morbidity : 5.1-33%
Mortality : 0.001-0.5%12
12Seiler ChA. Standard open surgical procedure in
appendicitis: From the past to the present. In Krähenbühl L,
Frei E, Klaiber Ch., Büchler MW. Acute Appendicitis: Standard
Treatment or Laparoscopic surgery? Prog Surg, Verlag
Karger, Basel 1998;25:59-69
2.5-24 cm long (in adulthood about 9 cm) and about
0.5 cm thick, at the beginning of the cecum caudal
departing, blind-ending, worm-shaped enteral
compartment. In the correct way, one has to say that
the cecum departs cranially from the appendix,
because the appendix represents the start of the large
bowel. But it is—as an blind-ending structure with a
comparably narrow lumen (1-2 mm)—turned off for
the passage of the bowel movement (feces), and is
therefore functionally and anatomically considered an
“appendix” of the cecum. The observation that the
cecum is only partly and the appendix is not filled with
meconium (therefore no growth stimulus is given)
explains why the vermiform appendix is so thin in
contrast to the colon/cecum.13 Although the appendix
belongs to the colon, it does not form Taenias, because
the outer lengthwise-muscle layer of the Muscularis
propria builds an even plate at the passage to the
appendix, and possibly has a pretty peristaltic
movement. This runs in the direction from the tip to
the base. At the point at which the Taenias of the cecum
converge, one can most easily find the base of the
appendix. Histologically it corresponds to the colon.
However, the appendix exhibits a high content of
defending cells, and several lymphoid follicles lying
tightly against one another in the mucosa and
submucosa, respectively, underlining its immuno-
logical importance. Noteworthy, the number and
density of mucosal lymphoid follicles increases during
adolescence. This period of enhanced development of
lymphoid follices corresponds exactly with the age
range showing the highest incidence of appendicitis.
Blood supply is through the mesenteriolum
(mesoappendix) by the appendicular artery
originating from the ileocecalic artery which in its turn
generally originate from the inferior right colic artery
coming from the superior mesenteric artery.
The mesenteriolum is an expansion of the iliac
mesenterium and passes under the ileum to the
appendix. The appendicular artery takes its course
along the free edge and works as a functional end
artery. Its branches break through the wall until they
reach the mucosa. In the luminal area arterioles build
a fine reticulum. The base of the appendix may be
598 Pediatric Surgery—Diagnosis and Management
supplied by small branches of the anterior and
posterior cecal artery. The venous drainage runs and
parallel to the arteries, whereby again a basket-like
reticulum is formed in the area of the lymphoid
follicles. The lymphatic drainage of the cecum passes
to the ileocecal lymph nodes along the superior
mesenteric artery into the cysterna chyli. There are
anastomoses to retroperitoneal lymph nodes. The
appendix in its turn does not have an own lymphatic
drainage but as a whole is considered, similar to the
tonsils, a lymphatic organ. Thereby the often observed
contemporarily inflammatory response of tonsils and
appendix can be explained. Malformations of the
appendix are very rare. Generally, it is a question of
either an agenesis or a reflection whereby the cecum
can also be involved. While the frequency of this
congenital malformation lies in the range of a
thousandth part, the diverticulum as acquired
dysplasia is more frequent. Diverticula are
evaginations of the mucosa through the muscularis
propria. A congenital “diverticulum”, also an
evagination affecting the entire wall, is added to the
rudimentary reflections.
The posteromedial passage about 2-3 cm below the
ileac opening into the cecum conforms to the
McBurney point at the outer belly. This point lies at
the junction between the lateral and the middle third
of a line thought of between the anterior superior iliac
spine and the bellybutton (Fig. 54.1).
The position of the vermiform appendix lies shortly
medial or under the McBurney point in about 59%. In
considerable 25% of all cases the appendix is
positioned between the anterior superior iliac spine
and the bellybutton. 27-65% have a retrocecal position
(Figs 54.2 A to D).14-16
This position particularly raises difficulties for
diagnosis and surgery. Retroileal or only partly
retrocecal (transverse) inflamed appendices usually
follow a typical clinical pattern while the sympto-
matology of strictly retrocecal, cranially directed
appendices is rather unspecific. Even with ultrasono-
graphy, retrocecal appendicitis is only visible for
skilled people and the operation is technically difficult
for beginners in the operating room.
CLINICAL SYMPTOMS AND DIAGNOSIS
Abdominal pain is a frequent symptom and the cause
of up to 20% of all visits. With every fifteenth child
there underlies a serious disease. This among others
can be an appendicitis. The other diseases with urgent
necessity for surgical interventions are rather rare. The
appendicitis is clinically recognized by a typical
tenderness to pressure, Blumberg’s sign, and the most
frequent accompanying symptoms, vomiting and loss
of appetite. However, diagnosis is still extremely
difficult and only ultrasonography, in the hands of an
Fig. 54.1: McBurney point Figs 54.2A to D: A. Retrocecal, B. Mediocaudal (Pelvic)
C. Retroileal, D. Lateral (Paracecal) position of the appendix
Diagnostic Laparoscopy 599
Appendicitis 599
experienced physician, is a reliable remedy.17 In daily
practice new examination methods like MRI, nuclear-
medical examinations (autologously marked
leukocytes), or CT are, because of their poor
availability, only of academic interest.
Appendicitis is a very rare event under an age of 4
and seldom up to 6 years, but if, rather less
symptomatic and painful. Unfortunately, just the
nearly obligatory perforation with all the signs of a
peritonitis leads to the doctor and therefore to a
diagnosis in this age group. Peritonitis is still the main
cause of the very high morbidity. According to results
from great studies the morbidity lies in a range
between 5-33%. Principal causes of a perforated
appendix with localized or already generalized
peritonitis are local infections especially with adipose
children, the occurrence of a paralytic ileus caused by
a peritonitis, or an intra-abdominal abscess. Also late
complications like adhesions and an adhesive
strangulation of intestines are typical consequences of
a peritonitis. On the other hand, not surgically
treatable diseases like enteritis are – as a differential
diagnosis—only difficult to distinguish from an
appendicitis. An often similar symptomatology, above
all a tenderness to pressure in the hypogastric zone
and the, for not skilled persons, complicated
examination under the difficult circumstances with
children make diagnosis extremely hard. Due to the
fear of an overlooked appendicitis a low specificity is
tolerated in favor of a high sensitivity. This means that
already in case of an insignificant suspicion for
appendicitis, the patient is attributed to a surgical
department and often also operated. The generally
accepted rates for appendectomies in case of a wrong
positive preoperative diagnosis are 20-25%. For the
year 1997, large studies within surgical quality-
assurance programs state childhood appendectomy-
rates with a negative histological finding between 18.6-
21.2%.18 In the past years enlarged attention has been
drawn to the increase of specificity to say of unerring
aim without accepting a low sensitivity, that is an
increased overlooked appendicitis-rate and therefore
an increased rate of perforation.19,20 In addition there
are intensive efforts to develop a simple strategy to
clarify acute abdominal pain in childhood. In a long-
term prospective study together with other hospitals
those criteria were proved that usually are referred to
for diagnosis and that are also feasible in a consulting
room or in basic-care providing hospitals. In contrast
to the acute abdominal pain of grown-ups, fewer
diseases are of question as differential-diagnostic
causes. Thereby the diagnostic pathway is vastly
uncomplicated.
