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Surgery_Schwartz. opportuni-ties for human papillomavirus infection. Am J Obstet Gynecol. 2003;189(3 suppl):S3-S11. 170. Palefsky JM. Anal squamous intraepithelial lesions: relation to HIV and human papillomavirus infection. J Acquir Immune Defic Syndr. 1999;21(suppl 1):S42-S48. 171. Bosarge PL, Como JJ, Fox N, et al. Management of penetrat-ing extraperitoneal rectal injuries: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2016;80(3):546-551. 172. Buie WD, Lowry AC, Rothenberger DA, et al. Clinical rather than laboratory assessment predicts continence after anterior sphincteroplasty. Dis Colon Rectum. 2001;44:1255-1260. 173. Baeten CG, Bailey HR, Bakka A, et al. Safety and efficacy of dynamic graciloplasty for fecal incontinence: report of a prospective, multicenter trial. Dynamic Graciloplasty Therapy Study Group. Dis Colon Rectum. 2000;43:743-751. 174. Hussain ZI, Lim M, Stojkovic SG. Systematic review of peri-anal implants in the treatment


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Surgery_Schwartz. multicenter trial. Dynamic Graciloplasty Therapy Study Group. Dis Colon Rectum. 2000;43:743-751. 174. Hussain ZI, Lim M, Stojkovic SG. Systematic review of peri-anal implants in the treatment of faecal incontinence. Br J Surg. 2011;98:1526-1536. 175. Vaizey CJ, Kamm MA, Roy AJ, et al. Double-blind crossover study of sacral nerve stimulation for fecal incontinence. Dis Colon Rectum. 2000;43:298-302. 176. Tan EK, Vaizey C, Cornish J, et al. Surgical strategies for faecal incontinence—a decision analysis between dynamic gracilo-plasty, artificial bowel sphincter, and end stoma. Colorectal Dis. 2008;10:577-586. 177. Cooksley CD, Hwang LY, Waller DK, et al. HIV-related malig-nancies: community-based study using linkage of cancer reg-istry and HIV registry data. Int J STD AIDS. 1999;10:795-802. 178. Goldberg H, Baxter NN, Hertz M, Madoff RD, Ricciardi R, Bullard KM. Colon and rectal complications in heart and lung transplant patients. J Am Coll Surg. 2006;202:55-61. 179. Ullery BW, Pieracci


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Surgery_Schwartz. H, Baxter NN, Hertz M, Madoff RD, Ricciardi R, Bullard KM. Colon and rectal complications in heart and lung transplant patients. J Am Coll Surg. 2006;202:55-61. 179. Ullery BW, Pieracci FM, Rodney JRM, Barie PS. Neutropenic enterocolitis. Surg Infect (Larchmt). 2009;10(3):307-314.Brunicardi_Ch29_p1259-p1330.indd 132923/02/19 2:30 PM


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Surgery_Schwartz. The AppendixFadi S. Dahdaleh, David Heidt, and Kiran K. Turaga 30chapterHISTORYAlthough anatomists such as Vesalius and Leonardo Da Vinci had written about the appendix, Claudius Amyand in the early 18th century was the first surgeon to describe a successful appendectomy.1 In subsequent centuries, significant progress was made in the diagnosis and management of appendicitis, especially after Chester McBurney advocated for early appen-dectomy in his 1889 publication.2 Famously, the magician Harry Houdini died of a ruptured appendix after suffering a blow to his abdomen. Following the introduction and widespread use of antibiotics in the 1940s, mortality rates improved further. In 1982, Kurt Semm, a gynecologist, reported on the first laparo-scopic appendectomy, which is now the most widely adopted technique.EMBRYOLOGY, ANATOMY, AND HISTOLOGYPreviously considered a vestigial organ, the appendix is now linked to the development and preservation of gut-associated lymphoid tissue (GALT)


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Surgery_Schwartz. adopted technique.EMBRYOLOGY, ANATOMY, AND HISTOLOGYPreviously considered a vestigial organ, the appendix is now linked to the development and preservation of gut-associated lymphoid tissue (GALT) and to the maintenance of intestinal flora. It has been suggested that appendectomy is associated with increased Clostridium difficile infections and increased subse-quent cancer (colon, esophageal) as a result of microbial altera-tion, although this is currently unproven.3 The protective effect of an early appendectomy against development of ulcerative colitis has been proposed to be mechanistically linked to the release of dimeric forms of IgA from plasma B cells and the Th2 response mediated by IL-13–producing natural killer T cells.4The appendix, along with the ileum and the colon, devel-ops from the midgut and first appears at 8 weeks of gestation. As the gut rotates medially, the cecum becomes fixed in the right lower quadrant, thus determining the final position of the appendix. The


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Surgery_Schwartz. from the midgut and first appears at 8 weeks of gestation. As the gut rotates medially, the cecum becomes fixed in the right lower quadrant, thus determining the final position of the appendix. The appendix is a true diverticulum of the cecum as it contains all the histological layers of the colon, although cer-tain differences in the irregularity of crypts remain. The average appendix measures 6 to 9 cm and derives its blood supply from the appendicular branch of the ileocolic artery. Visceral innerva-tion occurs along the superior mesenteric plexus (T10-L1) and the vagus nerves. The appendix is intraperitoneal and retrocecal in location, but it can be pelvic (30%) and retroperitoneal (7%).5 Grossly, the appendiceal base can be identified by tracing the convergence of the cecal taeneia.ACUTE APPENDICITISInflammation of the appendix is a significant public health prob-lem with a lifetime incidence of 8.6% in men and 6.7% in women, with the highest incidence occurring in the second and


Surgery_Schwartz

Surgery_Schwartz. APPENDICITISInflammation of the appendix is a significant public health prob-lem with a lifetime incidence of 8.6% in men and 6.7% in women, with the highest incidence occurring in the second and third decade of life.6 While the rate of appendectomy in developed countries has decreased over the last several decades, it remains one of the most frequent emergent abdominal operations.7The etiology of appendicitis is perhaps due to luminal obstruction that occurs as a result of lymphoid hyperplasia in pediatric populations; in adults, it may be due to fecaliths, fibro-sis, foreign bodies (food, parasites, calculi), or neoplasia.5,8-10 Early obstruction leads to bacterial overgrowth of aerobic organisms in the early period, and subsequently, it leads to mixed flora. Obstruction generally leads to increased intralumi-nal pressure and referred visceral pain to the periumbilical region.10 It is postulated that this leads to impaired venous drain-age, mucosal ischemia leading to bacterial


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Surgery_Schwartz. to increased intralumi-nal pressure and referred visceral pain to the periumbilical region.10 It is postulated that this leads to impaired venous drain-age, mucosal ischemia leading to bacterial translocation, and subsequent gangrene and intraperitoneal infection. Escherichia coli and Bacteroides fragilis are the most common aerobic and anaerobic bacteria isolated in perforated appendicitis.11,12 1History 1331Embryology, Anatomy, and Histology 1331Acute Appendicitis 1331Clinical Diagnosis 1332History / 1332Physical Examination / 1332Laboratory Findings / 1332Imaging / 1332Differential Diagnosis / 1335Management of Appendicitis 1335Uncomplicated Appendicitis / 1332Complicated Appendicitis / 1335Operative Intervention 1335Preoperative Preparation / 1335Operative Technique / 1336Novel Techniques / 1336Negative Exploration / 1336Incidental Appendectomy / 1336Special Circumstances 1337Appendicitis in Children / 1337Appendicitis in Older Adults / 1338Appendicitis in Pregnancy /


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Surgery_Schwartz. Techniques / 1336Negative Exploration / 1336Incidental Appendectomy / 1336Special Circumstances 1337Appendicitis in Children / 1337Appendicitis in Older Adults / 1338Appendicitis in Pregnancy / 1338Chronic or Recurrent Appendicitis / 1338Outcomes and Postoperative Course 1338Stump Appendicitis / 1338Appendiceal Neoplasms / 1338Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs or Carcinoid) / 1338Goblet Cell Carcinomas / 1339Lymphomas / 1339Adenocarcinoma / 1339Appendiceal Mucoceles and Mucinous Neoplasms of the Appendix / 1339Pseudomyxoma Peritonei Syndrome / 1340Brunicardi_Ch30_p1331-p1344.indd 133101/03/19 7:05 PM 1332Key Points1 Inflammation of the appendix is a significant public health problem with a lifetime incidence of 8.6% in men and 6.7% in women, with the highest incidence in the second and third decade of life.6 While the rate of appendectomy in devel-oped countries has decreased over the last several decades, it remains one of the most frequent emergent


