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Skandalakis’ Surgical Anatomy > Chapter 17. Appendix >

History of the Appendix

The anatomic and surgical history of the appendix is shown in Table 17-1.

Table 17-1. Anatomic and Surgical History of the Appendix

Leonardo da Vinci 1492 Showed appendix in drawings and called it “orecchio” (little ear); published in the 18th century
Berengario da Carpi 1521 First person to describe the appendix
Andreas Vesalius 1543 Showed the appendix in a drawing but did not describe it in the text
Jean Fernel 1544 Early description of appendicitis
Von Hilden 1652 Early description of appendicitis
Lorenz Heister 1711 Unequivocal description of perforated appendix with abscess formation
Giovanni Battista Morgagni 1719 First detailed anatomic description of appendix
Claudius Amyand 1736 Performed the first appendectomy? or Tait, 1980? or Krönlein, 1884?
Mestivier 1759 Described perforation of the appendix by a pin; considered perforation the cause of the abscess; the second unequivocal case identifying appendix as site of disease
John Hunter 1767 Described gangrenous appendix at autopsy
John Parkinson 1812 Described autopsy findings of 5-year-old child with perforated appendix containing a fecalith
Louyer-Villemay 1824 Described fatal gangrenous appendix in two young men; first clinical history of acute suppurative appendicitis
Francois Melier 1827 Presented six autopsy descriptions of appendicitis and suggested that perhaps surgical removal of the appendix was in order
Goldbeck 1830 Described acute suppurative appendicitis but said cause was irritation of cecum; first use of term “perityphlitis”
Guillaume Dupuytren 1835 Ascribed RLQ abscesses to pericecal origin without mention of appendix
Stokes 1838 Used large doses of opium to treat intraabdominal inflammations
Thomas Addison and 1839 Described symptomatology of appendicitis; stated that appendix was the cause of many or
Richard Bright   most of the inflammatory processes of the right iliac fossa
A. Grisolle 1839 Advocated drainage of abdominal abscesses following watchful waiting until fluctuation
Volz 1846 Identified the appendix as the origin of RLQ inflammatory process
Henry Hancock 1848 Recommended earlier operation for drainage of abscesses
Willard Parker 1867 Recognized obstructive origin of appendicitis; reported four cases of abscess secondary to perforated appendix; advised surgical drainage after the 5th day of the disease, but did not advise operation before perforation
Lawson Tait 1880 Removed a gangrenous appendix; in 1890 abandoned appendectomy
Abraham Groves 1883 Removed an inflamed appendix; not published until 1934
Mikulicz 1884 Removed the appendix but patient did not survive
Krönlein 1884 Perhaps, rather than Amyand in 1736, was first to perform appendectomy
Charter-Symonds 1885 Extraperitoneal removal of fecalith
Reginald Heber Fitz 1886 Advocated early surgical removal of acute appendix; first used term “appendicitis”
R.J. Hall 1886 Successfully removed perforated appendix within an irreducible inguinal hernia with pelvic
    abscess
John Homans 1886 Operated on an 11-year-old boy, draining the abscess with good recovery
Thomas G. Morton 1887 Successful operative removal of perforated appendix with draining of abscess
Edward R. Cutler 1887 Performed one of the first “clean” unruptured appendectomies; reported in 1889
Henry Sands 1888 Removed two fecaliths and closed the perforation of the appendix
Charles McBurney 1889 Described abdominal point tenderness (McBurney’s point)
June, 1894 Presented “gridiron incision” (McBurney’s incision) to Chicago Medical Society (CMS)
Lewis L. McArthur July, 1894 Published his vertical midline incision technique, which was postponed from presentation at June meeting of CMS
G.R. Fowler 1894 to 1895 Advocated “cuffing” of appendiceal stump
R.H.M. Dawbarn 1895 Advocated invagination of appendiceal stump to prevent postoperative fistula
William Henry Battle 1897 Advocated a vertical incision through the lateral edge of the right rectus sheath; others also advocated it, and incision sometimes is referred to as Battle-Jalaguier-Kammerer incision
A.C. Bernays 1898 Reported 71 consecutive appendectomies without mortality
Harrington, Weir, and Fowler 1899 Described medial extension of gridiron incision by dividing lateral portion of rectus sheath (Fowler-Weir extension)
A.J. Ochsner 1902 Advocated nonoperative treatment to localize spreading peritonitis
John B. Murphy 1904 Reported 2000 appendectomies without death
H.A. Kelly 1905 Advocated against “ligating, amputating, and burying the little stump”
A. E. Rockey, 1905 Each advocated transverse skin incision (later called Rockey-Davis incision)
G. G. Davis 1906  
P. Masson 1921 Described neuromas of the appendix; studied relationship between neuroendocrine cells and origin of carcinoid tumors
Arthur Rendle Short 1925 Investigated appendicitis as “a disease of Western civilization,” low-fiber diet
LeGrand Guerry 1926 Cited 2,959 personal cases of appendectomy
A.J.E. Cave 1936 Described appendiceal duplications and abnormalities
D.C. Collins 1951 Described agenesis of the appendix
1955 Study of 50,000 human appendix specimens
1963 Study of 71,000 human appendix specimens
Skandalakis et al. 1962 Collective review of cases of smooth muscle tumors of the colon and appendix as reported in the world literature
O’Neill 1966 Described use of appendix as fallopian tube
E. Higa et al. 1973 Described proliferative epithelial tumors of appendiceal mucosa
de Kok 1977 Laparoscope-aided appendectomy with mini-laparotomy
A.P. Dhillon, L. Papadaki, J. Rode 1982 to 1983 Studied subepithelial neuroendocrine cells; immunoreactivity for serotonin
Semm 1983 Laparoscopic appendectomy

History table compiled by David A. McClusky III and John E. Skandalakis.

References:

de Kok HJ. A new technique for resecting the non-inflamed not-adhesive appendix through a mini-laparotomy with the aid of the laparoscope. Arch Chir Neerl 1977;29:195-98.

Moore FD. The gastrointestinal tract and the acute abdomen. In: Warren R. (ed) Surgery. Philadelphia: WB Saunders, 1963.

O’Neill JJ. The use of the vermiform appendix as a fallopian tube. Am J Obstet Gynecol 1966;95:219-21.

Skandalakis JE, Gray SW, Shepard D, Bourne GH. Smooth Muscle Tumors of the Alimentary Canal: Leiomyomas and Leiomyosarcomas, a Review of 2525 Cases. Springfield, IL: Charles C. Thomas, 1962.

Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994.

Williams GR. Presidential address: A history of appendicitis. Ann Surg 1983;197:495-506.

Williams RS. Appendicitis: historical milestones and current challenges. Med J Aust 1992;157:784-87.

Williams RA, Myers P. Pathology of the Appendix and Its Surgical Treatment. New York: Chapman & Hall Medical, 1994.