In the author’s series collective unspecific
abdominal pain and functional discomforts were 40%,
infectious enteropathies 25%, appendicitis 12%, and
urogenital infections are remarkable 4%. All other
noteworthy diseases were reported in less than 1% of
all cases. From this is experience the following schemes
could be deduced.
The two main criteria are the clinical examination
and the ultrasonic examination by a physician who is
especially experienced in abdominal ultrasonography
in childhood and particularly in ultrasonic diagnostics
of the appendicitis. In addition, the typical history and
the results from laboratory experiments (Table 54.3)
are observed. These criteria are assessed individually.
If one or both main criteria (clinics, sonography) and
at least one accessory criterion (history, laboratory)
are met the patient is suspected of having an
appendicitis, and will need hospitalization. If no other
cause of disease is found and an appendicitis cannot
reliably be excluded, the hospitalization either leads
to an immediate surgery or to an re-evaluation after
two to six hours intervals without food intake and
parenteral fluid supply until verification or exclusion
of an appendicitis. This is recognizable with a relatively
high probability during the further course. If only one
main criterion, clinical or sonography, is typical for
an appendicitis and the second main criterion as well
as both accessory criteria are negative, the child can
be discharged under adequate care. Within 24 hours
an ambulatory control has to follow. If history and
laboratory investigations are positive and both main
criteria—clinics and ultrasound are negative, the
patient is hospitalized but is allowed to drink clear
liquid. IV fluid in these cases is not necessary.
If laboratory or history alone is positive, patient is
referred back to the practitioner/pediatrician for
further control. This procedure is in a more or less
structured manner applied in many pediatric clinics,
whereas the importance of ultrasonography is
definitely greater in European countries in contrast to
Asian countries and the United States. This method
has especially proved when the pediatric surgeon is
600 Pediatric Surgery—Diagnosis and Management
trained and experienced in abdominal sonography
because the valuation of a nevertheless dynamic
examination in combination with the own experience
in clinical examination turns out significantly better
in contrast to that of a radiologist who does perform
this examination without special background. In the
USA, the value of sonography is more inferior. In USA
and in Asian countries clinic symptomatology and
laboratory investigation are the most important
criteria. Especially in countries with many children and
less good medical care the greater experience of the
physician does successfully replace missing technical
devices like sonography, laboratory investigation and
radiography. On the other hand, in the USA, there
exists a more profit-orientated health system where
examination methods like ultrasonography are
difficult to establish.
Formerly practiced examinations, like the rectal-
axillary temperature difference are obsolete for the
diagnosis of appendicitis due to the unreliability of
the measurement.
The typical symptoms of appendicitis are also
apparent abdominal pain, guarding, relaxation-
position, nausea or vomiting. These are, especially in
childhood, very common symptoms which could
appear with various distinctions in many other
abdominal and also systemic diseases, and in
connection with enteritis. In childhood, abdominal
pain along with appendicitis first develop in the region
of the bellybutton and then within hours shift to the
right lower quadrant where they steadily increase. A
primary examination in this early stage makes
diagnosis very difficult. Because a high rate of wrong
positive diagnoses still leads to numerous unnecessary
appendectomies and therefore also to enormous costs,
many institutions try to establish clear diagnostic
criteria. These criteria should – also without technical
resources—enable a prompt (that means before
perforation occurs) diagnosis on the one hand and also
to prophylactically operate as few as possible children
on the other hand. All these efforts have shown that
the clinical experience of the examiner is the most
important instrument. Also computer-based decision-
making systems could not improve diagnosis of
appendicitis.25-27
The diagnostic accuracy in fact could be increased
through forms which were necessary for the computer
presentation but this was mainly due to the forced
precision of the surgical examination. All attempts, for
instance by entering into scoring systems, to establish
standardized diagnostics, following objectively
measurable criteria were disappointing (Table 54.4).28
The experience of the surgeon is presently and will
also be in the 21st century the most important and
safest diagnostic criterion.29 The so called “wait and
see” policy has proved helpful. Most hospitals in
Europe hospitalize a child with a well-founded
Table 54.3: Main and accessory criteria
Main criteria
The following clinical symptoms (“clinical picture”) were, based
on large investigations of the OMGE and also on own
observations, determined as positive and are listed with
decreasing frequency.
• Vomiting
• Anorexia
• Tenderness and rebound pain of the right side of abdomen
• Local or diffuse abdominal guarding
The sonographic criteria (“sonography”) were determined
by Puylaert in 1986; the following are considered as
positive:21
• Presentation of appendix
• Wall stiffness , missing compressibility
• Diameter > 6 mm is suspicious, > 9 mm corresponds with
an inflammation
• Perifocal edema
• Wall thickening and net-cap
• Fecolith
Accessory Criteria
The history is difficult to define but special points, e.g. duration
of pain > 6 hr, start of pain within the last 24 hr, pain shifting
to the right side of abdomen, proved typically positive. The
positive related to criteria “history” are:
• Start of pains without further common symptoms in the
region of the bellybutton
• The duration paint between the 6 to 24 hr, if no guarding
exists
• No intestinal infections in the near surroundings, with
healthy brothers and sisters
• Diarrhea, acute rhinitis, cough, and start of fever before
start of pain are negative signs
Laboratory—chemistry criteria (“laboratory”) which support
an appendicitis are:
• Leukocytosis between 10,000 and 20,000/mm3
• CRP at start of pain at least 8 hours before: > 0.522
The combination of ultrasonography and clinical finding
reach a specificity of 99% a sensitivity of 91%, and therefore
a positive predictive power of nearly 100% (own
observation).23,24
Diagnostic Laparoscopy 601
Appendicitis 601
suspicion of appendicitis but without clear diagnosis
and will re-examine the child after some hours without
food intake and perhaps with parenteral fluid supply.
As mentioned above, in Europe ultrasonography has
been additionally established as the most valuable
diagnostic resource. Thereby the rate of unnecessary
appendectomies could be, in large series, reduced to
13% and less. In the USA, computed tomography (CT)
is used instead of ultrasonography due to organizing
and cost-technical assumptions.
Fundamentally it can be written down that
diagnosis is based on clinical examination, laboratory
analysis and ultrasonography. The algorithm for the
management of appendicitis is given in Figure 54.3.