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Surgery_Schwartz. incidence in the second and third decade of life.6 While the rate of appendectomy in devel-oped countries has decreased over the last several decades, it remains one of the most frequent emergent abdominal operations.2 The natural history of appendicitis is unclear, but it appears that progression to perforation is not predictable and that spontaneous resolution is common, suggesting that nonper-forated and perforated appendicitis may, in fact, be different diseases.3 C-reactive protein, bilirubin, Il-6, and procalcitonin have all been suggested to be helpful in the diagnosis of appendicitis, specifically in predicting perforated appendicitis.4 Perforated appendicitis can be managed either operatively or nonoperatively. Immediate surgery is necessary in patients that appear septic, but this is usually associated with higher complications, including abscesses and enterocutaneous fis-tulae, due to dense adhesions and inflammation.5 Single incision appendectomy has not been shown to


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Surgery_Schwartz. this is usually associated with higher complications, including abscesses and enterocutaneous fis-tulae, due to dense adhesions and inflammation.5 Single incision appendectomy has not been shown to improve outcomes, including cosmetic outcomes, in prospective randomized studies and has been suggested to have a higher incisional hernia rate.6 While there is no evidence clearly evaluating long-term out-comes of patients undergoing incidental appendectomy with an asymptomatic appendix, the risk of adhesions and future complications after an appendectomy has been suggested to be higher than the risk of future appendicitis and increased economic costs. An incidental appendectomy is currently not advocated.7 Older adult patients are at a higher risk for complications due to their premorbid conditions, and it is prudent to obtain definitive diagnostic imaging prior to taking patients to the operating room.8 Patients with uncomplicated appendicitis do not require fur-ther antibiotics after an


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Surgery_Schwartz. and it is prudent to obtain definitive diagnostic imaging prior to taking patients to the operating room.8 Patients with uncomplicated appendicitis do not require fur-ther antibiotics after an appendectomy, while patients with perforated appendicitis are treated with 3 to 7 days of antibiotics.9 The most common mode of presentation for appendiceal car-cinoma is that of acute appendicitis. Patients also may pres-ent with ascites or a palpable mass, or the neoplasm may be discovered during an operative procedure for an unrelated cause.This sequence is not inevitable, however, and some episodes of acute appendicitis may resolve spontaneously. Due to differ-ences in epidemiology, nonperforated and perforated appendicitis are considered different diseases.13 Addition-ally, since not all nonperforated appendicitis progresses to per-forations, it is suggested that the pathogenesis of the two conditions may be different.CLINICAL DIAGNOSISHistoryIt is important to elicit an accurate history


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Surgery_Schwartz. appendicitis progresses to per-forations, it is suggested that the pathogenesis of the two conditions may be different.CLINICAL DIAGNOSISHistoryIt is important to elicit an accurate history from the patient and/or family, in the case of pediatric patients. Inflammation of the visceral peritoneum usually progresses to the parietal perito-neum, presenting with migratory pain, which is a classic sign of appendicitis (likelihood ratio+, 2.06 [1.63–2.60]).14 Inflam-mation can often result in anorexia, nausea, vomiting, and fever (Table 30-1). Regional inflammation can also present with an ileus, diarrhea, small bowel obstruction, and hematuria. Perti-nent negative history (including menstrual) must be obtained to rule out other etiologies of abdominal pain.Physical ExaminationMost patients lay quite still due to parietal peritonitis. Patients are generally warm to the touch (with a low-grade fever, ∼38.0°C [100.4°F]) and demonstrate focal tenderness with guarding. McBurney’s point, which


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Surgery_Schwartz. quite still due to parietal peritonitis. Patients are generally warm to the touch (with a low-grade fever, ∼38.0°C [100.4°F]) and demonstrate focal tenderness with guarding. McBurney’s point, which is found one-third of the distance between the anterior superior iliac spine and the umbili-cus, is often the point of maximal tenderness in a patient with an anatomically normal appendix. Certain physical signs with their respective eponyms can be helpful in discerning the location of the appendix: Rovsing’s sign, pain in the right lower quad-rant after release of gentle pressure on left lower quadrant (nor-mal position); Dunphy’s sign, pain with coughing (retrocecal 2appendix); obturator sign, pain with internal rotation of the hip (pelvic appendix); iliopsoas sign, pain with flexion of the hip (retrocecal appendix). In addition, pain with rectal or cervical examinations is also suggestive of pelvic appendicitis.Laboratory FindingsPatients with appendicitis usually have leukocytosis of


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Surgery_Schwartz. hip (retrocecal appendix). In addition, pain with rectal or cervical examinations is also suggestive of pelvic appendicitis.Laboratory FindingsPatients with appendicitis usually have leukocytosis of 10,000 cells/mm3, with a higher leukocytosis associated with gangrenous and perforated appendicitis (∼17,000 cells/mm3). C-reactive pro-tein, bilirubin, Il-6, and procalcitonin have all been sug-gested to help in the diagnosis of appendicitis, specifically in predicting perforated appendicitis.14,15 The authors believe that a white blood cell (WBC) count and a C-reactive protein are two appropriate lab tests to obtain in the initial work up of appendicitis; a pregnancy test is also essential in women of childbearing age. Lastly, a urinalysis can be valuable in ruling out nephrolithiasis or pyelonephritis.ImagingImaging is often utilized to confirm a diagnosis of appendici-tis because a negative operation rate is acceptable in <10% of male patients and <20% of female patients. Routine use


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Surgery_Schwartz. is often utilized to confirm a diagnosis of appendici-tis because a negative operation rate is acceptable in <10% of male patients and <20% of female patients. Routine use of crosssectional imaging somewhat reduces the rate of negative laparot-omies. Imaging studies are most appropriate for patients in whom a diagnosis of appendicitis is unclear or who are at high risk from operative intervention and general anesthesia, such as pregnant patients or patients with multiple comorbidities. Commonly utilized imaging modalities include computerized tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI).CT Scan. A contrast-enhanced CT scan has a sensitivity of 0.96 (95% confidence interval [CI] 0.95–0.97) and specificity of 0.96 (95% CI 0.93–0.97) in diagnosing acute appendicitis.16,17 Features on a CT scan that suggest appendicitis include enlarged lumen and double wall thickness (greater than 6 mm), 3Brunicardi_Ch30_p1331-p1344.indd 133201/03/19 7:05 PM 1333THE


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Surgery_Schwartz. Features on a CT scan that suggest appendicitis include enlarged lumen and double wall thickness (greater than 6 mm), 3Brunicardi_Ch30_p1331-p1344.indd 133201/03/19 7:05 PM 1333THE APPENDIXCHAPTER 30Table 30-1Signs and symptoms of appendicitis TRUE POSITIVE LIKELIHOOD RATIO95% CONFIDENCE INTERVALTRUE NEGATIVE LIKELIHOOD RATIO95% CONFIDENCE INTERVALDuration of symptoms (hours) >9 >12 >24 >481.010.960.650.490.97–1.050.90–1.040.47–0.900.36–0.670.941.191.471.200.62–1.420.87–1.631.14–1.901.08–1.34Fever1.640.89–3.010.610.49–0.77Gastrointestinal dysfunction Anorexia Nausea Vomiting1.271.151.631.14–1.411.04–1.361.45–1.840.590.720.750.45–0.770.57–0.910.69–0.80Pain Pain migration Pain progression Direct tenderness Indirect tenderness Psoas sign Rebound Percussion


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Surgery_Schwartz. migration Pain progression Direct tenderness Indirect tenderness Psoas sign Rebound Percussion tenderness Guarding Rigidity2.061.391.292.472.311.992.862.482.961.63–2.601.29–1.501.06–1.571.38–4.431.36–3.911.61–2.451.95–4.211.60–3.842.43–3.590.520.460.250.710.850.390.490.570.860.40–0.690.27–0.770.12–0.530.65–0.770.76–0.950.32–0.480.37–0.630.48–0.680.72–1.02Temperature (degrees centigrade) >37.7 >38.51.571.870.90–2.760.66–5.320.650.890.31–1.360.71–1.12White blood cells (109/L) ≥10 ≥154.207.202.11–8.354.31–12.000.200.660.10–0.410.56–0.78C-reactive protein (mg/L) >10 >201.972.391.58–2.451.67–3.410.320.470.20–0.510.28–0.81Conclusions: Individually, disease history, clinical findings, and laboratory tests are weak. But when combined, they yield high discriminatory power.Data from Andersson RE: Meta-analysis of the clinical and laboratory diagnosis of appendicitis, Br J Surg. 2004 Jan;91(1):28-37.wall thickening (greater than 2 mm), periappendiceal fat stranding, appendiceal wall thickening,