Embryogenesis

Normal Development

The appendix is the terminal portion of the embryonic cecum. The appendix becomes distinguishable by its failure to enlarge as fast as the proximal cecum. This difference in growth rate continues into postnatal life. At birth, the diameter of the colon is 4.5 times that of the appendix; at maturity, it is 8.5 times larger.5

The appendix is visible at about the eighth week of gestation. At first, it projects from the apex of the cecum. As the cecum grows, the origin of the appendix shifts medially toward the ileocecal valve (Fig. 17-1C). The taeniae of the longitudinal muscle coat of the colon originate from the base of the appendix, showing the same displacement.

Fig. 17-1.

Three types of cecum and appendix. A and B. Infantile forms. When present in the adult, they represent mild developmental arrest. C. Mature and most common form. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

The medial shift of the adult appendix fails to occur in 5-15% of individuals.6 In these cases, the appendix is funnel-shaped (Fig. 17-1A). If the appendix is of normal shape, it is still located symmetrically on the cecal apex (Fig. 17-1B).

Wakeley7 believed that asymmetric positioning of the appendix is due to faster relative growth of the right and anterior cecal walls in childhood. The symmetric position is the normal mature condition.

Maisel8 argued that there is a rotation of the right colon and cecum about their own long axis. Thus, the retrocecal appendix is the juvenile condition. The authors of this chapter do not find this argument convincing.

Until the 12th week, the appendix is circular in cross-section. After this time, it appears as lobed. Villi are found in the fourth and fifth months, disappearing before birth. A few lymph nodules appear in the wall of the appendix by the seventh month. They increase up to puberty, after which they gradually decrease. Obliteration of the lumen is common in elderly patients.

Congenital Anomalies

Because of its seemingly vestigial nature, one would expect to find great variability of the appendix, but this is not the case. Appendiceal variations are few, and are all rare. Although in humans the appendix appears to be vestigial as a digestive organ, it emerges as a fully developed and functional lymphoid organ.

Absence of the Appendix

Both Morgagni (in 1719)9 and Hunter (in 1762)10 reported on the absence of the appendix. Few cases of absent appendix or both absent appendix and cecum have been reported. Collins found 4 cases in 71,000 specimens examined,11 and reported only 46 cases in the literature (by 1931).12

An absent appendix may have failed to form in the eighth week. Alternatively, it may have developed at the same rate as the cecum, and thus be present, but lacking demarcation from the rest of the cecum. The latter is probably the case where there are more than four haustra in the cecum.13 According to Williams,14 the possibility of appendiceal autoamputation, intussusception, or volvulus15 suggests that any diagnosis of agenesis should be preceded by inspection of the bowel and abdominal cavity for a mummified appendix.

Chevre et al.,16 who encountered a case of appendiceal agenesis, cautioned that the diagnosis not be made without thorough exploration of the ileocecal and retrocecal areas.

Ectopic Appendix

Fawcitt found an appendix in the thorax, in association with malrotation and diaphragmatic defect.17 Babcock reported the removal of an appendix in the lumbar area.18 Abramson presented a case of an appendix which was located within the posterior cecal wall, and which did not have a serous coat.19

Left-Sided Appendix

There are four conditions that can result in a left-sided appendix. In order of frequency, they are: (1) situs inversus viscerum, (2) nonrotation of the intestines, (3) “wandering” cecum with a long mesentery, and (4) an excessively long appendix crossing the midline. Nisolle et al.20 described a case of left-sided appendicitis in which the extremity of a dilated right appendix was located in the left lower quadrant (LLQ) along the lateral pelvic wall.

Smith and colleagues stated that there were 40 cases of appendicitis and malrotation with the appendix in the left lower quadrant reported by 1933, and 97 cases of appendicitis and situs inversus reported by 1949.21 Collins found 40 cases of LLQ appendix and 17 cases of situs inversus (11 with dextrocardia) in his series of 71,000.11 Altogether, some 200 cases of left-sided appendix are in the literature.

Situs inversus can be predicted by noting the position of the patient’s heart. Nonrotation, however, may not be recognized if there are no radiographic films available. Further, it should be noted that in about one-half of patients with situs inversus, the pain of appendicitis is felt in the right lower quadrant (RLQ).

If the cecum and appendix are not in the right iliac fossa, the right paravertebral gutter and the right subhepatic space should be searched. If the cecum still cannot be found, the incision should be closed. A midline incision should be made that will give access to both the left and right lower quadrants.

Duplication of the Appendix

Waugh22 described three types of duplication of the appendix:

 

Double-barreled appendix, with a common muscularis and often a distal communication between the lumina (this type of tubular duplication is also found elsewhere in the large and small intestine)

“Bird-type” paired appendix. Structures are symmetrically placed on either side of the ileocecal valve (this condition occurs in conjunction with other severe defects, and may be a mild form of hindgut twinning)

Taenia coli-type duplication. A normal appendix develops at the usual site, and an additional small appendix forms on a taenia. This may represent a continued development of the transitory cecal protuberance observed from the sixth to the seventh week of development.

Appendiceal duplications as classified by Cave23 and Wallbridge24 are shown in Figures 17-2A-E. Kjossev and Losanoff25 found a second appendix at the splenic flexure (Fig. 17-2D), which they considered to be a new subtype of the Cave-Wallbridge Type B anomaly.

Fig. 17-2.

Duplication classification system of Cave and Wallbridge. A. Wallbridge type A anomaly. Single cecum and a partial duplication of the appendix with a single base. Varying degrees of appendiceal duplication are possible. B. Wallbridge type B1 anomaly. Two completely separate appendices arise from a single cecum and are disposed on either side of the ileocecal valve. C. Wallbridge type B2 anomaly. The second appendix is usually found arising from the taenia coli of the wall of the cecum. D. Figure shows type B1 (1) and B2 (2) anomalies; 3 represents duplication from the hepatic flexure; 4 represents duplication from the splenic flexure. E. Wallbridge type C anomaly. Double cecum, each with its own appendix. (A, B, C, E Modified from Williams RA. Development, structure and function of the appendix. In: Williams RA, Myers P. Pathology of the Appendix and Its Surgical Treatment. New York: Chapman & Hall Medical, 1994, pp. 9-30, with permission). (D Modified from Kjossev KT, Losanoff JE. Duplicated vermiform appendix. Br J Surg 1996;83:1259, with permission.)

Duplication is rare; Collins found only two cases of true congenital double appendix and one case of post-inflammatory pseudo-duplication in 71,000 specimens.11 Arda et al.,26 reporting in 1992, expanded case reports to around 100. A triplicated appendix with other anomalies was reported by Tinckler;27 a horseshoe appendix having a patent continuous lumen with two separate openings into the cecum and a fan-shaped mesoappendix was discovered during surgery by Mesko et al.28

Lin et al.29 urged surgeons to routinely check for appendiceal duplication at surgery, especially when clinical signs of appendicitis occur with visualization of a normal appendix at laparotomy. We agree that this is very wise advice.