Clinical Examination
A history of abdominal pain for last 12-24 hours
without fever or diarrhea migrating from the central
area to the right lower quadrant, typical tenderness
to pressure above the McBurney Point, and rebound
tenderness are frequent. The patient is anorectic and
frequently vomits in a relatively early stage. In most
cases the last defecation is still normal. The often
mentioned rectal-axillary temperature difference of
more than one centigrade celsius is unreliable. With
children it is often not carried out exactly and
moreover only appears in advanced stages. In later
stages abdominal guarding is added to distinct pain
existing in the right lower quadrant and tenderness to
touch. The tongue is coated in nearly all cases and
perioral paleness is found. In case of an existing
Douglas’ abscess frequent, highly liquid bowel
Fig. 54.3: Algorithm for the management of appendicitis
Table 54.4: MANTREL’s Score (Alvarado)29
Migration of pain from central area to right
lower quadrant 1 point
Anorexia or acetonuria 1 point
Nausea with vomiting 1 point
Tenderness in the right lower quadrant 2 point
Rebound tenderness 1 point
Elevated temperature ³ 38°C (100.4 °F) 1 point
Leukocytosis (>10,4000 cells/mm3) 2 point
Shifted WBC count (> 5% neutrophils) 1 point
Total possible points 10 points
602 Pediatric Surgery—Diagnosis and Management
movement can often simulate enteritis. Besides the
obligatory anorexia, a blown abdomen is the most
frequent symptom in children under the age of three.
Laboratory—Chemical Analysis
If appendicitis is the presumptive diagnosis, an
analysis of the urine is obligatory. Usually, the
determination of leukocytes, nitrate as well as
erythrocytes is sufficient to recognize an urinary tract
infection as differential diagnosis. Further helpful
information about the hydrational condition of the
child is offered by the specific weight and the
determination of ketone in the urine (acetonuria).
Blood examination for the red blood count and
differential white blood count, and the analysis of the
C-reactive protein (CRP) together with the clinical
findings reach a high sensitivity and specificity. The
laboratory finding is positive, if leukocytosis is of more
than 10,000/mm3 or a CRP-level higher than 0.5 mg/
dl exists.
Ultrasonography
Appendicitis-criteria according to Puylaert (Table 54.3):
The special power of sonography lies in the plain
presentation of typical and important differential
diagnoses(Figs 54.4A to D). Ileus, intussusception,
enlarged lymph nodes, ovarian cysts, renal and liver
affections, tumors, and others cause symptoms
mimicking an appendicitis and can be distinguished
safely (Figs 54.5A to D). Ultrasonography offers a
Fig. 54.4A: Sonographic view of appendicitis seen in
longitudinal view Fig. 54.4B: Sonographic view of appendicitis in
transverse section
Fig. 54.4C: Sonographic view of fecalith in
longitudinal section Fig. 54.4D: Sonographic view of fecalith in
transverse section
Diagnostic Laparoscopy 603
Appendicitis 603
sensitivity around 90% and a specificity of nearly 100%
for the detection or exclusion of an acute appen-
dicitis.31 There is a positive predictive value of 92%,
the negative predictive value is 99%.
MRI
On T2-weighted ultra turbo spin-echo images, acute
appendicitis appears with a markedly hyperintense
center, a slightly hyperintense thickened wall, and a
markedly hyperintense periappendiceal tissue.
Unenhanced axial T2-weighted spin-echo imaging is
the most sensitive sequence for. MR imaging seems to
be a valuable technique for depiction of acute
appendicitis (Fig. 54.6).32 Yet MR, as diagnostic
remedy, is not sufficiently evaluated to be able to give
a general judgement, but in the future it seems to be
able to replace ultrasonography as well as CT as
diagnostic resource because of the reproducible
presentation of pictures and the missing roentgen
burden.
CT Scan
Rarely used in Europe and Asia, more frequently
applied in the USA, CT together with contrast medium
is able to describe the inflammatory altered vermiform
appendix (Fig. 54.7).33 But one has to consider that such
Fig. 54.5A: Sonographic view of ileus Fig. 54.5B: Sonographic view of intussusception in
longitudinal section
Fig. 54.5C: Sonographic view of transverse
(intussusception section) Fig. 54.5D: Sonographic view of mesenteric lymph nodes
604 Pediatric Surgery—Diagnosis and Management
an examination is expensive and complex and also
includes burden with X-rays. Its efficacy in childhood
is lower than in connection with adults. Due to the
above mentioned reasons, CT is generally seen as
second choice after ultrasonography.34
Nuclear Medicine
During the past years studies have been published
dealing with the detection of inflammation by labeled,
autologous leukocytes. With this method a sensitivity
of 27-97% and a specificity between 38-94% can be
reached. Like for CT, radioactive substances are
necessary and an experienced ultrasound-examiner is
able to gain the same information without any burden
for the young patient. But for the detection of a
Meckel’s diverticulum radionuclide imaging can be a
very helpful tool (Fig. 54.8).
Diagnostic Laparoscopy
In contrast to adults the diagnostic laparoscopy has
only a minor importance for the diagnosis of acute
appendicitis in childhood. Exceptions are prepubertal
and pubertal girls, for these laparoscopy is an
important diagnostic tool.35,36 Otherwise it is reserved
to the clarification of chronically recurrent abdominal
pain also in connection with a simultaneously planned,
concomittant appendectomy (Figs 54.9A and B).37
For this purpose it is an ideal instrument.38
DIFFERENTIAL DIAGNOSIS
Functional discomfort generally manifests within a
few hours in a chronic course with a self-limiting
character of the single episode. The kind of pain is not
leading and the absence of a more exact specification
in young children is also unreliable. Often cyclic
vomiting is accompanying. Typically, children report
upon more pain during examination than objectively
can be observed. Attention intensifies sympto-
matology. The general condition is barely reduced.
Also appetite is not reduced. Enteritis as one of the
most important differential diagnoses in childhood is
most easily recognized by an exact clinical history and
Fig. 54.6: MRI depicting appendicitis
Fig. 54.7: CT scan depicting appendicitis
Fig. 54.8: Scintigraphy Meckel´s diverticulum
Diagnostic Laparoscopy 605
Appendicitis 605
observation. Mainly virally caused, children are
suffering from cough or cold, headache, fever and
fatigue in the days before abdominal pain appear.
