Appendectomy (Appendix Surgery)
What is an Appendix and Appendicitis?
The appendix is a single structure approximately the size of a green bean that extends off of the base of the cecum, which is the first part of the colon or large intestine. It is located in the right lower quadrant of the abdomen in most patients. However, its location can vary greatly and can be confused with other abdominal conditions.
Appendicitis is usually caused by firm stool or fecal matter that is lodged in the appendix and leads to an infection in the blocked portion of the appendix. That inflammation from the infection can lead to nausea and abdominal pain in the center of the abdomen. If the infection progresses and the outside of the appendix is irritated, the pain will localize to the position of the appendix, usually the right lower abdomen. If not treated, appendicitis can progress to a perforation or a hole, which can allow leakage of infection or fecal matter into the abdominal cavity. This infection can be localized as an abscess or can spread in the abdomen and lead to a more severe infection in the bloodstream called sepsis. If you think you have symptoms of appendicitis, you should seek medical attention immediately.
A less common problem with the appendix is caused by a mucus-producing tumor called a mucocele. It starts as a polyp in the appendix, similar to colon polyps, as the appendix is lined with the same lining as the colon. This condition is usually found incidentally on a CT scan done for another reason, as there are usually minimal symptoms associated with mucocele. If it is not recognized, the mucus-producing tumor can enlarge and cause the appendix to rupture. This can lead to the spread of the mucin, a gel-like substance, throughout the abdomen. This growth is called pseudomyxoma peritonei, and it can be a life-threatening form of cancer that is difficult to remove surgically.
Another type of tumor in the appendix is a carcinoid tumor. These can be benign or malignant and are best treated by the surgical removal of the appendix.
Causes, Risk Factors & PreventionIt is not clear why appendicitis happens or what risk factors are associated with the appendix becoming inflamed. There is no way to prevent appendicitis, but recognizing the symptoms early in the process of inflammation and seeking medical attention can prevent complications such as perforation. A colonoscopy is recommended beginning at age 50, and could lead to early detection of a tumor or polyp in or near the appendix.
Detection, Tests & Imaging
Appendicitis will usually cause abdominal pain that is localized to the right lower abdomen. Most patients with appendicitis do not have an appetite. The abdominal wall will be tender to touch or pressure; coughing or movement can make the pain more severe. A low-grade fever up to and over 101°F is common. Blood tests will usually show an elevated white blood cell count (infection-fighting cells), though it can be normal in appendicitis. In men, history and physical exam may be all that is needed to diagnose appendicitis as there are fewer organs in the right lower quadrant that can cause these symptoms. However, a CT scan is the most common imaging technique used to diagnose appendicitis as well as appendices masses and tumors. An ultrasound or an MRI can be performed if the patient is pregnant.
In the United States, the most common treatment for appendicitis is an appendectomy or the surgical removal of the appendix. The more-often used procedure is called laparoscopic appendectomy, which requires making small puncture wounds in the abdomen. This procedure results in a faster recovery.
Severe cases that involve more inflammation or an abscess may require open surgery to remove the appendix. In some instances, if there is an abscess present, the collection of pus around the appendix might be drained in the radiology department under local anesthesia, using the CT scanner to guide the placement of a needle. Antibiotics are prescribed to treat the infection. The patient can recover fully and may not even need surgery if a majority of the appendix is destroyed by the infection. This nonsurgical approach using antibiotics is more commonly done in Europe. Appendiceal tumors, cancers, carcinoids or mucoceles can be removed laparoscopically or with robotic-assisted laparoscopy. These problems may require the resection of a portion of the nearby colon to achieve clear margins and lymph nodes. Great care must be taken to avoid the rupture of the appendix and possible spread.
Most patients have a full recovery after an appendectomy. Some patients develop wound infections in their incisions which can be treated by draining the infection in an office setting. Antibiotics may not be needed if the infection is just in the incision. Deeper infections or abscesses can also develop in the postoperative period, usually within 10 to 14 days. These infections can be severe and can required a lengthy hospital stay with intravenous antibiotics, further procedures and even repeat surgery. Cancers or malignant carcinoids of the appendix could require chemotherapy postoperatively. The best way to avoid these problems is to detect the appendicitis or an appendiceal mass early, so surgical removal can be performed before a complication can occur.