Congenital Appendiceal Diverticula

Although the appendix is subject to diverticulum formation like the rest of the intestine, there have been few reports of the formation of true congenital appendiceal diverticula (Fig. 17-3).30-33 Favara31 found an association between genetic abnormalities and congenital diverticula.

Fig. 17-3.

Diverticulosis of the appendix.

Heterotopic Mucosa in the Appendix

Gastric mucosa, pancreatic tissue,34 and esophageal mucosa35 have been reported in the appendix. Haque et al.36 found heterotopic bone associated with mucin-producing tumors of the appendix.

Surgical Anatomy

Topography, Position, and Relations

The appendix arises from the cecum, which is related posteriorly to the iliopsoas muscle and the lumbar plexus of nerves. Anteriorly it is related to the abdominal wall, the greater omentum, or coils of ileum. In the cadaver, the apex of the cecum is usually found slightly to the medial side of the middle of the right inguinal ligament.

In living individuals the position of the cecum varies with posture, respiration, abdominal muscle tone, and state of intestinal distention. When an individual is standing upright, the cecum and appendix often hang over the pelvic brim. From the apex of the cecum (the only relatively fixed point) the appendix can project in any direction and the tip can become attached to almost any abdominal organ except the spleen (Fig. 17-4).

Fig. 17-4.

Variations in topographic position of the appendix. From its base at the cecum, the appendix may extend (A) upward, retrocecal and retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to the left, ileocecal (may pass anterior or posterior to the ileum). (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

There is little doubt that the terminology used to describe the position of the appendix is a major source of confusion to those who would attempt to apply the descriptions in the literature to the reality of the operating room. Sir Frederick Treves derived a schema for appendiceal positions based on the hands of a clock (Fig. 17-5).37

Fig. 17-5.

Graphic illustration of appendiceal position. (Adapted from Decker GAG, Du Plessis DJ. Lee McGregor’s Synopsis of Surgical Anatomy (12th ed). Bristol: Wright, 1986; with permission.)

The exact meaning of “retrocecal” is disturbingly unclear in a report by Wakeley in 1933,7 in which he reviewed 10,000 postmortem cases and described five typical locations of the appendix. In order of frequency they are (1) retrocecal-retrocolic, free or fixed; (2) pelvic or descending; (3) subcecal, passing downward and to the right; (4) ileocecal, passing upward and to the left anterior to the ileum; and (5) ileocecal, posterior to the ileum. If the position of the appendix is “retrocecal” or “retrocolic,” does this indicate whether the organ is intraperitoneal or extraperitoneal? Such a difference is no small matter.

Most series concurred with Wakeley’s findings regarding the two most common locations, but Buschard and Kjaeldgaard38 compiled significant variations from reports of many surgeons (Table 17-2).

Table 17-2. Survey of the Position of the Appendix, in Per Cent, in Various Materials

    Position, %
      Anterior Posterior    
Material Country No. Pelvic Ileocecal Retrocecal Subcecal Anterior Posterior
Collins USA 4,680 78.5 20.2 1.3 78.5 21.5
Peterson Finland 373 42.2 26.8 31.0 69.0 31.0
Maisel South Africa 300 58.0 10.2 26.7 5.0 68.2 31.7
Shah & Shah autopsy India 186 34.9 28.0 30.1 7.0 62.9 37.1
Liertz Germany 2,092 42.1 13.9 35.0 9.0 56.0 44.0
B & K CSSR 93 44.1 11.8 44.1 0.0 55.9 44.1
Waas Ceylon 266 24.1 28.6 35.3 12.0 52.7 47.3
Solanke Nigeria 125 31.2 29.2 38.4 11.2 50.4 49.6
B & K Denmark 141 33.4 7.8 56.7 2.1 41.2 58.8
Shah & Shah operation India 405 8.2 26.9 61.2 3.7 35.1 64.9
Wakeley Great Britain 10,000 31.0 1.4 65.3 2.3 32.4 67.6

Source: Buschard K, Kjaeldgaard A. Investigation and analysis of the position, fixation, length, and embryology of the vermiform appendix. Acta Chir Scand 1973;139:293-298.

O’Connor and Reed39 studied the location of the appendix in 129 patients undergoing abdominal procedures; these authors also had their own terminology of anatomic location of the appendix (Fig. 17-6). A summary of the findings of these workers is presented in Table 17-3. They stated that the retrocecal position of the appendix was indeed the most common, although it occurred in only 28-33% of instances.

Table 17-3. Distribution of Locations of the Vermiform Appendix

Positiona,b 
 
Nonappendicitis Appendicitisc 
 
Total Percentaged 
 
Preileal 1 5 6 4 (5%)
Postileal 7 3 10 8 (7%)
Subileal 11 8 19 15 (15%)
Pelvic 14 11 25 19 (19%)
Subcecal 9 5 14 11 (13%)
Paracecal 4 9 13 10 (13%)
Retrocecal 18 24 42 33 (28%)
Totals 64 65 129 100 (100%)

aAnterior positions 1-5: 56%.

bPosterior positions 6-7: 44%.

cDistribution of positions analyzed by Pearsons Chi-square (P >0.2).

dPercentages in parentheses include the 27 excluded cases.

Source: O’Connor CE, Reed WP. In vivo location of the human vermiform appendix. Clin Anat 1994;7:139-142.

Fig. 17-6.

Anterior and posterior positions of the appendiceal tip. (From O’Connor CE, Reed WP. In vivo location of the human vermiform appendix. Clin Anat 1994; 7:139-142; with permission.)

O’Connor and Reed’s findings included the observation that only 10% of the 21.5% rate of retrocecal appendices reported by Collins12 were mobile, but more than 40% of the Danish patients (out of a total of 56.7%) reported by Buschard and Kjaelgaard38 had mobile retrocecal appendices. Whether the appendix is “fixed” or “unfixed,” it would seem fairly reasonable to think that the truly major factor in appendectomy has to do with its intraperitoneal or extraperitoneal position.

Puylaert40 classified the orientation of the appendix as medial (35%), caudal (30%), retrocecal/retroperitoneal (25%), and lateral (10%).

Ajmani and Ajmani41 studied appendiceal arteries and the position of the appendix in natives of India. The most common position of the appendix was retrocecal/ retrocolic (58%); the pelvic position accounted for 23%. The other positions, in descending order of occurrence, were: postileal, 10%; subcecal, 5%; paracecal, 2%; and preileal, 2% (Table 17-4). The same authors reported an average appendiceal length of 9.5 cm in males and 8.7 cm in females.

Table 17-4. Showing Various Positions of Appendix and Their Percentage

Classification Retrocecal and Retrocolic Pelvic Postilial Subcecal Preilial Paracecal
Sex M F M F M F M F M F M F
No. of cases 52 6 15 8 9 1 5 nil 2 nil 2 nil
Total 58 23 10 5 2 2
Total in % 58% 23% 10% 5% 2% 2%

Source: Ajmani ML, Ajmani K. The position, length and arterial supply of vermiform appendix. Anat Anz (Jena) 1983;153:369-74.