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Surgery_Schwartz. of the clinical and laboratory diagnosis of appendicitis, Br J Surg. 2004 Jan;91(1):28-37.wall thickening (greater than 2 mm), periappendiceal fat stranding, appendiceal wall thickening, and/or an appendicolith (Fig. 30-1). While there remains a concern of ionizing radia-tion exposure with a CT scan, typical low-dose CT scans result in exposure of 2 to 4 mSv, which is not significantly higher than background radiation (3.1 mSv).18 Recent trials have also suggested that although low-dose CT scans of 2 mSv do not generate high-resolution images, using these lower resolution images does not affect clinical outcomes.19 Intravenous contrast is generally preferred in these studies, but it can be avoided in patients with allergies or low estimated glomerular filtration rate (less than 30 mL/minute for 1.73 m2). Several meta-analyses have suggested that CT scan is more sensitive and specific than ultrasound in diagnosing appendicitis.Ultrasound. Ultrasonography has a sensitivity of 0.85 (95%


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Surgery_Schwartz. for 1.73 m2). Several meta-analyses have suggested that CT scan is more sensitive and specific than ultrasound in diagnosing appendicitis.Ultrasound. Ultrasonography has a sensitivity of 0.85 (95% CI 0.79–0.90) and a specificity of 0.90 (95% CI 0.83–0.95).20 Graded compression ultrasonography is used to identify the anteroposterior diameter of the appendix. An easily compressible appendix <5 mm in diameter generally rules out appendicitis. Features on an ultrasound that suggest appendicitis include a diameter of greater than 6 mm, pain with compression, presence of an appendicolith, increased echogenicity of the fat, and periappendiceal fluid.21 Ultrasound is cheaper and more readily available than CT scan, and it does not expose patients to ionizing radiation, but it is user-dependent and has limited util-ity in obese patients. In addition, graded compression is usually Figure 30-1. McBurney’s point. 1 = anterior superior iliac spine; 2 = umbilicus; x = McBurney’s


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Surgery_Schwartz. user-dependent and has limited util-ity in obese patients. In addition, graded compression is usually Figure 30-1. McBurney’s point. 1 = anterior superior iliac spine; 2 = umbilicus; x = McBurney’s point.Brunicardi_Ch30_p1331-p1344.indd 133301/03/19 7:05 PM 1334SPECIFIC CONSIDERATIONSPART IITable 30-2Meta-analyses comparing CT scan and US outcomes AUTHORSUMMARYTERASAWAWESTONDORIAAL-KHAYALVAN RANDENYear 20042005200620072008 No. of studies 222157256 No. of patientsCTUSTotal117215162688NRNR5039NRNR13697NRNR13046NRNR671 SensitivityCTUS94% (CI: 91%–95%)86% (CI: 83%–88%)97% (CI: 95%–98%)87% (CI: 85%–89%)94% (CI: 92%–97%)88% (CI: 86%–90%)93% (CI: 92%–95%)84% (CI: 82%–85%)91% (CI: 84%–95%)78% (CI: 67%–86%)CT more sensitive than US in five of five meta-analysesSpecificityCTUS95% (CI: 93%–96%)81% (CI: 78%–84%)95% (CI: 93%–96%)93% (CI: 92%–94%)94% (CI: 94%–96%)93% (CI: 90%–96%)93 (CI: 92%–94%)96 (CI: 95%–96%)90% (CI: 85%–94%)83% (CI: 76%–88%)CT more specific than US in four of five


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Surgery_Schwartz. 93%–96%)81% (CI: 78%–84%)95% (CI: 93%–96%)93% (CI: 92%–94%)94% (CI: 94%–96%)93% (CI: 90%–96%)93 (CI: 92%–94%)96 (CI: 95%–96%)90% (CI: 85%–94%)83% (CI: 76%–88%)CT more specific than US in four of five meta-analysesPositive predictive valueCTUSNRNR94% (CI: 92%–95%)89% (CI: 87%–90%)NRNR90% (CI: 89%–92%)90% (CI: 89%–91%)NRNRCT has superior positive predictive value in one of two meta-analysesNegative predictive valueCTUSNRNR97% (CI: 96%–98%)92% (CI:91%–93%)NRNR96% (CI: 95%–97%)93% (CI: 92%–94%)NRNRCT has superior negative predictive value in both meta-analysesAccuracyCTUSNRNRNRNRNRNR94% (CI: 93%–94%)92% (CI: 92%–96%)NRNRCT is more accurate in the one study reporting resultsCI = confidence interval; CT = computed tomography; NR = not reported; US = ultrasonography.Brunicardi_Ch30_p1331-p1344.indd 133401/03/19 7:05 PM 1335THE APPENDIXCHAPTER 30painful for patients with peritonitis. A comparison of the effi-cacy of ultrasound v. CT scan is found in Table 30-2.MRI. MRI of the abdomen has


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Surgery_Schwartz. 133401/03/19 7:05 PM 1335THE APPENDIXCHAPTER 30painful for patients with peritonitis. A comparison of the effi-cacy of ultrasound v. CT scan is found in Table 30-2.MRI. MRI of the abdomen has a sensitivity of 0.95 (95% CI 0.88–0.98) and specificity of 0.92 (95% CI 0.87–0.95) for iden-tification of acute appendicitis.22 MRI is an expensive test that requires significant expertise to perform and interpret and is usually recommended in patients for whom the risk of ionizing radiation outweighs the relative ease of obtaining a contrast CT scan, i.e., pregnant or pediatric patients.Differential DiagnosisCauses of acute abdominal pain that are often confused with acute appendicitis include acute mesenteric adenitis, cecal diverticulitis, Meckel’s diverticulitis, acute ileitis, Crohn’s dis-ease, acute pelvic inflammatory disease, torsion of ovarian cyst or graafian follicle, and acute gastroenteritis. Frequently, no organic pathology is identified. Obtaining an antecedent history of a


Surgery_Schwartz

Surgery_Schwartz. acute pelvic inflammatory disease, torsion of ovarian cyst or graafian follicle, and acute gastroenteritis. Frequently, no organic pathology is identified. Obtaining an antecedent history of a viral infection (mesenteric adenitis or gastroenteritis) and a cervical exam in women (exquisite tenderness with motion in pelvic inflammatory disease) are essential before planning any intervention. Detailed menstrual history can distinguish mittel-schmerz (no fever or leukocytosis, mid-menstrual cycle pain) and ectopic pregnancies.MANAGEMENT OF APPENDICITISUncomplicated AppendicitisThe preferred approach to manage patients with uncomplicated appendicitis is an appendectomy. Several recent randomized trials and cohort studies have examined the role of nonopera-tive management of adult patients with appendicitis.23,24,25 In each of these well-designed studies with noninferiority as the endpoint, patients were randomized to either receiving antibiot-ics or undergoing an appendectomy, which was


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Surgery_Schwartz. appendicitis.23,24,25 In each of these well-designed studies with noninferiority as the endpoint, patients were randomized to either receiving antibiot-ics or undergoing an appendectomy, which was frequently per-formed open. A majority of the patients in the nonoperative arm received intravenous antibiotics for a short course followed by a course of a fluoroquinolone and metronidazole, or oral amoxi-cillin/clavulanic acid.23,26,27 Meta-analysis of the published data found that 26.5% of patients in the nonoperative group required an appendectomy within 1 year. In addition, the rate of adverse events following antibiotics therapy was higher (relative risk [RR] 3.18, 95% CI 1.63–6.21, P = 0.0007), and patients who recurred presented more frequently with complicated appen-dicitis (RR 2.52, 95% CI 1.17–5.43, P = 0.02).28,29 Currently, conservative management can be offered to informed patients using techniques of shared decision-making, but it is not the standard modality of management of


