Sami M. Shimi

*Department of Surgery, Ninewells Hospital and Medical School, University of Dundee Scotland, United Kingdom* 

### **1. Introduction**

136 Updated Topics in Minimally Invasive Abdominal Surgery

Van Dalen, R.; Bagshaw, PF.; Dobbs, BR.; Robertson, GM.; Lynch, AC. & Frizelle, FA. (2003).

reproductive age*. Surg Endosc*, Vol.2, No.2, pp. 1311- 1313, ISSN 0930-2794 Van den Broeck, WT.; Bijnen, AB.; Van Eerten, PV.; De Ruiter P. & Gouma DJ. (2000).

Vettoretto, N. & Agresta F. (2011). A brief review of laparoscopic appendectomy: the issues and the evidence. *Tech Coloproctol*, Vol.15, No.1, pp.1-6, ISSN 1428-045X Walsh, CA.; Tang, T. & Walsh SR. (2008). Laparoscopic versus open appendicectomy in pregnancy: a systematic review. *Int J Surg,* Vol., No., pp. 339-344, ISSN Wang, Y.; Reen, DJ. & Puri P. (1996). Is a histologically normal appendix following

Weston, AR.; Jackson, TJ. & Blamey, S.(2005). Diagnosis of appendicitis in adults by

Wei, HB.; Huang, JL.; Zheng, ZH.; Wei, B.; Zheng, F.; Qiu, WS.; Guo, WP.; Chen, TF. &

Wullstein, C. Barkhausen, S. & Gross, E. (2001). Results of laparoscopic vs. conventional

Yang, HR.; Wang, YC.; Chung, PK.; Chan, WK.; Jeng, LB. & Chen, RJ. (2005). Role of

Zbar, RI.; Crede, WB.; McKhann, CF. & Jekel, JF. (1993). The postoperative incidence of

Hospital. *Conn Med*, 57, Vol.9, No.12, pp. 123- 127, ISSN 1715-5258

18, [epub ahead of print], Vol.17, No. 13, ISSN 1007-9327

*Endosc*, Vol.14, No.10, pp. 938- 941, ISSN 0930-2794

1076-79, ISSN 1543-2165

379, ISSN: 1948-5204

1705, ISSN 0100-6991

Vol.48, No 1, pp.107-111, ISSN 0004-8666

The utility of laparoscopy in the diagnosis of acute appendicitis in women of

Selective use of dignostic laparoscopy in patients with suspected appendicitis. *Surg* 

emergency appendicectomy always normal? *The Lancet*, Vol.347, Issue 9008, pp.

ultrasonography or computed tomography: Asystemic review and meta-analysis. *International Journal of Technology Assessment in Health Care*, Vol.21, No.3, pp. 368-

Wang, TB.(2010). Laparoscopic versus open appendectomy: a prospective randomized comparison. *Surg Endosc*, Vol.59, No.1, pp. 266-9, ISSN 0930-2794 Wie, HJ.; Lee, JH.; Kyung, MS.; Jung, US.; Choi, JS. (2008). Is incidental appendectomy

necessary in women with ovarian endometrioma? *Aust N Z J Obstet Gynaecol*,

appendectomy in complicated appendicitis. *Dis Col Rectum*, Vol.44, No.11, pp. 1700-

leucocyte count, neutrophil percentage, and C-reactive protein in the diagnosis of acute appendicitis in the elderly. *Am Surg*,Vol.2, No.1, pp. 344-7, ISSN 1681-715 Yeh, CC.; Wu, SC.; Liao, CC.; Su, LT.; Hsieh, CH. & Li, TC. (2011). *Surgical Endoscopy,* Mar

small bowel obstruction following standard, open appendectomy and cholecystectomy: a six year retrospective cohort study at Yale- New Haven The term appendicitis was first used by an epic publication by FITZ (Harvard Medical School) in 1886. FITZ outlined the clinical diagnosis and suggested early removal of the appendix. This new concept was not readily accepted. The first recorded appendicectomy was reported from Australia and was done on a kitchen table in Toowoonba in 1893. Appendicectomy in the UK did not gain early acceptance until 1902, when Sir Frederick Treves operated on King Edward VII twelve days before his coronation.