Wakeley,7 who focused on Great Britain, reported that only 1.4% of appendices were ileocecal. Solanke,42 in Nigeria, found 19.2% in this position. Buschard and Kjaeldgaard,38 using measurements made in Denmark and the former Czechoslovakia (see Table 17-2), concluded that the pelvic position represented immaturity of cecal development and that the retrocecal position represented complete maturity. This theory concurs with those of Wakeley7 and DeGaris.43

The appendix can possibly change its position in living subjects when not held in place by adhesions. Buschard and Kjaeldgaard38 sought evidence of such change, but observed none. Although it has often been suggested,11,44 no consistent correlation between position of appendix and frequency of appendicitis has been confirmed. In a retrospective review of operative reports and in an analysis of 94 appendectomies, Shen and colleagues45 found that the retrocecal position of the appendix did not alter the clinical course of appendicitis.

Appendiceal Wall

The appendiceal wall is similar to the wall of the colon. It is formed by

 

The serosa

A muscular layer composed of the longitudinal and circular layers. At the appendiceal base, the longitudinal muscle produces a thickening that is related to all cecal taeniae

The submucosa, which contains many lymphoid islands

The mucosa

According to Owen and Nemanic,46 columnar epithelial cells and attenuated antigen-transporting membrane or M cells cover the mucosa. Ferguson47 stated that even though the association between columnar epithelial cells and lymphocytes within the epithelial layer of the gut and other organs is well known, much work remains to establish the real role of interactions between lymphocytes and the enteric mucosa.

Brunagel et al.48 described an appendicocutaneous fistula which occurred as a complication of abdominal draining.

Mesentery of the Appendix

Hollinshead49 proposed that “since the appendix is a part of the cecum and the latter has no true mesentery, the appendix does not either; however, there is usually a peritoneal fold enclosing the artery to the appendix which is commonly referred to as the mesenteriole or mesentery of the appendix.”

The mesentery of the appendix is embryologically derived from the posterior side of the mesentery of the terminal ileum. The mesentery attaches to the cecum as well as to the proximal appendix. It contains the appendicular artery. The mesentery frequently appears to be too short for the appendix, which may be sharply bent on itself.

Morphology of the Appendix

The posteromedial side of the cecum gives origin to the vermiform appendix about 1.7 cm from the end of the ileum. Variations have been found in the diameter of the appendix at its base at the cecum: Hollinshead49 found an average of 0.6 cm, Anson and McVay50 reported an average of 0.8 cm, and Maingot51 found a range of 0.5-1.5 cm.

The average appendiceal length as reported by a number of authors is shown in Table 17-5. Apparent differences in dimension seem to exist in varying populations, but no correlation exists between the length of the appendix and its position.38

Table 17-5. Average Dimensions of the Appendix from Various Sources

Authors Year Length, cm
Ferguson 1891 11.5
Kelynack 1893 9.0
Bryant 1893 8.25
Monks & Blake 1902 7.9
Kelly & Hurdon 1905 9.1
Deaver 1913 8.9
MacPhail 1917 9.9
Lewis 1918 8.3
Robinson 1923 9.2
Royster 1927 7.5
Henke & Lubarsch 1929 9.5
Hafferl 1953 9.0
Hollinshead 1956 8.5
Goss 1959 8.3
Solanke 1970 9.6
Anson & McVay 1971 6-12 (range)
Warwick & Williams 1973 9.0
Buschard & Kjaeldgaard 1973 9.12 (operation) (CSSR)
9.75 (operation) (Denmark)
9.96 (autopsy) (Denmark)
Ajmani & Ajmani 1983 8.7 (female)
9.5 (male)
Puylaert 1990 9.0
Williams & Myers 1994 9.0

Based on data from the following:

Ajmani ML, Ajmani K. The position, length and arterial supply of vermiform appendix. Anat Anz (Jena) 1983;153:369-374.

Buschard K, Kjaeldgaard A. Investigation and analysis of the position, fixation, length, and embryology of the vermiform appendix. Acta Chir Scand 1973;139:293-298.

Puylaert JBCM. Ultrasound of Appendicitis. New York: Springer-Verlag, 1990.

Solanke TF. The position, length and content of the vermiform appendix in Nigerians. Br J Surg 1970;57:100-102.

Williams RA, Myers P. Pathology of the Appendix and Its Surgical Treatment. New York: Chapman & Hall Medical, 1994.

Vascular Supply

Arteries and Veins

(Figs. 17-7, 17-8) The appendicular artery arises from the ileocolic artery, an ileal branch, or from a cecal artery. Although the appendicular artery is usually singular (Fig. 17-7A, B), Michels52 found two appendicular arteries in 10 of 132 specimens examined (Fig. 17-7C). A much higher frequency of duplication among Indian subjects was reported by Shah and Shah.44 In 30% of their subjects, there were two arteries. In addition to the typical appendicular artery, the base of the appendix may be supplied by a small branch of the anterior or posterior cecal artery.

Fig. 17-7.

Blood supply to the appendix. A and B. Usual type with a single appendicular artery. C. Paired appendicular arteries. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; after Solanke TF. The blood supply of the vermiform appendix in Nigerians. J Anat 1968;102:353-361; with permission.)

Fig. 17-8.

Variations in the origin of the accessory appendicular arteries. (Modified from Ajmani ML, Ajmani K. The position, length and arterial supply of vermiform appendix. Anat Anz 1983; 153:369-374; with permission.)

Solanke,53 in his study of Nigerians, found variation in the pattern of arterial blood supply to the appendix. Eighty of the 100 cadavers received, in addition to blood from the main appendicular artery, supply from one or more accessory appendicular arteries. He also noted a high frequency of arterial anastomoses, which could serve as alternate routes for circulation in the event of occlusion of the main appendicular artery.

Van Damme54 stated that the appendicular branch of the ileocolic artery can be doubled in 5% of cases. In agreement with Van Damme, Bertelli et al.55 consider the cecoappendicular branches of the ileocolic artery to be terminal branches.

Ajmani and Ajmani,41 in their study of Indian subjects, stated that the main appendicular artery springs from the ileocecal artery. In 39% of their cadavers, the accessory appendicular arteries arose from various vessels (Fig. 17-8, Table 17-6).

Table 17-6. Showing Origin of Accessory Appendicular Arteries

Origin Posterior Cecal Ileocecal Anterior Cecal Arterial Loop
Sex M F M F M F M F
No. of cases 22 5 6 2 1 1 2 nil
Total (39) 27 8 2 2
Total in percentage 69.23% 20.5% 5.12% 5.12%

Source: Ajmani ML, Ajmani K. The position, length and arterial supply of vermiform appendix. Anat Anz (Jena) 1983; 153:369-74.

