Appendix
The 'Absent'
Michael Rolff, MD; Lars Vedel Jepsen, MD; Jack
During an operation for suspected appendicitis, the surgeon concluded that the appendix was absent. The causes of this situation are presented and a guide to its management is suggested. \s=b\
(Arch Surg. 1992;127:992)
occasionally that surgeon, operating Itfindtient suspected of having appendicitis, the We illustrate this occurs
a
on a
acute a case to
pa¬
cannot
appendix. report prob¬ lem, discuss the causes of the situation, and suggest ways in which it should be handled.
REPORT OF A CASE admitted to the hospital with a 36-hour 19-year-old history of diffuse abdominal pain that later localized to the right iliac fossa. He had vomitted once. No other gastrointestinal A
man was
symptoms were noted. His temperature was 38.3°C. His abdomen
tender in the right iliac fossa with localized peritoneal signs. No mass was present. Rectal examination revealed tenderness on the right side. Of note in his history was an episode of similar symptoms and signs 4 years previously. He was admitted to the hospital but the attack passed spontaneously after 12 hours' observation. As a 2-year-old child, he had undergone a left-sided inguinal herniotwas
omy. With
a preoperative diagnosis of acute appendicitis, the pa¬ tient was surgically explored through an incision in the right iliac fossa. No free fluid was in the peritoneal cavity. The operating junior surgeon could not find the appendix despite full mobilization of the cecum and tracing the cecal taeniae to their point of convergence. A senior surgeon was called and he also could not find a structure that resembled an appendix. However, at the confluence of the cecal taeniae, a thin string¬ like structure was found and removed. No lumen could be identified in this structure and the surgeons were convinced that it was a fibrous adhesion and not the appendix. No cause for the patient's symptoms could be found in the abdomen. The patient made an uneventful recovery. Pathologic examination revealed a 5.5-cm-long structure mea¬ suring between 1 and 3 mm in diameter. Microscopy showed an obliterated appendix. The mucous membrane was replaced by fi¬ brosis. A thin muscle layer could be identified. No signs of acute inflammation were noted.
COMMENT The appendix maybe "absent" at laparotomy for four rea¬ sons: congenital absence, obHteration after a previous attack of acute appendicitis, previous surgical removal, or deficient anatomic knowledge on the part of the surgeon. Congenital absence of the appendix is extremely rare. Only 76 cases had
Accepted for publication From the
Reprints
November 29, 1991.
Department of Surgery, H\l=o/\rsholm(Denmark) Hospital.
not
available.
Hoffmann, FRCSEd
been at
reported by 1983.] This diagnosis shouldnot be made laparotomy before all other causes of an absent appen¬
dix have been excluded. There is no doubt that an attack of acute appendicitis can resolve spontaneously.2 The attack may be so severe that the appendix is totally destroyed or transformed into a fibrous strand by the inflammatory process.3 This situation is illus¬ trated by our patient. An appendix may have been removed incidentally at a previous operation for a disease unrelated to the appendix, typically hysterectomy. Appendixes may even be removed left- or right-sided inguinal herniotomy.4 The pa¬ during tient may be unaware that the appendix has been removed so that all previous abdominal incisions should make the surgeon aware of this possibility when he or she encounters an absent appendix. A surgeon's inadequate knowledge of anatomy is the most likely and certainly the most dangerous cause of an absent appendix. In the three situations mentioned above, the fact that the appendix is actually missing or reduced to a fibrous thread precludes the possibility that the patient has acute ap¬ pendicitis, so that closure of the abdomen after excluding other causes of the patient's symptoms is unlikely to cause problems. However, if an appendix harboring acute inflam¬ mation is overlooked, dire consequences will ensue. Four principles must be adhered to when the appendix is difficult to find. The cecum and terminal ileum must be fully mobi¬ lized to reveal a retrocecal, retrocolic, or retroileal appendix. The confluence of the three cecal taeniae, the only constant anatomic landmark of the appendix, must be demonstrated unequivocally. The incision must be extended if exposure is inadequate. Finally, the abdomen must not be closed on an absent appendix before the situation has been confirmed by a senior surgeon. Any tissue situated at the confluence of the taeniae must be removed and sent for pathologic study to confirm or negate the diagnosis of an absent appendix. It should be remembered that an appendix may be reduced to a thin fibrous strand by previous inflammation, and that even a normal appendix may be only 1 cm long.4 A tiny nod¬ ule containing little more than lymphoid tissue may be the only trace of an appendix.5 References 1.
Shperber J, Halevy A, Sayfan J, Olan J. Congenital appendix. Isr J Med Sci. 1983;19:214-215.
absence of the
ver-
miform 2.
Coldrey E.
Five years of conservative treatment of acute
appendicitis.
J Int Coll Surg. 1959;32:255-261. 3. Hoffmann J, Lindhard A, Jensen H-E. Appendix mass: conservative management without interval appendectomy. Am J Surg. 1984;148:379-382. 4. Ellis H. Appendix. In: Schwartz SI, Ellis H, eds. Maingot's Abdominal Operations. 9th ed. East Norwalk, Conn: Appleton & Lange; 1990:953-977. 5. Robinson JO. Congenital absence of the vermiform appendix. Br J Surg. 1952;39:344-345.