Abdominal pain itself is diffuse, cramping and at the
beginning associated with episodes of diarrhea. Such
episodes occur in advanced stages of an appendicitis
only. Nevertheless, a careful observation is important
then, because viruses preferentially attack-with
(Paramyxoviridae-mumps, enteric viruses-Coxsackie
B) or without (Adenovirus) viremia-lymphatic organs,
to which also the appendix belong. Particularly the
intestinal types of the adenovirus group which do not
attack the respiratory organs are able to cause swelling
of mesenteric lymph nodes for months and can be a
trigger for appendicitis. With abdominal ultra-
sonography, the picture of a mesenteric lymphadenitis
is observed which is a frequent finding together with
ear-ache and simultaneously appearing abdominal
pain in the right upper quadrant. The blood count is
rather indicating a leukopenia than a leukocytosis, the
CRP level is low. In the differential blood count a
lymphocytosis would appear. Bacterial enteritis is
mainly caused by Campylobacter, Yersinia, and
Salmonella. Typically diarrhea, in most cases connected
with subfebrile or febrile temperatures, is in the
foreground whereas abdominal pain is appearing late
and seems to be diffuse. Often also family members,
friends, or playmates are afflicted. The blood sample
shows a strongly increased number of leukocytes, in
particular a leftward shift is existing, and the CRP is
increased.39 Bacterial enteritis are also able to initiate
appendicitis and the following three germs
Campylobacter jejuni, Yersinia pseudotuberculotica and
enterocolitica are the most frequent inducers of a
bacterial appendicitis.40 Especially appearing in
childhood up to the age of four, an inflamed Meckel’s
diverticulum is barely to distinguish from an acute
appendicitis. But in general this is only a rare event.
The probability that a Meckel’s diverticulum becomes
symptomatic is about 2%. Of this percentage only a
small part appears as inflammation, another part
manifests as bleeding or ileus.
In young women during puberty, diseases of the
internal genitalia are more common causes of
discomfort. Functional ovarian cysts are very frequent.
These typically disappear with start of menses but can
also persist for months and therefore cause pain. They
are ultrasonographically easy to identify. The
treatment, if necessary, is only conservative. If the cysts
are larger than 5-8 cm, a laparoscopic enucleation is
possible. These, including many small cysts, may lead
to a torsion of the ovary and therefore to intensive
acute abdominal pain. The torsion of an ovarian cyst
is, in any case, an indication for immediate surgery.
This is only limitedly valid during neonatal period.
At that age, the necrotic ovary may possibly be
resorbed. Also without torsion or bleeding, ovarian
cysts, predominantly in puberty, are the cause of deep-
seated rather chronic, cyclically relapsing abdominal
pain. Teratoma, dysgerminoma, and other germ cell
tumors but also malformations of the uterus or the
vagina (Mayer-Rokitansky-Küster-Hauser syndrome,
Uterus dimetria with one-sided vaginal atresia) may
cause symptoms of appendicitis. Laparoscopy
represents for all of these diseases an essential part of
diagnostics.41
Fig. 54.9A: Appendix seen in laparoscopy Fig. 54.9B: Laparoscopic view with 2 mm scope
606 Pediatric Surgery—Diagnosis and Management
Also sexual transmitted diseases like PID (pelvic
inflammatory disease) are possible differential
diagnoses. This disease almost only appears in sexual
active girls. The inverted conclusion that an
appearance of PID is coupled with a loss of virginity
however is not admissible. In most cases the right-
sided salpingitis with an abscess in the small pelvis
can only be distinguished from an appendicitis by an
ultrasonographically skilled examiner, and can also
be in connection with an appendicitis ab externis.
Furthermore, in sexually mature young women one
has to think of pregnancy or ectopic pregnancy.
If the pain is appearing periodically and menarche
fails to come, the cause may be a congenital
malformation like the Mayer-Rokitansky-Küster-
Hauser syndrome (Rokitansky sequence).42 This
syndrome represents a congenital combination of
malformations which is characterized by a normal
female chromosome complement (46XX), normal
secondary sex characters, vaginal atresia, and uterus
malformation (bicornuate or bipartite). The vaginal
atresia leads to an obstruction of menstrual blood,
which increases in consequence of every period and
therefore causes pain. During this stage of
development, also an endometriosis can get
symptomatic although, this is typically causing
dysmenorrhea and dyspareunia in young women.
In pre-school children of both gender pneumonias,
in particular lobular pneumonias on the right in
connection with peritoneal symptoms may simulate
an appendicitis. There is a typical retraction of the
intercostal space during inspiration, cough, and
hyperpyrexia. Sonographically, free fluid is copiously
found in the abdomen together with a pleural Winkel’s
effusion but there is no indication for an inflammatory
event in the right lower quadrant. A pulmonal
radiography leads to the right diagnosis.
Urinary tract infection is a frequent, spastic, and
painful event in preschool children, can be
accompanied by fever and may correspond to the first
symptoms of a vesicoureteral reflux. In school-age
children, dysuria appears as an accompanying
symptom of appendicitis in up to 20%.
A bacterial meningitis starting with abdominal pain
and cramps is extremely dangerous. However, in most
cases headache, visual disturbance, hyperpyrexia, neck
stiffness, diffuse peritoneal guarding, and foudroyant
worsening of the general condition of the child exist.
In such cases, the lumbar puncture is favored above
other diagnostics.
Otitis media may too cause abdominal pain in pre-
school children. Abdominal sonography frequently
reveals an accompanying mesenteric lymphadenitis.
These findings are, in case of a hasty examination, often
misinterpreted as appendicitis.
Pseudoappendicitis diabetica: In diabetes mellitus right-
sided abdominal pain can occur which impose colicly,
chronically, and heavily. An unnecessary operation as
well as an actual appendicitis recognized too late, lead
to the high morbidity among these children. In case of
known diabetes and especially of an existing diabetic
decompensation, ultrasonography is an helpful
instrument.
The idiopathic net torsion as well as the idiopathic
segmental infarct of the greater omentum are clinically
similar to an appendicitis, in particular if the maximal
point lies on the right side. Both events can be
diagnosed laparoscopically and treated accordingly.43
Abdominal lymphangiomas are also sometimes
operated as a misdiagnosed appendicitis. With
ultrasonographic help, this presumptive diagnosis
should be detected preoperatively and therefore, a
transverse laparotomy should be chosen. Typhlitis in
connection with an acute leukemia is hardly to
distinguish from appendicitis. This is a fatal prognosis
due to the frequently associated, uncontrollable sepsis.
Furthermore, other differential diagnosis of
abdominal pain include clinical history, pancreatitis,
cholelithiasis, urolithiasis, peptic ulcer, dyspepsia,
amebic abscess, hepatitis, and injuries through anal
foreign bodies. These are promptly to distinguish only
with a careful clinical history and examination.
In general the following standard is valid: the
younger a child is and the more anxious the mother
is, the sooner the patient should be hospitalized.
Most Frequent Misdiagnosis44
• Gastroenteritis
• Upper respiratory tract infection
• Sepsis of other origin
• Urinary tract infection
• Encephalitis
• Febrile seizure
• Blunt abdominal trauma.
Diagnostic Laparoscopy 607
Appendicitis 607
ETIOLOGY
The etiology of appendicitis is not clarified until now,
although two facts are supported by some studies. On
the one hand, genetic differences in the development
of immunologic protection-factors could be
responsible for, on the other hand also environmental
and dietary factors seem to play an important role.