The appendicular vein and artery are enveloped by the mesentery of the appendix. The appendicular vein joins cecal veins to become the ileocolic vein, which is a tributary of the right colic vein.56

Lymphatic Drainage

Lymphatic drainage from the ileocecal region is through a chain of nodes on the appendicular, ileocolic, and superior mesenteric arteries through which the lymph passes to reach the celiac lymph nodes and the cisterna chyli (Figs. 17-9, 17-10). A secondary drainage (which passes anterior to the pancreas) to subpyloric nodes was described by Braithwaite.57 It should be remembered that lymph nodules in the wall of the appendix are not connected with the lymphatic drainage of the organ. The lymphocytes formed in the nodules pass into the lumen of the appendix.

Fig. 17-9.

Anterior view of the external lymphatic drainage of the appendix with the position of the lower ileocolic lymph nodes indicated (L). (Modified from Williams RA. Development, structure and function of the appendix. In: Williams RA, Myers P. Pathology of the Appendix and Its Surgical Treatment. New York: Chapman & Hall Medical, 1994, pp. 9-30; with permission.)

Fig. 17-10.

Posterior view of the external lymphatic drainage of the appendix and cecum with the position of the lower ileocolic lymph nodes indicated (L). (Modified from Williams RA. Development, structure and function of the appendix. In: Williams RA, Myers P. Pathology of the Appendix and Its Surgical Treatment. New York: Chapman & Hall Medical, 1994, pp. 9-30; with permission.)

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Innervation

Sympathetic innervation of the appendix originates from the celiac and superior mesenteric ganglia. Parasympathetic innervation originates from the vagus nerve. Sensory innervation for pain is carried by the eighth thoracic spinal nerve, or perhaps by the 10th and 11th thoracic nerves.

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Histology

Though the thick appendiceal wall has the same four layers as the colon (serosa or adventitia, muscularis externa, submucosa, and mucosa), it differs by having the following characteristics: its outer layer of longitudinal smooth muscle is complete, and the mucosa and submucosa have multiple lymph nodules.

The histology of the appendix has been considered previously in this chapter under the heading “Appendiceal Wall.”

Physiology

The physiologic action of this vestigial organ in human beings is not known. Due to the presence of numerous lymphatic follicles however, it is generally accepted that the appendix performs immune functions. But this does not mean that a normal appendix should not be removed in an exploratory (diagnostic) laparotomy. The reason is very simple: there is the possibility of future acute appendicitis with or without gangrene, perforation, and localized or generalized peritonitis.

Surgical Anatomy of Appendectomy

Exposure and Mobilization

The incision for appendectomy (Fig. 17-11) is usually made over McBurney’s point.58 It is made at right angles to a line between the anterior superior iliac spine and the umbilicus at two-thirds the distance from the umbilicus. One-third of the incision should be above the line; two-thirds should be below.59

Fig. 17-11.

Incision for appendectomy (blue line) in relation to McBurney’s point. Inset: Actual location of 30 appendices in 30 patients. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; redrawn from DuPlessis DJ. A Synopsis of Surgical Anatomy, 11th Ed. Bristol, England: Wright and Sons, 1975; with permission. Inset: Redrawn from DeGaris CF. Topography and development of the cecum and appendix. Ann Surg 113:540, 1941; with permission.)

The surgeon must not expect to find the appendix exactly at McBurney’s point. Using roentgenography, DeGaris43 found the base of the appendix to be near McBurney’s point in 7 of 30 patients; it was displaced in 23 (Fig. 17-11). Karim et al.60 described 70% of appendices visualized in 51 subjects as lying inferior to the interspinous line. In a study of 275 double-contrast barium enemas, Ramsden and colleagues61 found only 35% of appendiceal bases lying within 5 cm of McBurney’s point; 15% were more than 10 cm away.

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Identification

The cecum should be identified first. The cecum can be distinguished from the transverse colon by the absence of attachments of the greater omentum. If the cecum cannot be located, malrotation of the intestines or an undescended cecum should be considered (see “Topography, Position, and Relations”).

Once the cecum has been identified, one of the taeniae coli should be traced downward to the base of the appendix. The base always arises from the cecum at the convergence of the taeniae, even though the tip of the appendix is very mobile. It may be necessary to incise the posterior peritoneum lateral to the cecum to expose a deeply buried retrocecal appendix.

Congenital absence of the appendix is too rare to be entertained seriously. However, apparent absence of the appendix can be the result of intussusception. With intussusception, there should be an obvious dimple at the normal site of the appendix. The wise surgeon will always inspect the abdomen for signs of previous operation.

Surgical Applications

 

The convergence of the taeniae coli at the appendiceal base will help the surgeon find a hidden appendix.

Right psoas muscle test: The forced extension of the right thigh produces increased pain in the RLQ of the abdomen when the inflamed appendix and its short mesentery rest on the peritoneum which covers the right major psoas muscle.

Right obturator muscle test: Flexion and lateral rotation of the right thigh produces increased pain in the RLQ and right pelvic area when the inflamed appendix is closely related to the obturator internus muscle.

Each position of the appendix produces and mimics a different clinical picture:

 

Retrocecal appendix: RLQ or right flank pain with ureteric irritation

Pelvic appendix: Pelvic pain with urinary symptoms; rule out pelvic inflammatory disease

Subhepatic appendix: Due to cecal malrotation; presents gallbladder symptoms

Upper or lower midline appendix: Epigastric or hypogastric pain

Situs inversus: When present, pain is located at the LLQ

If the diagnosis of acute appendicitis in children is not certain, we advise emergency surgery for females and close follow-up for males. Diagnostic aids, such as an emergency Gastrografin enema, are of occasional help. Delay in making the appropriate diagnosis is a major factor in the occurrence of perforation, according to Berry and Malt.62 Despite the fact that mortality has been reduced over the years, morbidity is high with delayed diagnosis and surgery.

Guidry and Poole63 reported that the appendix was in a “hidden” location in 15% of patients with simple appendicitis or without appendicitis, compared with 68% of patients with gangrenous or perforative appendicitis. The same authors concluded that anatomic variations in the location of the appendix may be responsible for a late diagnosis, causing delayed appendectomy.

Stevenson64 advised elective appendectomy with the clinical diagnosis of appendiceal colic.

Wong et al.65 recommended Tc-99m IgG scintigraphy as a definitive test for the diagnosis of acute appendicitis. This test did not produce false-positive results. Chen et al.66 reported that abdominal sonography to detect acute appendicitis has a sensitivity of 99.3%, an accuracy of 91.6%, a positive predictive value of 90.5%, and a negative predictive value of 97.0%. Chen and colleagues advise routine sonography of the abdomen in patients with clinical appendicitis.

Crombe et al.,67 in a study similar to that of Chen et al., likewise recommended systematic abdominal ultrasonography when acute appendicitis is suspected in adults.

Buckley et al.68 advocate laparoscopic appendectomy because of the reduction in complications and shorter hospital stay. Reiertsen et al.69 found laparoscopic appendectomy “at least as good” as open appendectomy. Williams et al.70 reported that laparoscopic appendectomy resulted in less parenteral analgesia and made earlier hospital discharge possible, but at a significantly higher expense. Ortega and colleagues71 mentioned the same benefits, but coupled with increased operative time. In the majority of cases retroperitoneal dissection is not required. O’Connor and Reed39 observed that the appendix was most commonly retrocecal in position, but this accounted for only 33% of cases. This fact, they believed, may encourage greater use of laparoscopic appendectomy.