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Surgery_Schwartz. CI 1.17–5.43, P = 0.02).28,29 Currently, conservative management can be offered to informed patients using techniques of shared decision-making, but it is not the standard modality of management of appendicitis, except in patients with significant phobia of surgery.30 Societal costs and long-term implications of the conservative strategy have not yet been completely evaluated.Timing of Surgery. Emergent surgery is often performed in patients with appendicitis, but studies have evaluated the perfor-mance of urgent surgery (waiting less than 12 hours) in a semi-elective setting after administering antibiotics upon admission. The studies did not reveal any significant difference in outcomes, except for a slightly longer hospital stay in those undergoing urgent surgery.31-33 Currently, delaying surgery less than 12 hours is acceptable in patients with short duration of symptoms (less than 48 hours) and in nonperforated, nongangrenous appendicitis.Approach of Surgery. Numerous


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Surgery_Schwartz. delaying surgery less than 12 hours is acceptable in patients with short duration of symptoms (less than 48 hours) and in nonperforated, nongangrenous appendicitis.Approach of Surgery. Numerous meta-analyses comparing laparoscopic to open appendectomy have demonstrated relative equivalence of the techniques, with laparoscopic appendec-tomy resulting in a shorter length of stay (LOS), faster return to work, and lower superficial wound infection rates, especially in obese patients.34,35 Open appendectomy results in shorter operative times and lower intra-abdominal infection rates.36 Costs of the two techniques are relatively similar because of the offset of costs in laparoscopic techniques by shorter LOS. In the United States, laparoscopic appendectomies are increas-ingly utilized.37Complicated AppendicitisPerforated and gangrenous appendicitis and appendicitis with abscess or phlegmon formation are considered complicated conditions. Patients with perforated appendicitis usually


Surgery_Schwartz

Surgery_Schwartz. AppendicitisPerforated and gangrenous appendicitis and appendicitis with abscess or phlegmon formation are considered complicated conditions. Patients with perforated appendicitis usually pres-ent after 24 hours of onset, although 20% of patients present within 24 hours. Such patients are often acutely ill and dehy-drated and require resuscitation. Usually, the perforated abscess is walled off in the right lower quadrant, although retroperito-neal abscesses including psoas abscess, liver abscesses, fistu-las, and pylephlebitis (portal vein inflammation) can also occur when left untreated.Perforated appendicitis can be managed either operatively or nonoperatively. Immediate surgery is necessary in patients that appear septic, but this is usually associated with higher complications, including abscesses and enterocuta-neous fistulae due to dense adhesions and inflammation. The management of long-duration, complicated appendici-tis is often staged.38,39 Patients are resuscitated and


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Surgery_Schwartz. abscesses and enterocuta-neous fistulae due to dense adhesions and inflammation. The management of long-duration, complicated appendici-tis is often staged.38,39 Patients are resuscitated and treated with IV antibiotics.40,41 Patients with longstanding perforation are better treated with adequate percutaneous image-guided drain-age.42 This strategy is successful in 79% of patients who achieve complete resolution, which occurs more often in lower-grade abscesses, transgluteal drainage, and with CT(vs. ultrasound-) guided drainage43 Operative intervention is performed in patients who fail conservative management and in patients with free intra-peritoneal perforation.Interval Appendectomy. The majority of patients with perfo-rated appendicitis (80%) have resolution of their symptoms with drainage and antibiotics. There remains debate about the value of performing an interval appendectomy 6 to 8 weeks after the original inflammatory episode.44-46 Proponents of this approach cite the


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Surgery_Schwartz. drainage and antibiotics. There remains debate about the value of performing an interval appendectomy 6 to 8 weeks after the original inflammatory episode.44-46 Proponents of this approach cite the incidence of recurrent appendicitis (7.4%–8.8%) and the presence of appendiceal neoplasms detected on the appendec-tomy (relevant benign lesions 0.7%, malignant lesions 1.3%).47 Opponents cite the high incidence of no future events after a median follow-up of 34 months in 91% of patients. Currently, shared decision-making is necessary before proceeding with an interval appendectomy.39OPERATIVE INTERVENTIONPreoperative PreparationOnce the decision to proceed with surgical intervention is made, patients can be taken to the operating room rather expeditiously. While resuscitative efforts are important in patients who pres-ent with significant dehydration or in a compromised host, the majority of patients can be taken to the operating room within a short interval. Placement of a Foley catheter


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Surgery_Schwartz. in patients who pres-ent with significant dehydration or in a compromised host, the majority of patients can be taken to the operating room within a short interval. Placement of a Foley catheter is optional but not necessary while performing an appendectomy. Preopera-tive antibiotics must be administered at least 30 to 60 minutes prior to skin incision. The choice of antibiotics include cefoxi-tin, ampicillin/sulbactam, and cefazolin plus metronidazole for 4Brunicardi_Ch30_p1331-p1344.indd 133501/03/19 7:05 PM 1336SPECIFIC CONSIDERATIONSPART IIuncomplicated appendicitis. Patients with ß-lactam allergies can be given clindamycin in combination with a fluoroquinolone, gentamicin, or aztreonam. Postoperative antibiotics are usually not necessary.In patients with perforated appendicitis undergoing opera-tive intervention, preoperative antibiotics are necessary to cover gram-negative bacteria and anaerobes. Monotherapy with piper-acillin/tazobactam or combination of cephalosporin with


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Surgery_Schwartz. opera-tive intervention, preoperative antibiotics are necessary to cover gram-negative bacteria and anaerobes. Monotherapy with piper-acillin/tazobactam or combination of cephalosporin with metro-nidazole are reasonable choices. The duration of postoperative antibiotics is generally less than 4 days once complete source control has been achieved (STOP-IT trial).48 Patients with incomplete drainage, persistent catheters, complications from surgery, and uncertain resolution of inflammation might need a longer duration of antibiotics.49Operative TechniqueOpen Appendectomy. An open appendectomy is usually per-formed under general anesthesia, although regional anesthesia can be used. After wide prep and drape, an incision is usually made on McBurney’s point either in an oblique fashion (McBur-ney’s incision) or transverse incision (Rocky-Davis incision). A lower midline laparotomy incision is more appropriate for perforated appendicitis with a phlegmon. A muscle-splitting approach can be


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Surgery_Schwartz. incision) or transverse incision (Rocky-Davis incision). A lower midline laparotomy incision is more appropriate for perforated appendicitis with a phlegmon. A muscle-splitting approach can be utilized to access the peritoneum in patients that are well paralyzed. The bed is positioned in Trendelen-burg’s with the left side down. The appendix is usually readily identified, but if necessary, it can be found by tracing the ante-rior taenia (taenia Liberia) of the cecum distally. We generally ligate the mesentery early to allow better exposure. If the base of the appendix is viable, ligating the appendix is acceptable. This can be imbricated with a Z-stitch or purse string configura-tion, or alternatively the mucosa can be fulgurated. In the event of retraction of the appendiceal artery or unexpected bleeding, the incision can be extended medially (Fowler extension). Skin closure is usually performed in a layered fashion, but in cases with significant abscess or contamination, closure


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Surgery_Schwartz. bleeding, the incision can be extended medially (Fowler extension). Skin closure is usually performed in a layered fashion, but in cases with significant abscess or contamination, closure by sec-ondary intention or delayed primary closure has been consid-ered. Recent trials have suggested no difference in surgical site infection rates between primary and delayed primary closure.50 Placement of surgical drains has not been proven to be benefi-cial in multiple clinical trials for either complicated or uncom-plicated appendicitis.51,52Laparoscopic Appendectomy. Patients undergoing laparo-scopic appendectomy are positioned supine with the left arm tucked for better access. Monitors and assistants are positioned appropriately. Access to the peritoneum can be obtained using either the Hasson technique in a periumbilical fashion or with a Verees or optical trocar in the left upper quadrant 3 cm below the costal margin in the midclavicular line. Five-mm ports are usually placed in the


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Surgery_Schwartz. technique in a periumbilical fashion or with a Verees or optical trocar in the left upper quadrant 3 cm below the costal margin in the midclavicular line. Five-mm ports are usually placed in the suprapubic and left lower quadrant areas. It is also technically feasible to place the third port in the right upper quadrant. The bed is positioned in Trendelenburg, with the left side down to sweep the bowel away. The appendix is grasped and elevated upwards to identify the window between the mesoappendix and the cecum (Fig. 30-2). Occasionally, it is essential to release the mesenteric attachments of the cecum to mobilize a retrocecal or pelvic appendix to obtain this view. Using a Maryland grasper, the window is created, and the mesoappendix is divided with cautery, clip, or a bipolar energy source. The base of the appendix is divided either with an endoscopic stapler or after placing an endoloop. In the case of a nonviable appendix base, a staple line through the cecum that avoids the