Striking are variations of sexual distribution, of
different populations, and between towns and rural
districts. An explanation for the latter distinction could
be the higher socio-economic status of the white
population in countries like the USA and Europe, or
that of inhabitants of large towns. There are also
existing seasonal differences with the greatest
accumulation of appendicitis during summer season
and the lowest appearance in winter.45
Most authors consider the fiber-deficient nutrition
of the industrial countries and large towns as the most
important etiologic factor. This is supported by the
fact that fecoliths, which often occur in consequence
of constipation, are also the most frequent starting-
point of appendicitis. The association between fecoliths
and appendicitis is proved.46 The fecolith leads to a
occlusion of the lumen, therefore to a local obstruction,
to ischemia, and finally to a local inflammation. The
so called appendicitic primary lesion is generated.
From these foci granulocytes start migration through
all wall layers.
As immunohistochemical investigations have
shown, the previously common saying that the
vermiform appendix is nothing than a useless,
rudimentary organ, is not right. The appendix
morphologically and topographically correspond to
a GALT (gut associated lymphoid tissue).47 The
appendix together with the tonsils, the Peyer’s
plaques, and the mesenteric lymph nodes appears
responsible for immunoregulatory mechanisms in the
lymphatic system. Therein, partial causes of
inflammation could be found. Possibly the first step
of inflammation, the focal infiltration of the lamina
propria, is demonstrably associated with an increase
of T lymphocytes (CD3) and plasma cells concerning
the whole organ.48 Meanwhile it is known that during
inflammations of the appendix different cytokine
levels (IL-2, IL-6, TNF-alpha) are increased. These are
also used for the detection and proof of chronically
relapsing appendicitis.49
The germs which are found with appendicitis
generally correspond with the intestinal flora. About
20% are aerobic germs, 20% are anaerobic, and in about
60% aerobic as well as anaerobic germs are found in
smears taken during appendicitis.50
The most common germ is E. coli followed by
Bacteroides fragilis, Peptostreptococcus and Pseudomonas
sp. Viral infections with mumps virus, Coxsackie type
B, and adenoviruses are frequently seen in
appendicitis. The real significance of this observation
is still not verified, although in general, the meaning
is distributed that, based on a lymphoid hyperplasia
appendicitis can evolve. Occasionally, in immuno-
suppressed patients (e.g. AIDS patients, patients under
chemotherapy) a viral infection with cytomegalovirus
(CMV) or Epstein-Barr viruses can act as primary
promoter of inflammation. Uncommon causes include
yersiniosis, parasites (oxyures), Crohn´s disease,
foreign bodies, tuberculosis, volvulus of appendix,
intussusception, septa, tumors, and diverticula.51
Necrotizing enterocolitis seems to be responsible for
the very rare appendicitis in the neonatal period.52
Eating habits: Absence of dietary fiber.
Fecolith: Occlusion of the lumen – local obstruction –
ischemia – local inflammation – migration of
granulocytes through all layers.
Yersiniosis: The infection with Yersinia pseudo-
tuberculotica and enterocolitica, Campylobacter jejuni,
Salmonella typhi, and also the very rare infection with
Mycobacterium tuberculosis are considered as trigger
of appendicitis. The bacterial colonization with E. coli
is rather a part of an already commenced inflammation
than a possible primary cause.
Viral infection or lymphoid hyperplasia: Under
chemotherapy, immunosuppression, AIDS
Worms, especially oxyures (Enterobius vermicularis)
and ascarides are by far the most frequently seen
parasites. They are able to induce a lymphoid reaction
or cause appendicitis through obstruction. Helminthic
diseases are a common incidental finding in
histologically not-inflammatory altered appendices.
The incidence is, with about 4%, highest in childhood
(between the age of 6 and 15).53
Chronic inflammatory diseases (Crohn´s disease): Also
Crohn´s disease is able to primarily or secondarily
manifest in the appendix and causes an inflammation
there. In these cases an ileocecal resection is necessary.
608 Pediatric Surgery—Diagnosis and Management
Foreign bodies: Ingested foreign bodies in the lumen
like screws, plastic parts, or kernels are inducing an
inflamed appendix. But in general it cannot be deduced
from these events that swallowing of foreign bodies
leads with a higher probability to appendicitis.
Tuberculosis may be the cause of an appendicitis,
but is rather simulating one, e.g. with mesenteric
expansion (sometimes observed as primary mani-
festation in pre-school children). Typically, there are
multiple, enlarged mesenteric lymph nodes and
caseating granulomas in the peritoneum.
Volvulus of the appendix and appendiceal
intussusception:
A volvulus of the vermiform appendix is a rare
event in childhood. In the literature only a small
number of cases are described.54-56 It presents itself as
an intermittently occurring abdominal pain which
acutely exacerbates. Mucoceles, fecoliths (Bonnoud),
and idiopathic forms are described as the main causes.
In these situations the color-coded Doppler
ultrasonography is useful. Also the intussusception
of the appendix into the cecum is a very rare event
and is promptly revealed by ultrasonography (beside
this, intussusception represents an indirect proof of
peristaltic movement). There also exists a congenital
form of an inverse appendix.
Septa and atresia are extremely rare, duplications
are seen more frequently. They lead to a mucous
retention. A septum at the base of the appendix can
be simulated by a mucous fold (Gerlach’s valve).
APPENDICEAL NEOPLASMS
Most frequent neoplasms are carcinoids with a
frequency of 0.02-1.5% in all histological preparations.
In principle, carcinoids are malignant tumors. The
appendiceal carcinoid exhibits less DNA-aneuploidy
than carcinoids of the ileum and therefore, more
frequently shows a benign course.57 Due to the risk of
metastasis mainly in mesenteric lymph nodes and
liver, all carcinoids with an unsteady behavior, those
above a diameter of 1 cm, positive lymph nodes,
infiltration of the serosa or the mesenteriolum, or a
position at the basis should be considered for
hemicolectomy or at least for further clarification with
indium111-labeled octreotid. At a size < 1cm no further
therapy is necessary, if appendectomy was carried out
and the base lies in the uneffected region. If the tumor
is larger than 2 cm, a right-sided hemicolectomy is
indicated. Appendiceal carcinoids emerge from
neuroendocrine, subepithelial cells. In contrast to
jejunoileal carcinoids, the staining with S-100 for
appendiceal carcinoids is positive. Rarely, also
adenocarcinomas or adenomas are possible. In these
cases one has to look for familiar polyposis which is
an indication for prepubertal, subtotal colectomy. But
adenocarcinomas of the appendix are an extreme rarity
in childhood. The age-peak lies in the 6th decade.
Rarely lymphoma may also involve the appendix
(Fig. 54.10). Benign tumors are mainly asymptomatic
mucosal hyperplasias, metaplasias, or adenomas,
which, for instance as cystadenomas are producing
mucine and can become sypmtomatic therefore. They
form mucoceles which may rupture and cause a
peritoneal pseudomyxoma. All, benign as well as
malignant tumors of the appendix may, to a
significantly higher rate be associated with
synchronous or metachronous, gastrointestinal tumors
with another localization.58
PATHOGENESIS
In most cases appendicitis follows a cascadic pattern.