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The 'Absent'
Michael Rolff, MD; Lars Vedel Jepsen, MD; Jack
During an operation for suspected appendicitis, the surgeon concluded that the appendix was absent. The causes of this situation are presented and a guide to its management is suggested. \s=b\
(Arch Surg. 1992;127:992)
occasionally that surgeon, operating Itfindtient suspected of having appendicitis, the We illustrate this occurs
a
on a
acute a case to
pa¬
cannot
appendix. report prob¬ lem, discuss the causes of the situation, and suggest ways in which it should be handled.
REPORT OF A CASE admitted to the hospital with a 36-hour 19-year-old history of diffuse abdominal pain that later localized to the right iliac fossa. He had vomitted once. No other gastrointestinal A
man was
symptoms were noted. His temperature was 38.3°C. His abdomen
tender in the right iliac fossa with localized peritoneal signs. No mass was present. Rectal examination revealed tenderness on the right side. Of note in his history was an episode of similar symptoms and signs 4 years previously. He was admitted to the hospital but the attack passed spontaneously after 12 hours' observation. As a 2-year-old child, he had undergone a left-sided inguinal herniotwas
omy. With
a preoperative diagnosis of acute appendicitis, the pa¬ tient was surgically explored through an incision in the right iliac fossa. No free fluid was in the peritoneal cavity. The operating junior surgeon could not find the appendix despite full mobilization of the cecum and tracing the cecal taeniae to their point of convergence. A senior surgeon was called and he also could not find a structure that resembled an appendix. However, at the confluence of the cecal taeniae, a thin string¬ like structure was found and removed. No lumen could be identified in this structure and the surgeons were convinced that it was a fibrous adhesion and not the appendix. No cause for the patient's symptoms could be found in the abdomen. The patient made an uneventful recovery. Pathologic examination revealed a 5.5-cm-long structure mea¬ suring between 1 and 3 mm in diameter. Microscopy showed an obliterated appendix. The mucous membrane was replaced by fi¬ brosis. A thin muscle layer could be identified. No signs of acute inflammation were noted.
COMMENT The appendix maybe "absent" at laparotomy for four rea¬ sons: congenital absence, obHteration after a previous attack of acute appendicitis, previous surgical removal, or deficient anatomic knowledge on the part of the surgeon. Congenital absence of the appendix is extremely rare. Only 76 cases had
Accepted for publication From the
Reprints
November 29, 1991.
Department of Surgery, H\l=o/\rsholm(Denmark) Hospital.
not
available.
Hoffmann, FRCSEd
been at
reported by 1983.] This diagnosis shouldnot be made laparotomy before all other causes of an absent appen¬
dix have been excluded. There is no doubt that an attack of acute appendicitis can resolve spontaneously.2 The attack may be so severe that the appendix is totally destroyed or transformed into a fibrous strand by the inflammatory process.3 This situation is illus¬ trated by our patient. An appendix may have been removed incidentally at a previous operation for a disease unrelated to the appendix, typically hysterectomy. Appendixes may even be removed left- or right-sided inguinal herniotomy.4 The pa¬ during tient may be unaware that the appendix has been removed so that all previous abdominal incisions should make the surgeon aware of this possibility when he or she encounters an absent appendix. A surgeon's inadequate knowledge of anatomy is the most likely and certainly the most dangerous cause of an absent appendix. In the three situations mentioned above, the fact that the appendix is actually missing or reduced to a fibrous thread precludes the possibility that the patient has acute ap¬ pendicitis, so that closure of the abdomen after excluding other causes of the patient's symptoms is unlikely to cause problems. However, if an appendix harboring acute inflam¬ mation is overlooked, dire consequences will ensue. Four principles must be adhered to when the appendix is difficult to find. The cecum and terminal ileum must be fully mobi¬ lized to reveal a retrocecal, retrocolic, or retroileal appendix. The confluence of the three cecal taeniae, the only constant anatomic landmark of the appendix, must be demonstrated unequivocally. The incision must be extended if exposure is inadequate. Finally, the abdomen must not be closed on an absent appendix before the situation has been confirmed by a senior surgeon. Any tissue situated at the confluence of the taeniae must be removed and sent for pathologic study to confirm or negate the diagnosis of an absent appendix. It should be remembered that an appendix may be reduced to a thin fibrous strand by previous inflammation, and that even a normal appendix may be only 1 cm long.4 A tiny nod¬ ule containing little more than lymphoid tissue may be the only trace of an appendix.5 References 1.
Shperber J, Halevy A, Sayfan J, Olan J. Congenital appendix. Isr J Med Sci. 1983;19:214-215.
absence of the
ver-
miform 2.
Coldrey E.
Five years of conservative treatment of acute
appendicitis.
J Int Coll Surg. 1959;32:255-261. 3. Hoffmann J, Lindhard A, Jensen H-E. Appendix mass: conservative management without interval appendectomy. Am J Surg. 1984;148:379-382. 4. Ellis H. Appendix. In: Schwartz SI, Ellis H, eds. Maingot's Abdominal Operations. 9th ed. East Norwalk, Conn: Appleton & Lange; 1990:953-977. 5. Robinson JO. Congenital absence of the vermiform appendix. Br J Surg. 1952;39:344-345.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/26/2015