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Surgery_Schwartz. source. The base of the appendix is divided either with an endoscopic stapler or after placing an endoloop. In the case of a nonviable appendix base, a staple line through the cecum that avoids the ileocecal valve might be sufficient, unless sig-nificant inflammation is present. The appendix is retrieved through the midline port in a specimen bag, especially if an appendiceal lesion is suspected. If a periappendiceal phlegmon is encountered or if the operation is being performed for perfo-rated appendicitis, careful sweeping of the bowel with a blunt dissector can release the appendix. It is important to carefully separate adjacent bowel, which can be friable in such settings. Conversion to open surgery should be considered for failure to progress. Typically, once the base of the appendix is identified, it is generally more helpful to divide the stump first. An endo-scopic stapler or endoloop can be used for the base, provided the base is viable. Occasionally, an ileocecectomy is


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Surgery_Schwartz. is identified, it is generally more helpful to divide the stump first. An endo-scopic stapler or endoloop can be used for the base, provided the base is viable. Occasionally, an ileocecectomy is necessary when resection of the base of the appendix or cecum is likely to impinge on the ileocecal valve. The mesoappendix is similarly divided with either a stapler with thin leg length staples, a clip, cautery, or energy device.Novel TechniquesThree novel techniques have been investigated in the performance of an appendectomy: single incision appendectomy, natural orifice transluminal endoscopic surgery (NOTES), and robotic appendec-tomy. Single incision appendectomy has not been shown to improve outcomes, including cosmetic outcomes, in pro-spective randomized studies and has been suggested to have a higher incisional hernia rate.53 NOTES surgery has been shown to have better cosmetic outcome and less postoperative pain in a meta-analysis of NOTES procedures including appendectomies,


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Surgery_Schwartz. to have a higher incisional hernia rate.53 NOTES surgery has been shown to have better cosmetic outcome and less postoperative pain in a meta-analysis of NOTES procedures including appendectomies, although only 40 patients were included in the analysis.54 The risk of luminal contamination and closure of enteral or vaginal mucosa remain suboptimal; for this reason, there has not been widespread dissemination of this technique.55 Robotic appendectomy allows flexible motions of intraperitoneal instruments and is therefore superior in ergonomics for the surgeon.56 However, it is extremely expensive and requires larger ports based on most of the current platforms; thus, this technique is also not utilized widely.Negative ExplorationUpon performing a laparoscopy or laparotomy for suspected appendicitis, if one finds no evidence of appendicitis, a thor-ough exploration of the peritoneum must be performed to rule out contributing pathology. A normal appendix is often removed to reduce future


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Surgery_Schwartz. if one finds no evidence of appendicitis, a thor-ough exploration of the peritoneum must be performed to rule out contributing pathology. A normal appendix is often removed to reduce future diagnostic dilemma.57 Management of incidentally found common conditions is summarized in Table 30-3.Incidental AppendectomyThe practice of prophylactic appendectomy has been considered during other operations to prevent the future risk of appendici-tis.6,58 It is routinely performed in children undergoing chemo-therapy, compromised hosts with an unclear physical exam, patients with Crohn’s disease with a normal cecum, patients traveling to remote places with no urgent care, and in patients undergoing cytoreductive operations for ovarian malignancies.59 While there is no evidence clearly evaluating long-term out-comes of patients undergoing incidental appendectomy with an asymptomatic appendix, the risk of adhesions and future complications after an appendectomy has been suggested to be higher than


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Surgery_Schwartz. out-comes of patients undergoing incidental appendectomy with an asymptomatic appendix, the risk of adhesions and future complications after an appendectomy has been suggested to be higher than the risk of future appendicitis and increased economic costs. For these reasons, an incidental appendectomy is currently not advocated. 56Brunicardi_Ch30_p1331-p1344.indd 133601/03/19 7:05 PM 1337THE APPENDIXCHAPTER 30SurgeonAssistantAnesthesiologistFigure 30-2. Operating room setup.SPECIAL CIRCUMSTANCESAppendicitis in ChildrenAlmost 1 in 8 children undergo a workup for the diagnosis of appendicitis.60,61 Of these, infants and young children are most likely to present with perforated disease (51%–100%), while school-age children have lower rates of perforation.62,63,64 While most age groups demonstrate the same symptoms previously described in adults, neonates can also present with abdominal distension and lethargy or irritability. The Pediatric Appendici-tis Score has components similar to


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Surgery_Schwartz. the same symptoms previously described in adults, neonates can also present with abdominal distension and lethargy or irritability. The Pediatric Appendici-tis Score has components similar to the Alvarado Score and is scored of 10 points, with maximum weight (2 points each) for right lower quadrant tenderness and pain with cough, percussion or hopping. A score of 7 or greater indicates that the patient has a high chance of having appendicitis (78%–96% percent).65In the pediatric population, special considerations must be made to exclude relevant differential diagnoses such as intus-susception (currant jelly stools, abdominal mass), gastroenteritis (often no luekocytosis), malrotation (pain out of proportion), pregnancy (ectopic), mesenteric adenitis, torsion of the omen-tum, and ovarian or testicular torsion.Table 30-3Management of Intraoperative Findings Mimicking AppendicitisOvarian TorsionConservative management with detorsion and oophoropexyCrohn’s terminal ileitisAppendectomy if


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Surgery_Schwartz. testicular torsion.Table 30-3Management of Intraoperative Findings Mimicking AppendicitisOvarian TorsionConservative management with detorsion and oophoropexyCrohn’s terminal ileitisAppendectomy if base uninflamedMeckel’s diverticulitisSegmental small bowel resection and primary anastomosisAppendiceal MassLaparoscopic appendectomy/ileocecectomy without capsular disruption or spillage and retrieval in a bagBrunicardi_Ch30_p1331-p1344.indd 133701/03/19 7:05 PM 1338SPECIFIC CONSIDERATIONSPART IIWith regard to the management of children with appen-dicitis, early appendicitis is treated preferably with a laparo-scopic appendectomy, which has better outcomes than open appendectomies in children.66,67 For patients with complicated appendicitis, urgent appendectomy is advocated in the setting of no abscess or mass. Laparoscopic appendectomy appears to retain its benefits in this setting as well.68,69 In the setting of a perforation, antibiotics are continued after surgery for at least 3


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Surgery_Schwartz. of no abscess or mass. Laparoscopic appendectomy appears to retain its benefits in this setting as well.68,69 In the setting of a perforation, antibiotics are continued after surgery for at least 3 days, and preferably 5 days (APSA guidelines).70,71 Manage-ment of perforated appendicitis with abscess is similar to adults, although no adverse effects of an early laparoscopic appendec-tomy have been seen even in this setting.39,72,73,74Nonoperative management of appendicitis has also been studied in children.75-77 It may be safe for children with early presentation (less than 48 hours), limited inflammation (WBC less than 18,000/cu.ml), appendicoliths, and no evidence of rup-ture on imaging.78 Patients are usually administered IV antibi-otics until inflammation reduces and then transitioned to oral antibiotics.79 This is usually effective in reducing inflammation (88%–92%), but has a recurrence rate of 22% at 1 year and increased resource utilization.80Appendicitis in Older AdultsOlder


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Surgery_Schwartz. to oral antibiotics.79 This is usually effective in reducing inflammation (88%–92%), but has a recurrence rate of 22% at 1 year and increased resource utilization.80Appendicitis in Older AdultsOlder adult patients can have diminished inflammation and thus present with perforation or abscess more frequently.81,82 Such patients are at a higher risk for complications because of their premorbid conditions, and it is more prudent to obtain definitive diagnostic imaging prior to taking patients to the operating room. Laparoscopic appendectomy is safe and might allow patients to reduce pain and their hospital stay.83 Appendicitis in PregnancyAppendicitis occurs in 1 in 800 to 1 in 1000 pregnancies, mostly in the first and second trimesters. Its incidence is rare in the antepartum state, and it can occur in the postpartum state in geriatric pregnancies (maternal age greater than 35 years).84 While the majority of the clinical features are similar, patients can also present with heartburn,