Fecoliths, helminthes, viral lymphadenitis, or foreign
bodies cause an obstruction of the lumen whereby
pressure arise to the mucosa and the wall of the
appendix which subsequently leads to a venous
congestion and arterial hypoperfusion of the distal part
of the vermiform appendix. Meanwhile, pathogenic
bacteria start to overgrow this area and migrate
through the underlying mucosa. The intraluminal
increase in pressure develops very rapidly because the
Fig. 54.10: Lymphoma appendix
Diagnostic Laparoscopy 609
Appendicitis 609
vermiform appendix is not expansible due to its
structural design.59 Granulocytes migrate through the
mucosa, submucosa, muscularis, and finally also
through the serosa. Aschoff’s primary complexes are
formed which are aggregations of neutrophil
granulocytes. On the serosa fibrin is built up and the
whole wall slowly becomes necrotic. The base of the
vermiform appendix is generally free from
inflammation. This may be due to an additional blood
supply via branches of the cecal artery at the base,
whereas the appendicular artery as an terminal branch
is not able to sufficiently ensure the peripheral blood
supply during an inflammation. If this process cannot
be stopped, perhaps a necrosis develops followed by
open ulceration and then perforations results.
Unlimited, this may first of all result in local and then
in a generalized peritonitis, sepsis and death, or a
perityphlitic abscess is formed which breaks through
and drains, building a fistula. Whether an arising
inflammation always and absolutely leads to the end
point gangrene or perforation is questionable.
Autotherapy or curing by conservative treatment is
also possible. Several studies and investigation indicate
that chronically relapsing abdominal pain in the right
lower quadrant may be due to afflictions of the
appendix.60 By studying the cytokine expression of the
vermiform appendix, nearly identically increased
values were found in acute appendicitis and in
appendectomies due to chronic recurrent abdominal
pain, whereas in elective appendectomies due to other
causes expression patterns comparable to those of
unaffected appendices were found.61
Also the fact that many patients are free from pain
after appendectomy supports the hypothesis of a
recurrently appearing appendicitis.62
Histopathologic Classification
(According to Zimmermann, Bern)
I II
Acute appendicitis Chronic appendicitis
Appendicitis due to specific Appendicitis in inflammatory
infections and infestations bowel disease
Idiopathic granulomatous Eosinophilic appendicitis
appendicitis
Appendicitis in arteritis and Neurogenic appendicitis/
collagen vascular disorders appendicopathy (Masson´s
pseudoappendicitis)
Other types
CURRENT CLASSIFICATION OF APPENDICITIS
ACCORDING TO HISTOLOGICAL BASIS
Acute appendicitis (Fig. 54.11): Thickened, rigidity of
wall, injected; mucous membrane defect, neutrophil
granulocytes in the mucosa and submucosa/disorder
of mucosal epithelium, granulocyte accumulation,
extravascular granulocytes, leukocytes in the lumen.
Phlegmenous and ulcerophlegmenous appendicitis
(Figs 54.12A and B): Fibrinously purulently coated,
surrounding (mesenteric) phlegmonas; passing
through all wall layers, including serosa; fibrinous
appositions, defects of the superficial wall layers up
to the serosa. After 10–14 hours: transmural
granulocytic inflitration; phlegmonous inflammation.
After 24 hours ulcers = ulcerophlegmonous
inflammation.
Gangrenous appendicitis: Necrotic wall areas without
opening; gangrene of the whole wall without
perforation.
Perforating appendicitis: (Figs 54.13A and B) Perforation
and outflow of fecal content through defects of the
abdominal cavity; defects of the whole wall.
Neurogenic appendicitis: Macroscopically nearly not
remarkable, obliteration; intramucous or submucous
proliferation of nervefibers, possibly with central
neurinoma at the peak in case of obliteration.
Focal appendicits: Macroscopically normal; histo-
logically, in case of an extensive incision, inflammation
restricted to one area is detectable – if only few
incisions are carried out, not visible “normal”
histology.
Recurrent appendicitis: Macroscopically, frequently
thickened, partly whitish glittering, or totally normal.
Increased fat tissue. Frequently coproliths in the
lumen. Histologically rare lymphocytic infiltration,
extensively multiplied reactive lymph nodes,
lymphoid hyperplasia. Sometimes fibrotic recons-
truction.
Fig. 54.11: Resected specimen of acute appendicitis
610 Pediatric Surgery—Diagnosis and Management
COMPLICATIONS OF APPENDICITIS
1. Diffuse peritonitis.
2. Perforation with stercoral abscess, covered with the
greater omentum or ileal loops, in case of a
retrocecal position through the cecum or open with
Douglas’ abscess and diffuse peritonitis,
respectively. At an age of 0-4 the frequency of
perforations is at least 40%.
3. Thrombophlebitis of the appendicular vein with
propagation and septic liver abscesses.
4. Healing with scar formation and relapsing
appendicitis at the base of scar obliteration.
5. Adhesive strangulation of the intestines.
6. Appendicular mucocele: Obstruction of secretion
in case of an over-wounded appendicitis and
allantoid distension of the thinned appendix
distally from the obliteration (scar, coprolith,
foreign body, etc.) with recurrent pain sympto-
matology.
THERAPY
Surgical Therapy
The surgical excision of the inflamed vermiform
appendix is the commonly accepted treatment. The
McBurney’s incision (gridiron incision) as it was
introduced by McBurney and Murphy 1894, is the
Fig. 54.12A: Phlegmonous appendicitis seen
laparoscopically Fig. 54.12B: Phlegmonous appendicitis
Fig. 54.13A: Perforated appendicitis Fig. 54.13B: Resected specimen of perforated appendicitis
Diagnostic Laparoscopy 611
Appendicitis 611
method of choice. Since 1983 the first laparoscopic
appendectomy was reported by K Semm, a Munich
gynecologist, this surgical method has developed into
an accepted alternative.63
Gridiron incision: This operation method starts from
an access in the right lower quadrant, which crosses
the McBurney point in the main cleavage line. After
discission of the subcutis, the external oblique
aponeurosis is cleaved along the strands, the
underlying musculature is extensively bluntly
separated, and finally the peritoneum is incised
following the craniocaudal direction. By luxating the
cecum, the base of the appendix can be presented. The
vascular supply is interrupted by clinging ligations of
the mesenteriolum. A contusion mark is set at the base,
where the appendix will be ligated and above be
abscised. After disinfection with iodine the stump is
sent to the bottom of a cecal purse string suture.
Originally, this was also covered by serous tunic fixed
with suture. In France, it is not usual to sink the stump.
Also in case of a laparoscopic surgery no stump-
sinking is performed. Some centers prefer a drainage
in case of a perforation or an intra-abdominal abscess.