The study by Hansen et al.72 found no difference in morbidity between laparoscopic and open cases of acute appendicitis. Minné et al.73 stated that for the routine patient with acute appendicitis, laparoscopic appendectomy does not offer any proven benefits compared to the open approach. Mutter et al.74 reported that there were no significant advantages of laparoscopic appendectomy over open appendectomy for male patients, and recommended that laparoscopic appendectomy be performed only in men with atypical symptomatology and in obese patients. In contrast, Cox et al.75 stated that there were significant advantages for men in terms of a more rapid recovery compared to open appendectomy, and no significant disadvantages.

 

Appendicitis in pregnancy is a diagnostic problem. Baer et al.76 emphasized the displacement of the appendix by the gravid uterus and the corresponding relocation of the pain (Fig. 17-12).

Serour et al.77 reported 3 cases of acute appendicitis following blunt abdominal trauma, and after an extensive review of the world literature found posttraumatic appendicitis to be a real entity to take into consideration.

Ohno et. al.78 presented the first report of appendiceal intussusception secondary to tubulovillous adenoma arising from the appendix.

Nycum et al.79 reported a case of asymptomatic intussusception of the appendix secondary to endometriosis. Collins,11 after studying 71,000 human appendiceal specimens over the course of 40 years, reported the incidence of all causes of intussusception to be 0.1%.

Hoeksema and Gusz80 used colonoscopy to diagnose appendiceal intussusception, which was treated by laparoscopic appendectomy.

Lessin et al.81 stated that in clinically equivocal cases of appendicitis, ultrasonography is a good diagnostic modality.

Scineaux et al.82 recommended transvaginal ultrasonography as a diagnostic tool for patients with recurrent pelvic pain. They relied on this modality to diagnose appendicitis in a woman with chronic endometriosis.

In contrast, a study by Lee et al.83 disputes the value of ultrasound and CT as a diagnostic tool, and recommends selective use of diagnostic laparoscopy. We quote:

Migratory pain, physical examination, and initial leukocytosis remain reliable and accurate in diagnosing acute appendicitis. Neither CT nor US improves the diagnostic accuracy or the negative appendectomy rate; in fact, they may delay surgical consultation and appendectomy. In atypical cases, one should consider the selective use of diagnostic laparoscopy instead.

Fig. 17-12.

Changes in position and direction of appendix during pregnancy. PP = postpartum. (Modified from Baer JL, Arens RA. Appendicitis in pregnancy. JAMA 1932;98:1359; with permission.)

 

Benign and malignant neoplasms of the appendix are very rare, and according to Lyss,84 occur in 1.08% to 1.3% of all appendiceal specimens. The most common neoplastic processes are carcinoids, mucoceles, and rarely, epithelial and nonepithelial tumors.

In a review of the world literature from 1875 to 1996, Hatch et al.85 found only 23 leiomyomas and 5 leiomyosarcomas of the appendix. They strongly advised a right colectomy if the tumor shows two or more mitotic figures in every ten high-power fields.

Krisher et al.86 reported significantly increased rates of postoperative intra-abdominal abscess in children with perforated appendicitis when laparoscopic appendectomy was compared with open surgery in a tertiary care facility.

Anatomic Complications of Appendectomy

(Table 17-7)

Table 17-7. Summary of Anatomical Complications of Appendectomy

Procedure Vascular Injury Organ Injury Inadequate Procedures
Appendectomy Hematoma of the mesentery, hemoperitoneum, intraluminal bleeding, right iliac artery and vein Perforation of cecum or intestinal loop, of right ureter, of right uterine tube or ovary Unnecessary delay in locating appendix, failure to remove tip of appendix, remaining stump too long (appendicitis may recur)

Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.

Vascular Injury

Hematoma of the mesentery of the appendix or of the ileocecal mesentery can occur as a result of appendectomy. Intraluminal bleeding is also possible. The right iliac vessels may be injured, especially with a downward-projecting “pelvic” appendix.

Hemoperitoneum can occur secondary to improper ligation of the mesentery of the appendix. McGraw87 recommended ligation of individual branches of the appendicular artery in the mesoappendix. Kazarian et al.88 found 6 cases of intraperitoneal hemorrhage among 539 operations for appendicitis.

Organ Injury

The cecum, the terminal ileum, or any loop of intestine can be injured by excessive traction or rough handling. Difficult pelvic appendectomy can also cause injury to the right ureter, right uterine tube, or ovary.

A fecal fistula can form secondary to inadequate ligation or failure to invert the appendiceal stump. The fistula may occur when preoperative perforation or severe inflammation is located at the base of the appendix or in the wall of the cecum; notwithstanding, many surgeons do not invert the stump. Kazarian et al.88 reported an occurrence rate of fecal fistula of 0-1.4%.

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Nerve Injury

Motor Nerves

With the use of a vertical incision, there is always the possibility of injury to the 10th, 11th, or 12th thoracic nerves, or occasionally, the iliohypogastric nerve. Such an injury will result in some degree of late muscle atrophy of the lower part of the internal oblique and transversus abdominis muscles, as well as the rectus abdominis, and the possible (but rare) development of inguinal hernia. It is always good practice to avoid damaging nerves whenever possible.

Sensory Nerves

Division of lateral and anterior cutaneous branches of the intercostal nerves may produce transitory numbness around the incision. This will disappear in 2 to 3 months.

Inadequate Procedure

Sound knowledge of the embryology and anatomy of the intestines is necessary to avoid inadequate procedures. Such information reduces the time a surgeon spends trying to locate and identify the appendix. This embryologic/anatomic knowledge can prevent mismanagement of acute appendicitis in an undescended cecum.

Examples of inadequate procedure are an uninverted long appendiceal stump that may be subject to recurring acute appendicitis, and a long inverted stump that may produce a radiographic filling defect that simulates a tumor. When surgeons leave an appendiceal tip in situ because of local severe inflammatory process, they do so of necessity, but realizing that complications may follow later.

The advice of Lin and colleagues29 (which we presented earlier in the chapter) to routinely check for appendiceal duplication at surgery is another version of the sage advice that to be forewarned is to be forearmed.

Price et al.89 advocated interval appendectomy as a critical component of the complete management of appendiceal abscess, and presented two cases in which initial drainage did not obviate the need for later extirpation.

Katkhouda et al.,90 citing results from a minimally invasive surgical service and a general service, found significantly reduced rates of intra-abdominal abscess for perforated appendicitis in the former.