Surgery_Schwartz

Surgery_Schwartz. can occur in the postpartum state in geriatric pregnancies (maternal age greater than 35 years).84 While the majority of the clinical features are similar, patients can also present with heartburn, bowel irregularity, flatulence, or a change in bowel habits. The point of maximum tender-ness is usually displaced on physical exam. Ultrasonography is the preferred imaging modality, although nonvisualization can occur. Sensitivity can vary from 67% to 100%, and specificity varies from 93% to 96%.39 An alternative imaging modality is MRI, with a sensitivity of 94% and specificity of 97%.85 While CT can be performed in pregnancy, the risk of fetal irradiation leads many practitioners to avoid it unless other modalities are inconclusive.86 When discussing options with the patient and the patient’s family, it is important to note that the risk of fetal loss is up to 36% if appendiceal perforation occurs.87 Therefore, there remains a lower threshold to operate on such patients, with an


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Surgery_Schwartz. patient’s family, it is important to note that the risk of fetal loss is up to 36% if appendiceal perforation occurs.87 Therefore, there remains a lower threshold to operate on such patients, with an acceptable negative exploration rate of as high as 30%. Lapa-roscopic appendectomies can be safely performed in pregnant patients, although studies suggest a variable but reproducible higher rate of fetal loss (around 7% vs. 3%) than open tech-niques. Lower intra-abdominal pressures (10–12 mmHg) during insufflation have been suggested to reduce early labor. Nonoper-ative management has also been proposed for pregnant patients, but treatment failure rates have been reported as high as 25%.Chronic or Recurrent AppendicitisPatients with recurrent right lower quadrant abdominal pain not associated with a febrile illness with imaging findings sugges-tive of an appendicolith or dilated appendix are classified as having chronic appendicitis.88 Patients often report resolution of symptoms with an


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Surgery_Schwartz. with a febrile illness with imaging findings sugges-tive of an appendicolith or dilated appendix are classified as having chronic appendicitis.88 Patients often report resolution of symptoms with an appendectomy. In the absence of imaging abnormalities, prophylactic appendectomy is not encouraged.45OUTCOMES AND POSTOPERATIVE COURSEAppendectomy is a relatively safe procedure with an extremely low mortality rate (less than 1%). The commonest adverse events include soft tissue infections, either superficial or deep (including abscesses). Patients with uncomplicated appendicitis do not require further antibiotics after an appendec-tomy, while patients with perforated appendicitis are treated with 3 to 7 days of antibiotics (4 days from the STOP-IT trial).89 Patients with wound infections can be managed with simple wound opening and packing, and delayed primary closure has not been shown to be beneficial.90 In laparoscopic cases, these are usually the periumbilical ports.91 Patients with


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Surgery_Schwartz. be managed with simple wound opening and packing, and delayed primary closure has not been shown to be beneficial.90 In laparoscopic cases, these are usually the periumbilical ports.91 Patients with deep space abscesses are managed with percutaneous drainage and antibiot-ics. Fistulas (appendicocutaneous or appendicovesicular) are managed conservatively as the first step. Bowel obstructions and infertility are infrequent but reported.Stump AppendicitisAn uncommon complication after surgery is the development of appendicitis in an incompletely excised appendiceal stump (greater than 0.5 cm stump length). Optimal management requires reexcision of the appendiceal base, but diagnosis can be difficult and requires careful assessment of the patient’s history, physical exam, and imaging studies.92 Use of the “appendiceal critical view” (appendix placed at 10 o’clock, taenia coli/libera at 3 o’clock, and terminal ileum at 6 o’clock) and identification of where the taeniae coli merge and


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Surgery_Schwartz. Use of the “appendiceal critical view” (appendix placed at 10 o’clock, taenia coli/libera at 3 o’clock, and terminal ileum at 6 o’clock) and identification of where the taeniae coli merge and disappear is paramount to identifying and ligating the base of the appendix during the ini-tial operation (Fig. 30-3). In patients who have had prior appen-dectomy, a low index of suspicion is important to prevent delay in diagnosis and complications. Prior appendectomy should not be an absolute criterion in ruling out acute appendicitis.Appendiceal NeoplasmsThe incidence of appendiceal neoplasms is estimated at around 1% of all appendectomy specimens, although the true incidence of appendiceal neoplasms is not known.93 Neoplasms that occur in the appendix are predominantly gastroenteropancreatic neu-roendocrine tumors (or GEP-NETs, previously called carci-noids), mucinous neoplasms, or adenocarcinomas.94-96 Almost one-third of the neoplasms of the appendix present with acute appendicitis, while


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Surgery_Schwartz. tumors (or GEP-NETs, previously called carci-noids), mucinous neoplasms, or adenocarcinomas.94-96 Almost one-third of the neoplasms of the appendix present with acute appendicitis, while the others are often incidentally detected or are detected after regional spread of disease.97Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs or Carcinoid)Appendiceal carcinoid tumors are submucosal rubbery masses that are detected incidentally on the appendix.98 Carcinoid tumors of the appendix are relatively indolent but can develop nodal or hepatic metastases.99 Infrequently, these can be associ-ated with a carcinoid syndrome if there are hepatic metastases (2.9%).100 Upon incidental findings of a suspected carcinoid, the surgeon must evaluate the nodal basin along the ileocolic ped-icle and also examine the liver for any signs of metastases. For lesions that are less than 1 cm (95% of all lesions), a negative margin appendectomy is adequate. For tumors 2 cm or larger, a right hemicolectomy


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Surgery_Schwartz. examine the liver for any signs of metastases. For lesions that are less than 1 cm (95% of all lesions), a negative margin appendectomy is adequate. For tumors 2 cm or larger, a right hemicolectomy is recommended. For lesions 1 to 2 cm in size, there is no consensus on a completion colectomy. A right colectomy is often performed for mesenteric invasion, enlarged 78Brunicardi_Ch30_p1331-p1344.indd 133801/03/19 7:05 PM 1339THE APPENDIXCHAPTER 30Figure 30-3. A and B. Appendiceal critical view.ABnodes, or positive or unclear margins. Measurement of serum chromogranin A is recommended.Goblet Cell CarcinomasThese lesions were mistakenly called goblet cell carcinoids, implying a rather indolent biology, while goblet cell carcinomas are adenocarcinoid with both adenocarcinoma and neuroendocrine features.101,102 Such lesions carry a worse prognosis than carcinoids but slightly better than adenocarcinomas. There is a high risk of peritoneal recurrence in such cases. For incidentally


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Surgery_Schwartz. features.101,102 Such lesions carry a worse prognosis than carcinoids but slightly better than adenocarcinomas. There is a high risk of peritoneal recurrence in such cases. For incidentally detected lesions, a systematic surveillance of the peritoneum must be per-formed, and a peritoneal cancer index score must be documented if disease is present.103 In the absence of metastatic disease, a right hemicolectomy is generally appropriate, although some advocate for a right colectomy only for tumors 2 cm or larger.104LymphomasAppendiceal lymphomas are rare (1%–3% of lymphomas, usu-ally non-Hodgkin’s) and difficult to diagnose preoperatively (appendiceal diameter can be 2.5 cm or larger).105,106 Manage-ment includes an appendectomy in most cases.AdenocarcinomaPrimary adenocarcinoma of the appendix is a rare neoplasm with three major histologic subtypes: mucinous adenocarcinoma, colonic adenocarcinoma, and adenocarcinoid. The most common mode of presentation for appendiceal carcinoma is


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Surgery_Schwartz. is a rare neoplasm with three major histologic subtypes: mucinous adenocarcinoma, colonic adenocarcinoma, and adenocarcinoid. The most common mode of presentation for appendiceal carcinoma is acute appendicitis. Patients also may present with ascites or a palpable mass, or the neoplasm may be discovered during an operative procedure for an unrelated cause. The recommended treatment for all patients with adenocarcinoma of the appendix is a formal right hemicolectomy. Appendiceal adenocarcinomas have a propensity for early perforation, although they are not clearly associated with a worsened prognosis. Overall 5-year sur-vival is 55% and varies with stage and grade. Patients with appendiceal adenocarcinoma are at significant risk for both syn-chronous and metachronous neoplasms, approximately half of which will originate from the gastrointestinal tract.Appendiceal Mucoceles and Mucinous Neoplasms of the AppendixThe term appendiceal mucocele broadly describes a mucus-filled appendix that