MINIMAL INVASIVE TECHNIQUES
The Laparoscopic Appendectomy
The minimal invasive surgery has helped to reduce
the complication rate in cholecystectomy (the second
in frequency operation after appendectomy), the stay
in hospital, and the duration of pain. In 1893 Semm,
for the first time, has also successfully described
appendectomy via laparoscopy. In some pediatric
surgery centres, nearly all cases of appendicitis are
endoscopically operated (e.g. University hospital Jena,
Germany; university hospital Utrecht, Netherlands).
Today, 80% of all appendectomies are performed
conventionally, 20% laparoscopically (laparoscopic
appendectomies in 1996: in Switzerland about 30%,
in France and Austria about 7-9%, in the Netherlands
4% , and about 20% in the USA). This is, even though
several studies not only have shown no disadvantages
of the minimal invasive technique but more or less
significant advantages.64 But, a final, statistically really
unobjectionable comparison does not exist yet. In the
author’s series there were advantages in favor of the
laparoscopic technique in inflamed appendicitis and
especially in the group of perforating appendicitis.65
The causes of the delayed popularity of the
laparoscopic appendectomy are various. The gridiron
incision is not only an established technique, but also
the most frequent teaching operation. In addition, the
laparoscopic operation is technically much more
pretentious and therefore the learning process is
slower and the fear of complication higher. Also for
the non-medical staff, the expenditure in the operation
room is much higher. The minimal invasive technique
is especially device-depending and therefore much
more expensive. Considering the epidemiologic
importance of the appendicitis, this cost factor may
be crucial.66 In general, a better diagnostic view, a
lower wound-infection rate, a shorter postoperative
pain phase, a shorter duration of hospitalization, and
a better cosmetic result are the stated advantages of
the minimal invasive technique in contrast to an open
appendectomy (Fig. 54.14A and B).67 But in fact, there
are no prospectively randomized studies in childhood
and only a small number in adults which statistically
Fig. 54.14A: Laparoscopically assisted appendectomy Fig. 54.14B: Wound after 2 trocar technique
612 Pediatric Surgery—Diagnosis and Management
unobjectionably investigate the benefit of both
methods for the patients.68 Other differential diagnosis
can easily be identified and tackled (Fig. 54.15).
In acute appendicitis a very small skin incision in
case of a conventional appendectomy is, in general
only possible with a loss of view and with an increase
in risk. Especially in case of generous indications in
the conventional technique and therefore a high
percentage of appendectomies with a histologically
unaffected appendix, the portion of very small skin
incisions is high. As a result, the difference to minimal
invasive surgery is not so clear considering the
postoperative recovery period and the cosmetic result.
But in case of a histologically verified appendicitis,
there is a significant difference in favor of the
laparoscopy considering the dimension of the skin
incision (particularly, if devices of the new generation
with 1.2-5 mm optics and instruments are used).
The disadvantages of laparoscopy are a prolonged
duration of operation and the non-sinking of the
appendiceal stump associated with an increased
incidence of abscesses. Meanwhile, the latter is
considered as a typical complication of laparoscopic
appendectomy. The endoabdominal abscess seems to
be caused by an unclean excision of the appendix or
by a local distribution of previously encapsulated
abscesses, respectively. To avoid this reliably, a
mechanical clamp-suture instrument should be used.
A further technical advantage is the possibility of a
carefully directed aspiration of pus with the help of
an endobag (plastic recovery-bag) whereby the
appendix can be removed from the abdomen without
contamination of the abdominal wall. In principle, the
removal of the appendix is easier because it can be
worked in situ and the basis is hardly affected from
the inflammatory process.69 In particular in case of a
perforation, the noticeable advantages are a shorter,
postoperative duration of pain and a shorter resting
period.
Delayed Resection
In case of an existing perforation with local peritonitis
or perityphlitic abscesses, a drainage with antibiotic
protection as initial treatment, alone can make cure
possible. Some weeks later the elective stump
appendectomy follows.70 Thereby, the morbidity of
peritonitis and abscess formation could be decreased.71
The drainage is performed under ultrasonographic
control or CT directed and therefore is often carried
out in the interventional center of the radiologic
department. But this can, in no case prevent the patient
from being appendectomized.
NON-SURGICAL THERAPY
Antibiotic Therapy in Appendicitis
The antibiotic therapy ranks high in the treatment of
appendicitis.72 An antibiotic therapy without surgery
is only suggestive in case of insufficient possibilities
for surgery or perforation in combination with
drainage (delayed surgery). In such cases, drainage is
performed under ultrasound- or CT-directed control.
If the acute inflammation is abated and the drainage
is removed, resection of appendix via laparoscopy or
gridiron incision is necessary. But this treatment option
has only a rare importance in childhood. It is mainly
important for the treatment of appendicitis in adults.
The germ-spectrum in appendicitis which is found
in the lumen primarily shows E. coli, Bacteroides fragilis,
Enterobacter, and Pseudomonas. In the course of
inflammation anaerobic germs increasingly colonize
appendix and ileum.73,74 Interestingly, there are also
found seasonal differences of the germ-spectrum.
There are numerous recommendations concerning the
question whether antibiotics are necessary in principle
as well as the correct selection of the right antibiotic.
From all these studies, it finally can be concluded that
the administration of a broad-spectrum antibiotic at
least half an hour before skin incision leads to best
Fig. 54.15: Laparoscopic dissection of Meckle’s diverticulum
Diagnostic Laparoscopy 613
Appendicitis 613
results. Whether the postoperative antibiosis has to
be continued, depends on the surgical finding, local
circumstances, and additional risk factors like diabetes
mellitus as concomitant disease.
Recommendation
Perioperative prophylaxis: Single dose of cephalosporin,
e.g. Cefoxitim, amoxicillin + clavulanic acid,
piperacillin, or clindamycin/gentamicin; also
metronidazole alone is an possible alternative.
Postoperative treatment: Gangrenous or perforation:
broad-spectrum antibiotic for 3-5 days.
Peritonitis: Broad-spectrum antibiotic + metronidazole
for 5-10 days.
POSTOPERATIVE CARE
Postoperative care is confronted with two fundamental
problems. Cure shall proceed without further
infections and normal feeding shall quickly be possible.
Both aims are not difficult to reach in childhood
because in case of a technically troublefree
appendectomy – no matter which technique is used –
a rapid cure (within one or three days) is the rule.
Especially the degree of inflammation and to a minor
extent age and the anesthetic procedure are crucial for
cure.75 The duration of hospitalization are strongly
reflecting cultural and health-political circumstances.
So in Europe, the patient with a common health
insurance is generally nursed in the unit for one week
and is then discharged in healthy condition. In
America, the patients is often discharged on the same
day because the costs are extremely high for the family
and not always covered by the insurance company.
Despite this, the complication rates are comparable.