References

1. Fitz R. N Y Med J 1886;47:508

2. McBurney C. N Y Med J 1889;i:679

3. Worcester A. Ann Gyn Pediatr 1892;v:49

4. Morson DP, Dawson IMP. Gastrointestinal Pathology. London: Blackwell Scientific Publications, 1972, p 397.

5. Collins DC. The length and position of the vermiform appendix: a study of 4,680 specimens. Ann Surg 1932; 96:1044-48.

6. May EA. Chronic appendicitis: its roentgen diagnosis. J Med Soc NJ 1937; 34:91.

7. Wakeley CPG. The position of the vermiform appendix as ascertained by an analysis of 10,000 cases. J Anat 1933; 67:277.

8. Maisel H. The position of the human vermiform appendix in fetal and adult age groups. Anat Rec 1960; 136:385.

9. Morgagni JB. The seats and causes of disease investigated by anatomy. Alexander LB (trans). New York: Hafner Publishing, 1960.

10. Hunter W. Medical commentaries. London, 1762.

11. Collins DC. 71,000 human appendix specimens: a final report, summarizing forty years’ study. Am J Proctol 1963; 14:365-81.

12. Collins DC. The chronic inflammatory and obliterative reactions of the vermiform appendix. Thesis. Post-Graduate School, University of Minnesota, June 1932.

13. Schridde H. Über den angeborenen Mangel des Processus vermiformis. Virchows Arch (Pathol Anat) 1904; 177:150.

14. Williams RA. Development, structure and function of the appendix. In: Williams RA, Myers P. Pathology of the Appendix and Its Surgical Treatment. New York: Chapman & Hall Medical, 1994, pp. 9-30.

15. Fenoglio-Preiser CM, Lantz PE, Listrom MB. Gastrointestinal Pathology: An Anthology and Text. New York: Raven Press, 1989.

16. Chevre F, Gillet M, Vuilleumier H. Agenesis of the vermiform appendix. Surg Laparosc Endosc Percutan Tech 2000; 10:110-112.

17. Fawcitt R. Appendix situated within thorax. Br J Radiol 1948; 21:523-5.

18. Babcock WW. Lumbar appendicitis and lumbar appendectomy. Surg Gynecol Obstet 1946; 82:414-6.

19. Abramson DJ. Vermiform appendix located within the cecal wall. Dis Colon Rectum 1983; 26:386-9.

20. Nisolle JF, Bodart E, de Caniere L, Bahati M, Michel L, Trigaux JP. [Acute left-side appendicitis: diagnostic contribution of tomodensitometry.] Arch Pediatr 1996;3:47-50. [PubMed: 8745827]

21. Smith DE, Jacquet JM, Virgilio RW. Left upper quadrant appendicitis. Arch Surg 1974; 109:443. [PubMed: 4852649]

22. Waugh TR. Appendix vermiformis duplex. Arch Surg 1941; 42:311-320.

23. Cave AJE. Appendix vermiformis duplex. J Anat 1936;70:283-292.

24. Wallbridge PH. Double appendix. Br J Surg 1963;50:346-347.

25. Kjossev KT, Losanoff JE. Duplicated vermiform appendix. Br J Surg 1996;83:1259. [PubMed: 8983623]

26. Arda IS, S¸enocak ME, Hièsönmez A. Duplication of the vermiform appendix: case report and review of the literature. Paed Surg Int 1992;7:221-222.

27. Tinckler LF. Triple appendix vermiformis: a unique case. Br J Surg 1968;55:79-81. [PubMed: 5635427]

28. Mesko TW, Lugo R, Breitholz T. Horseshoe anomaly of the appendix: a previously undescribed entity. Surgery 1989;106:563-566. [PubMed: 2772830]

29. Lin BC, Chen RJ, Fang JF, Lo TH, Kuo TT. Duplication of the vermiform appendix. Eur J Surg 1996;162:589-591. [PubMed: 8874171]

30. Royster HA. Appendicitis. New York: Appleton, 1927.

31. Favara BE. Multiple congenital diverticula of the vermiform appendix. Am J Clin Pathol 1968; 49:60-64.

32. Balsano NA, Reynolds BM. Ruptured true congenital diverticulum of vermiform appendix without associated appendicitis. NY State J Med 1971; 71:2877-78.

33. Wetzig NR. Diverticulosis of the vermiform appendix. Med J Aust 1986; 145:464-5.

34. Budd DC, Fouty WJ. Familial retrocecal appendicitis. Am J Surg 1977; 133:670-1.

35. Droga BW, Levine S, Baber JJ. Heterotopic gastric and esophageal tissue in the vermiform appendix. Am J Clin Pathol 1963; 40:190. [PubMed: 14064868]

36. Haque S, Eisen RN, West AB. Heterotopic bone formation in the gastrointestinal tract. Arch Pathol Lab Med 1996;120:666-670. [PubMed: 8757473]

37. Treves F. Lectures on the anatomy of the intestinal canal and peritoneum in man. Br Med J 1885; 1:527-30.

38. Buschard K, Kjaeldgaard A. Investigation and analysis of the position, fixation, length, and embryology of the vermiform appendix. Acta Chir Scand 1973;139:293-298. [PubMed: 4698491]

39. O’Connor CE, Reed WP. In vivo location of the human vermiform appendix. Clin Anat 1994; 7:139-142.

40. Puylaert JBCM. Ultrasound of Appendicitis. New York: Springer-Verlag, 1990.

41. Ajmani ML, Ajmani K. The position, length and arterial supply of vermiform appendix. Anat Anz (Jena) 1983; 153:369-74.

42. Solanke TF. The position, length and content of the vermiform appendix in Nigerians. Br J Surg 1970; 57:100-2.

43. DeGaris CF. Topography and development of the cecum and appendix. Ann Surg 1941; 113:540-48.

44. Shah MA, Shah M. The position of the vermiform appendix. Indian Med Gaz 1945; 80:494-5.

45. Shen GK, Wong R, Daller J, Melcer S, Tsen A, Awtrey S, Rappaport W. Does the retrocecal position of the vermiform appendix alter the clinical course of acute appendicitis? Arch Surg 1991; 26:569-70.

46. Owen RL, Nemanic P. Antigen processing structures of the mammalian intestinal tract. Scanning Electron Microsc 1978;II: 367-78.

47. Ferguson A. The immune system and mucosal transformation – historical perspective. Digestion 1990;46(Suppl 2):255-61.

48. Brunagel G, Decker P, Hirner A. [Delayed appendico-cutaneous fistula: a rare complication of simple abdominal drainage.] Zentralbl Chir 1996;121:67-69. [PubMed: 8852744]

49. Hollinshead WH. Anatomy for Surgeons. New York: Hoeber-Harper, 1956.

50. Anson BJ, McVay CB. Surgical Anatomy (5th ed). Philadelphia: Saunders, 1971.

51. Maingot R. Abdominal Operations (6th ed). New York: Appleton-Century-Crofts, 1974.

52. Michels NA. The variant blood supply to the small and large intestines. J Int Coll Surg 1963; 39:127.

53. Solanke TF. The blood supply of the vermiform appendix in Nigerians. J Anat 1968;102:353-361. [PubMed: 5643847]

54. Van Damme JPJ. Behavioral anatomy of the abdominal arteries. Surg Clin North Am 1993;73:699-725.

55. Bertelli L, Lorenzini L, Bertelli E. The arterial vascularization of the large intestine: anatomical and radiological study. Surg Radiol Anat 1996;18(Suppl I):S1-S59.