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Surgery_Schwartz. half of which will originate from the gastrointestinal tract.Appendiceal Mucoceles and Mucinous Neoplasms of the AppendixThe term appendiceal mucocele broadly describes a mucus-filled appendix that could be secondary to neoplastic or nonneoplastic 9pathologies (mucosal hyperplasia, simple or retention cysts, mucinous cystadenomas, mucinous cystadenocarcinoma). The most common form of presentation is incidental; however, pre-sentation with appendicitis occurs in a third of cases.107,108 On cross-sectional imaging, a low attenuation, round, well encapsu-lated cystic mass in the right or quadrant is often encountered, and features such as wall irregularity and soft tissue thickening are suggestive of a neoplastic process. It is important to carefully assess for the presence of ascites, peritoneal disease, and scal-loping of the liver surface on imaging upon initial evaluation. A reliable diagnosis cannot be established using imaging alone, and it is recommended that surgical excision


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Surgery_Schwartz. disease, and scal-loping of the liver surface on imaging upon initial evaluation. A reliable diagnosis cannot be established using imaging alone, and it is recommended that surgical excision without capsular disruption is undertaken.109 The importance of careful handling of a mucocele and the avoidance of rupture cannot be overem-phasized because the intraperitoneal spread of neoplastic cells at subsequent development of pseudomyxoma peritonei are nearly certain in cases of adenocarcinoma.110,111 When suspecting a mucinous neoplasm of the appendix, it is imperative to systemat-ically examine the peritoneum and document a peritoneal cancer index score if mucin is present. Biopsies to examine the content of epithelial cell, neoplastic cells, and mucin can be helpful.In cases where a homogeneous cyst without nodularity or signs of dissemination is encountered, laparoscopic excision is acceptable, provided that a stapler is fired across the base of the cecum to avoid a positive margin.


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Surgery_Schwartz. cyst without nodularity or signs of dissemination is encountered, laparoscopic excision is acceptable, provided that a stapler is fired across the base of the cecum to avoid a positive margin. The specimen should be placed in a plastic bag and carefully removed through a small incision. In the absence of mesenteric or peritoneal involvement, an appendectomy with concurrent appendiceal lymphadenec-tomy is sufficient, as the chances of lymph node involvement are quite low. If peritoneal spread is evident upon exploration, it is important to obtain biopsies and document the peritoneal dis-ease burden. An appendectomy is acceptable if the patient has acute appendicitis, but suboptimal debulking is discouraged. In addition, colorectal, ovarian, and endometrial cancers can coex-ist in the setting of appendiceal mucoceles, and careful examina-tion of intra-abdominal structures is important.When there is discordance between the primary lesion histology and the peritoneum, the peritoneal


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Surgery_Schwartz. setting of appendiceal mucoceles, and careful examina-tion of intra-abdominal structures is important.When there is discordance between the primary lesion histology and the peritoneum, the peritoneal histology is usu-ally given priority. For instance, if patients had a neoplasm in the appendix but adenocarcinoma in the peritoneum, the patient would be considered as having adenocarcinoma (AJCC M1b) disease. The recent AJCC 8th edition and the PSOGI 2016 Brunicardi_Ch30_p1331-p1344.indd 133901/03/19 7:05 PM 1340SPECIFIC CONSIDERATIONSPART IITable 30-4AJCC 8th edition and the PSOGI 2016 classification consensus of mucinous neoplasia of the appendixLESIONPERITONEAL DISEASE AT DIAGNOSISPROGNOSISTREATMENTLow-grade appendiceal mucinous neoplasm (LAMN)Confined to the appendixExcellent-curativeNegative margin appendectomy, rarely need ileocecectomyLAMNPeri-appendiceal Acellular mucin dissecting through the wall (t4a) or adjacent organs (t4b)Excellent-low risk of recurrenceNegative margin


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Surgery_Schwartz. margin appendectomy, rarely need ileocecectomyLAMNPeri-appendiceal Acellular mucin dissecting through the wall (t4a) or adjacent organs (t4b)Excellent-low risk of recurrenceNegative margin appendectomy, resection of acellular mucinLAMNPeri-appendiceal Epithelial cells dissecting through the wall (t4a) or adjacent organs (t4b)Excellent-high risk of recurrenceNegative margin appendectomy, peritoneal surveillance with second look laparoscopy vs. HIPECLAMNDistant epithelial cells or acellular mucin (M1a)Low grade mucinous carcinoma peritoneiExcellent-high risk of recurrenceNegative margin appendectomy, omentectomy, HIPECHigh-grade appendiceal mucinous neoplasm (HAMN-rare)Management is identical to a LAMN with risk stratification as shown above but slightly worse prognosis.Mucinous adenocarcinomaConfined to the appendixVery GoodRight hemicolectomyMucinous adenocarcinomaPeritoneal DisseminationHigh grade mucinous carcinoma peritonei with or without signet ring cellsWell Differentiated-Very


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Surgery_Schwartz. to the appendixVery GoodRight hemicolectomyMucinous adenocarcinomaPeritoneal DisseminationHigh grade mucinous carcinoma peritonei with or without signet ring cellsWell Differentiated-Very goodModerately differentiated –GoodPoorly differentiated/signet ring cell histology:10 year survival of 10-20%Cytoreductive surgery and HIPEC, with systemic chemotherapy for high grade histologiesAdenocarcinoma (non-mucinous, including goblet cell histology)Management identical to the mucinous histologies, with more extensive use of systemic chemotherapySerrated Adenoma (rare)Confined to appendixExcellent-curativeAppendectomyAdenoma (rare)Confined to appendixExcellent-curativeAppendectomyData from American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017 and Carr NJ, Cecil TD, Mohamed F, et al: A Consensus for Classification and Pathologic Reporting of Pseudomyxoma Peritonei and Associated Appendiceal Neoplasia: The Results of


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Surgery_Schwartz. Springer New York, 2017 and Carr NJ, Cecil TD, Mohamed F, et al: A Consensus for Classification and Pathologic Reporting of Pseudomyxoma Peritonei and Associated Appendiceal Neoplasia: The Results of the Peritoneal Surface Oncology Group International (PSOGI) Modified Delphi Process, Am J Surg Pathol. 2016 Jan;40(1):14-26.classification consensus has resulted in a therapy-directed clas-sification of mucinous neoplasms of the appendix, summarized in Table 30-4.112Pseudomyxoma Peritonei SyndromePatients with appendiceal mucinous neoplasms develop perito-neal dissemination leading to pseudomyxoma peritonei (PMP) syndrome. This can occur in gastric, ovarian, pancreatic, and colorectal primary tumors as well.111 Patients with this syn-drome can have varied prognosis ranging from curative to pal-liative. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the standard of care for patients with PMP syndrome from appendiceal primaries.113-115Early


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Surgery_Schwartz. to pal-liative. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the standard of care for patients with PMP syndrome from appendiceal primaries.113-115Early detection and management of limited peritoneal dis-ease is favorable and preferred as opposed to extensive intra-peritoneal mucin development. The surgical technique involves parietal and visceral peritonectomies, and intraperitoneal administration of heated (42oC [108oF]) chemotherapy (usually mitomycin) in the abdomen. Previously considered a morbid surgery, high volume centers and standardized practices have made the morbidity and mortality similar to any major open GI procedure. This technique can also be performed laparoscopi-cally when the disease is detected early and is low volume.REFERENCESEntries highlighted in bright blue are key references. 1. Amyand C. Of an inguinal rupture, with a pin in the appendix coeci, incrusted with stone; and some observations on wounds in the guts.


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Surgery_Schwartz. highlighted in bright blue are key references. 1. Amyand C. Of an inguinal rupture, with a pin in the appendix coeci, incrusted with stone; and some observations on wounds in the guts. Phil Trans. 1735;39:329-342. 2. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. N Y State Med J. 1889;50:6 and Clostridium difficile colitis: relationships revealed by clinical observations and immunology. World J Gastroenterol. 2013;19:5607-5614. 3. Mohammadi, M, Song, H, Cao, Y: Risk of lymphoid neo-plasms in a Swedish population-based cohort of 337,437 patients undergoing appendectomy. Scand J Gastroenterol 2016;51:583–589. 4. Sahami S, Kooij IA, Meijer SL, Van den Brink GR, Buskens CJ, Te Velde AA. The link between the appendix and ulcerative Brunicardi_Ch30_p1331-p1344.indd 134001/03/19 7:05 PM 1341THE APPENDIXCHAPTER 30colitis: clinical relevance and potential immunological mecha-nisms. Am J Gastroenterol.