These facts show that not the postoperative care in an
unit but the perioperative and operative care are the
most crucial components for a rapid recovery. In case
of an appendicitis without complications the patients
is already allowed to drink water after 6-8 hours, and
if this is tolerated well it is started with a pasty diet. In
most cases the patients are allowed to take regular food
after three days. During the first days sufficient fluid
intake is important, but fresh fruits and vegetables,
sweets, and flatulent food should be avoided for at
least 10-14 days. In case of peritonitis or an intensive
manipulation of the cecum (perhaps with intramural
hematoma) a paralytic ileus may occur post-
operatively. In these cases, it is better to adhere to food
withdrawal and parenteral fluid supply, as well as
electrolyte substitution. A temporary stomach tube
often simplifies the situation. Fever can persist for
some days but is not always associated with the need
for antibiotic therapy. But if the fever reappears several
days after surgery, one has to think of a subcutaneous
or intra-abdominal abscess. If there is no bowel
evacuation after three to four days, stimulation with a
small clyster, in case of preschool children with the
help of an intestinal tube, has a relieving effect. But it
is always to think of a fluid deficit which has to be
corrected. Bed rest is only necessary as long as the
patient himself wants to stay there. Also younger
children are able to walk without pain after surgery.
The pain situation itself is very individual. In general
in young patients a single dose of a nonsteroid
antirheumatic like paracetamol or metamizole (in most
cases given as suppository on the operating table or
on the first postoperative day) is sufficient for pain
relief. All complicated cases with median laparotomy,
intraperitoneal or subcutaneous drainage, or
generalized peritonitis are, of course exceptions. For
these cases an additional intravenous dose of opiates
with fewer side-effects (e.g. tramadol or nubain) is
often necessary.
POSTOPERATIVE COMPLICATIONS
The complication rates after appendectomy are still
lying between 5.1-33%, whereby the highest
proportion is found in the group of the perforating
appendices. In spite of a drastic improvement after
the introduction of antibiotic therapy, the mortality
rate lies, mainly due to multimorbid patients, still
between 0.001-0.5%. Complications can be classified
into early, that means immediately occurring after
surgery, and late complication. Early complications are
first of all peritonitis, the intra-abdominal abscess, the
disturbance of wound healing, and the paralytic ileus.
They nearly always occur due to a perforating
appendicitis. The causes of perforation are first of all
associated with a delayed start of treatment and a
history anamnesis of more than 36 hours (in > 65% of
all perforations).76 Precautions to avoid these
complications are a perioperative antibiotic
prophylaxis, clean and fast surgery, lowest possible
contamination of the abdominal wall, adequate
614 Pediatric Surgery—Diagnosis and Management
preoperative fluid replacement, and careful lavage
with normal saline. Drainages, which are not unusual
in adults, are very controversial in children.77
Most hospitals also refuse drainage in case of a
multiquadrant peritonitis. One exceptions might be
the primary drainage without resection of the
appendix in case of an extremely progressive appen-
dicitis. Appendectomy is performed as described
above, after the abatement of inflammation. If an intra-
abdominal abscess is existing, there are again two
treatment options. In most cases, a complete resolution
of the abscess can be achieved and therefore a
relaparotomy be avoided by intravenous adminis-
tration of antibiotics and temporary food with-
drawal.78 The second option is surgery. Either a
relaparotomy is performed or a laparotomy is carried
out to clear or drain the abscesses. The process can be
followed by ultrasonography.79
Late complications are ileus, caused by adhesions,
and stump appendicitis. Also chronic pain may occur
as a consequence of nerve lesions, consecutive
development of neurinomas, or scar pain. The
adhesive strangulation of intestines is typically taking
place after a peritonitis and nearly always requires
relaparotomy or laparoscopy.
Perioperative complications are a rupture of the
appendix, possibly a cecal lesion, a erroneous opening
of the bladder, or bleeding due to an insufficient
ligation of the appendicular artery. In case of minimal
invasive surgery technical complication are added.
These are injuries of blood vessels with severe bleeding
due to the first trocar or the Veress’ needle, and injuries
of abdominal organs also due to trocar insertion or
through monopolar coagulation, resulting in a leakage
current. Perforations of intestinal loops, liver, spleen
and bladder as well as thermic damages of cecum or
ileum are occurring.
PROGNOSIS
The operative treated appendicitis is considered as
cured after wound healing. A relapse is only possible,
if a residual stump was left. Indigestions or immuno-
logical deficiencies in cases of a premature
appendectomy were not observed till now. Although,
all possible functions of the appendix are only partly
clarified.
Since the notion appendicitis exists, also the
conception of chronic appendicitis is known.
Although, the existence of such a chronic course is
denied by the vast majority of surgeons. On the other
hand, the recurrent appendicitis is accepted and
proved by several studies.80 It has been shown that
patients who are again and again suffering from more
or less typical discomforts are not operated until the
clinically clear picture of an acute appendicitis is
observed. The diagnosis is objectively verified by
adequate studies. That means that there exists a milder
course of the disease which sooner or later ends up in
a complicated appendicitis in most cases. In these cases
the early appendectomy is an advantage and often the
diagnostic laparoscopy is the better operative access.
FUTURE ASPECTS AND RESEARCH
The vermiform appendix is increasingly confronted
with new scopes for instance as conduit or replacement
in operations of the lower urinary tract. There are also
new indications like PFIC (progressive familial
intrahepatic cholestasis), where the appendix is needed
as diversification between gallbladder and skin.
Therefore, the indication for appendectomy has to be
more precisely in the future. Due to the better
diagnostic situation today, fewer false positively
diagnosed patients are appendectomized.81
Appendicitis is one of the most discussed topics of
surgical research. Clinical investigation about
diagnostic criteria, especially the attempt to establish
computer-based systems, are supported by the OMGE.
Until now these efforts were disappointing. Clinical
history and examination should be structurally
recorded. Therefore, large prospective studies are
necessary to answer the questions whether it shall be
operated early or only actively be observed, or whether
technical developments like ultrasonography are able
to replace the active observation. Due to these and
other studies, progress has been made in the
establishment of objective parameters for the
recognition of appendicitis which are now a part of
our evidence-based medicine. Immunocytochemical
and immunohistological investigations are carried out
in many centers. The role of cytokines for the
development of appendicitis is a large chapter of the
surgical research. The key-words are among others
Pgp 9.5, nerve growth factor, and growth-associated
protein 43. One part of research is dealing with
neuroimmunological processes within the appendix.
Thereby specific neuropeptides like SP are investigated
Diagnostic Laparoscopy 615
Appendicitis 615
referring to their importance for the immune system
and the appendicitis, respectively. It is postulated that
up to a fourth of all appendectomies, in which a
histologically unaffected appendix was found, are
cases of neuroimmunoappendicitis, which are based
on an increased density of nerve fibers sensitive to two
neuropeptides.82 Currently, a meta-analysis has
revealed that appendectomized patients less
frequently fall sick with ulcerative colitis. Also nothing
is known about the responsible immunological
processes.83
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