56. Kelly HA, Hurdon E. The Vermiform Appendix and Its Diseases. Philadelphia: Saunders, 1905.

57. Braithwaite LR. The flow of lymph from the ileocecal angle and its possible bearing on the cause of duodenal and gastric ulcer. Br J Surg 1923; 11:7.

58. McBurney C. Experiences with early operative interference in cases of disease of the vermiform appendix. NY Med J 1889, 50:676.

59. Du Plessis DJ. A Synopsis of Surgical Anatomy (11th ed). Bristol: Wright and Sons, 1975.

60. Karim OM, Boothroyd AE, Wyllie JH. McBurney’s point – fact or fiction? Ann R Coll Surg Engl 1990; 72:304-8.

61. Ramsden WH, Mannion RA, Simpkins KC, deDombal FT. Is the appendix where you think it is — and if not does it matter? Clin Radiol 1993; 47:100-3.

62. Berry J Jr., Malt RA. Appendicitis near its centenary. Ann Surg 1984; 200:567-75.

63. Guidry SP, Poole GV. The anatomy of appendicitis. Am Surg 1994;60:68-71. [PubMed: 8273977]

64. Stevenson RJ. Chronic right-lower-quadrant abdominal pain: is there a role for elective appendectomy? J Pediatr Surg 1999;34:950-54. [PubMed: 10392911]

65. Wong DW, Vasinrapee P, Spieth ME, Cook RE, Ansari AN, Jones M Jr, Mandal A. Rapid detection of acute appendicitis with Tc-99m-labeled intact polyvalent human immune globulin. J Am Coll Surg 185:534-543, 1997. [PubMed: 9404876]

66. Chen SC, Chen KM, Wang SM, Chang KJ. Abdominal sonography screening of clinically diagnosed or suspected appendicitis before surgery. World J Surg 1998;22:449-452. [PubMed: 9564286]

67. Crombe A, Weber F, Gruner L, Martins A, Fouque P, Barth X. [Abdominopelvic ultrasonography in suspected acute appendicitis: prospective study in adults]. Ann Chir 2000;125:57-61. [PubMed: 10921186]

68. Buckley RC, Hall TJ, Muakkassa FF, Anglin B, Rhodes RS, Scott-Conner CEH. Laparaoscopic appendectomy: is it worth it? Am Surg 1994; 60:30-4.

69. Reiertsen O, Trondsen E, Bakka A, Andersen OK, Larsen S, Rosseland AR. Prospective nonrandomized study of conventional versus laparoscopic appendectomy. World J Surg 1994; 18:411-6.

70. Williams MD, Miller D, Graves ED, Walsh C, Luterman A. Laparoscopic appendectomy, is it worth it? South Med J 1994; 87:592-8.

71. Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B, and the Laparoscopic Appendectomy Study Group. A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Am J Surg 1995; 169:208-213.

72. Hansen JB, Smithers BM, Schache D, Wall DR, Miller BJ, Menzies BL. Laparoscopic vesus open appendectomy: prospective randomized trial. World J Surg 20:17-21, 1996. [PubMed: 8588406]

73. Minné L, Varner D, Burnell A, Ratzer E, Jeffrey Clark, Haun W. Laparoscopic vs open appendectomy: prospective randomized study of outcomes. Arch Surg 132:708-712, 1997. [PubMed: 16449399]

74. Mutter D, Vix M, Bui A, Evrard S, Tassetti V, Breton JF, Marescaux J. Laparoscopy not recommended for routine appendectomy in men: results of a prospective randomized study. Surgery 120:71-74, 1996. [PubMed: 8693426]

75. Cox MR, McCall JL, Toouli J, Padbury RTA, Wilson TG, Wattchow DA, Langcake M. Prospective randomized comparison of open versus laparoscopic appendectomy in men. World J Surg 20:263-266, 1996. [PubMed: 8661828]

76. Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy. JAMA 1932; 98:1359.

77. Serour F, Efrati Y, Klin B, Shikar S, Weinberg M, Vinograd I. Acute appendicitis following abdominal trauma. Arch Surg 131: 130-785-786, 1996.

78. Ohno M, Nakamura T, Hori H, Tabuchi Y, Kuroda Y. Appendiceal intussusception induced by tubulovillous adenoma with carcinoma in situ: report of a case. Surg Today 2000;30:441-444. [PubMed: 10819482]

79. Nycum LR, Moss H, Adams JQ, Macri CI. Asymptomatic intussusception of the appendix due to endometriosis. So Med J 1999;92(5):524-25.

80. Hoeksema MA, Gusz JR. Appendiceal intussusception. J Am Coll Surg 2001;192:538. [PubMed: 11294412]

81. Lessin MS, Chan M, Catallozzi M, Gilchrist BF, Richards C, Manera L, Wallach MT, Luks FI. Selective use of ultrasonography for acute appendicitis in children. Am J Surg 1999;177:193-96. [PubMed: 10219853]

82. Scineaux TL, Sills ES, Perloe M, Daly JP. Transvaginal ultrasonographic identification of appendicitis in a setting of chronic pelvic pain and endometriosis. South Med J 2001;94:73-74. [PubMed: 11213949]

83. Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg 136:556-562, 2001. [PubMed: 11343547]

84. Lyss AP. Appendiceal malignancies. Semin Oncol 15:129, 1988. [PubMed: 3285476]

85. Hatch KF, Blanchard DK, Hatch GF III, Wertheimer-Hatch L, Davis GB, Foster RS Jr, Skandalakis JE. Smooth muscle (stromal) tumors of the appendix and colon. World J Surg 2000;24:430-436. [PubMed: 10706915]

86. Krisher SL, Browne A, Dibbins A, Thacz N, Curci M. Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis. Arch Surg 2001;136:438-441. [PubMed: 11296116]

87. McGraw AB. Factors contributing to low mortality from appendectomy for acute appendicitis: ten year study. Arch Surg 1949;58:171.

88. Kazarian KK, Roeder WJ, Mersheimer WL. Decreasing mortality and increasing morbidity from acute appendicitis. Am J Surg 1970; 119:681. [PubMed: 5445991]

89. Price MR, Haase GM, Sartorelli KH, Meagher DP Jr. Recurrent appendicitis after initial conservative management of appendiceal abscesses. J Pediatr Surg 1996;31:291-294. [PubMed: 8938362]

90. Katkhouda N, Friedlander MH, Grant SW, Achanta KK, Essani R, Paik P, Velmahos G, Campos G, Mason R, Mavor E. Intra-abdominal abscess rate after laparoscopic appendectomy. Am J Surg 2000;180:456-461.

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