### **2. Epidemiology**

The epidemiology of appendicitis has caused a lot of intrigue. Although appendicitis was unknown before the 18th Century, there was a striking increase in its prevalence from the end of the 19th Century. There were suggestions that it was a side effect of modern western life. Although evidence for this was lacking, the rapid emergence of appendicitis in developed countries in the 20th Century and its rarity in rural areas and in undeveloped countries was sited as evidence. By the mid 1920s appendicitis became sufficiently common. Several theories have been advanced to account for the prevalence of the disease. One theory suggested that diet was responsible for the geographical distribution of appendicitis. It was however clear that diet could not fully explain the epidemiology of appendicitis. An alternative hypothesis proposed that improved hygiene in developed countries reduced the exposure of infants to enteric organisms would, modify the immune response to virus infections which might then cause appendicitis. Although this theory was accepted for many years, the hygiene hypothesis does not adequately explain the recent decline in the frequency of appendicitis in the latter half of the 20th Century. It remains uncertain whether there has been a real change in the incidence of appendicitis or whether the presentation and course of the disease has indeed changed.

The current incidence of appendicitis is about 100 per 100,000 person-years in Europe/America. Whereas the appendectomy rate is still decreasing, the incidence of appendicitis is now nearly stable. During the last 30 years the incidence of perforated appendicitis has not changed (approximately 20 per 100,000 person-years). Established risk factors for acute appendicitis are age (peak: 10-19 years), sex, and ethnic group/race. Classical theories (diet, hygiene) present illuminating models to explain the rise and fall of incidence in the last century; however, from a contemporary perspective the evidence is insufficient. The study of the epidemiology of appendicitis is complicated by the influence

Appendicitis and Appendicectomy 139

the mortality of appendicitis from 26% overall to less than 1% over the same period. The mortality rate of 0.08% reported is testament to the benefits of advancing technology in managing a persistent rate of perforation and its attendant complications. Perforation continues to disproportionately affect those individuals at the extremes of age. This is most likely due to delays in presentation and diagnosis related to an inability to communicate in the younger population. In the older population, a combination of delayed presentation, confounding medical conditions and a decreased index of suspicion may contribute to this

Emergency appendectomy was originally advocated because of the very high mortality of perforated appendicitis and the assumption that acute appendicitis evolved to perforated disease, a pathophysiologic hypothesis that has never been proven. This notion was first proposed by Reginald Fitz, the originator of the term appendicitis, in 1886. Fitz was the first to identify inflammation of the appendix as a cause for right lower quadrant infections, previously known as thyphilitis. In making the argument that the appendix causes this entity, however, Fitz incidentally noted that one-third of patients undergoing autopsy in the pre-appendectomy era had evidence of prior appendiceal inflammation, suggesting that appendicitis often resolved spontaneously without surgery. Later evidence from submariners who developed appendicitis while at sea and received delayed surgical therapy has shown that in most cases the acute disease can resolve with non-operative

Perforated and non-perforated appendicitis have followed radically different epidemiologic trends over the past 2 decades. While perforated appendicitis slowly but steadily increased in incidence, non-perforated appendicitis stabilised or declined. If perforated appendicitis was simply the result of appendicitis that was not surgically treated early enough, the trends should have been more nearly parallel throughout all the time periods studied. Time series analysis showed that on a year-to-year basis, there was a significant positive correlation between perforated and non-perforated appendicitis for men but not for women. These unassociated epidemiologic trends suggest that the pathophysiology of these diseases is different. If true, it might follow that many patients presenting with non-perforated appendicitis might experience spontaneous resolution without perforation. There is

An alternative hypothesis suggests that several factors (ie, prehospital time, availability of operating room for emergency surgery, time of presentation) have been shown to be significantly associated with perforated appendicitis. Compared with uncomplicated appendicitis, perforated appendicitis is associated with a two- to tenfold increase in

The diagnosis of appendicitis is predominantly a clinical one. The history and examination are pivotal to determining the correct diagnosis. The pain can be a generalised colicky abdominal pain that became more localised to the right iliac fossa over the course of three days. Owing to the embryological origin of the appendix as a midline structure, the majority of patients with acute appendicitis first notice a pain which starts in the region of the umbilicus. This is usually a dull ache or it may be colicky pain when the appendix lumen is obstructed. The pain may change from an intermittent pain to a constant localised sharp pain. After a period of time the pain shifts to the right lower quadrant of the abdomen

historical, clinical, and immunologic evidence to support this hypothesis.

observation.

mortality

**4. Diagnosis** 

antibiotic and supportive therapy.

of referral, infrastructure, and surgical treatment strategy on the incidence of acute appendicitis. Therefore, there is a strong need for good prospective studies with highquality data.