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Surgery_Schwartz. appendix and ulcerative Brunicardi_Ch30_p1331-p1344.indd 134001/03/19 7:05 PM 1341THE APPENDIXCHAPTER 30colitis: clinical relevance and potential immunological mecha-nisms. Am J Gastroenterol. 2016;111(2):163-169. 5. Prystowsky JB, Pugh CM, Nagle AP. Current problems in sur-gery. Appendicitis. Curr Probl Surg. 2005;42:688-742. 6. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiol-ogy of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910-925. 7. Song H, Abnet CC, Andrén-Sandberg A, Chaturvedi AK, Ye W. Risk of gastrointestinal cancers among patients with appendectomy: a large-scale Swedish register-based cohort study during 1970-2009. PLoS One. 2016;11(3):e0151262. 8. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology. 2000;215(2):337-348. 9. Burkitt DP. The aetiology of appendicitis. Br J Surg. 1971;58(9): 695-699. 10. Arnbjornsson E, Bengmark S. Obstruction of the appendix lumen in relation to pathogenesis of acute


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Surgery_Schwartz. DP. The aetiology of appendicitis. Br J Surg. 1971;58(9): 695-699. 10. Arnbjornsson E, Bengmark S. Obstruction of the appendix lumen in relation to pathogenesis of acute appendicitis. Acta Chir Scand. 1983;149(8):789-791. 11. Lau WY, Teoh-Chan CH, Fan ST, Yam WC, Lau KF, Wong SH. The bacteriology and septic complication of patients with appendicitis. Ann Surg. 1984;200(5):576-581. 12. Bennion RS, Baron EJ, Thompson JE Jr, et al. The bacteri-ology of gangrenous and perforated appendicitis—revisited. Ann Surg. 1990;211(2):165-171. 13. Andersson R, Hugander A, Thulin A, Nyström, Olaison G. Indications for operation in suspected appendicitis and inci-dence of perforation. BMJ. 1994;308(6921):107-110. 14. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91(1):28-37. 15. Acharya A, Markar SR, Ni M, Hanna GB. Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis. Surg Endosc.


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Surgery_Schwartz. Group. Low-dose CT for the diagnosis of appendi-citis in adolescents and young adults (LOCAT): a pragmatic, multicentre, randomised controlled non-inferiority trial. Lancet Gastroenterol Hepatol. 2017;2(11):793-804. 20. Keyzer C, Zalcman M, De Maertelaer V, et al. Com-parison of US and unenhanced multi-detector row CT in patients suspected of having acute appendicitis. Radiology. 2005;236(2):527-534. 21. Kessler N, Cyteval C, Gallix B, et al. Appendicitis: evalu-ation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology. 2004;230(2):472-478. 22. Barger RL Jr, Nandalur KR. Diagnostic performance of mag-netic resonance imaging in the detection of appendicitis in adults: a meta-analysis. Acad Radiol. 2010;17(10):1211-1216. 23. Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncom-plicated appendicitis: an open-label, non-inferiority, ran-domised controlled trial. Lancet.


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Surgery_Schwartz. on the efficacy and safety of antibiotics (amoxi-cillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg. 2014;260(1):109-117. 27. Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348. 28. Harnoss JC, Zelienka I, Probst P, et al. Antibiotics versus surgical therapy for uncomplicated appendicitis: system-atic review and meta-analysis of controlled trials (PROS-PERO 2015: CRD42015016882). Ann Surg. 2017;265(5): 889-900. 29. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of ran-domised controlled trials. BMJ. 2012;344:e2156. 30. Sartelli M, Viale P, Catena F, et al. 2013 WSES guidelines for management of intra-abdominal


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Surgery_Schwartz. uncomplicated acute appendicitis: meta-analysis of ran-domised controlled trials. BMJ. 2012;344:e2156. 30. Sartelli M, Viale P, Catena F, et al. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2013;8(1):3. 31. Ingraham AM, Cohen ME, Bilimoria KY, et al. Effect of delay to operation on outcomes in adults with acute appendicitis. Arch Surg. 2010;145(9):886-892. 32. Abou-Nukta F, Bakhos C, Arroyo K, et al. Effects of delaying appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg. 2006;141(5):504-506; discussion 506-507. 33. Stahlfeld K, Hower J, Homitsky S, Madden J. Is acute appen-dicitis a surgical emergency? Am Surg. 2007;73(6):626-629; discussion 629-630. 34. Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized dou-ble-blind study. Ann Surg. 2005;242(3):439-448; discussion 448-450. 35. Enochsson L, Hellberg A, Rudberg C, et al. Laparoscopic vs open appendectomy in overweight


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Surgery_Schwartz. beyond: a comparison with younger geri-atric patients. Am J Med Sci. 2007;334(4):255-259.Brunicardi_Ch30_p1331-p1344.indd 134201/03/19 7:05 PM 1343THE APPENDIXCHAPTER 30 83. Harrell AG, Lincourt AE, Novitsky YW, et al. Advantages of laparoscopic appendectomy in the elderly. Am Surg. 2006;72(6):474-480. 84. Andersen B, Nielsen TF. Appendicitis in pregnancy: diag-nosis, management and complications. Acta Obstet Gynecol Scand. 1999;78(9):758-762. 85. Bree RL, Ralls PW, Balfe DM, et al. Evaluation of patients with acute right upper quadrant pain. American College of Radiology. ACR Appropriateness Criteria. Radiology. 2000;215(suppl):153-157. 86. McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative appendectomy in pregnant women is associ-ated with a substantial risk of fetal loss. J Am Coll Surg. 2007;205(4):534-540. 87. Cohen-Kerem R, Railton C, Oren D, Lishner M, Koren G. Pregnancy outcome following non-obstetric surgical interven-tion. Am J Surg.


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Surgery_Schwartz. risk of fetal loss. J Am Coll Surg. 2007;205(4):534-540. 87. Cohen-Kerem R, Railton C, Oren D, Lishner M, Koren G. Pregnancy outcome following non-obstetric surgical interven-tion. Am J Surg. 2005;190(3):467-473. 88. Giuliano V, Giuliano C, Pinto F, Scaglione M. Chronic appen-dicitis “syndrome” manifested by an appendicolith and thick-ened appendix presenting as chronic right lower abdominal pain in adults. Emerg Radiol. 2006;12(3):96-98. 89. Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appen-dicectomy. Cochrane Database Syst Rev. 2003;(2):CD001439. 90. Rucinski J, Fabian T, Panagopoulos G, Schein M, Wise L. Gangrenous and perforated appendicitis: a meta-analytic study of 2532 patients indicates that the incision should be closed primarily. Surgery. 2000;127(2):136-141. 91. Fleming FJ, Kim MJ, Messing S, Gunzler D, Salloum R, Monson JR. Balancing the risk of postoperative surgical infec-tions: a multivariate


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Surgery_Schwartz. LiverDavid A. Geller, John A. Goss, Ronald W. Busuttil, and Allan Tsung 31chapterHistory of Liver Surgery 1346Liver Anatomy 1346Segmental Anatomy / 1346Hepatic Artery / 1348Portal Vein / 1348Hepatic Veins and Inferior Vena Cava / 1349Bile Duct and Hepatic Ducts / 1350Neural Innervation and Lymphatic Drainage / 1350Liver Physiology 1351Bilirubin Metabolism / 1352Formation of Bile / 1352Drug Metabolism / 1352Liver Function Tests / 1352Hepatocellular Injury / 1353Abnormal Synthetic Function / 1353Cholestasis / 1353Jaundice / 1353Molecular Signaling Pathways in the Liver 1354Acute Phase Reaction / 1354LPS Signaling / 1355Nitric Oxide / 1355Heme Oxygenase System / 1356Toll-Like Receptors / 1357Radiologic Evaluation of the Liver 1357Ultrasound / 1357Computed Tomography / 1358Magnetic Resonance Imaging / 1359Positron Emission Tomography / 1360Acute Liver Failure 1360Etiology / 1361Clinical Presentation / 1361Diagnosis and Clinical Management / 1361Prognosis / 1362Liver Transplantation


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Surgery_Schwartz. Imaging / 1359Positron Emission Tomography / 1360Acute Liver Failure 1360Etiology / 1361Clinical Presentation / 1361Diagnosis and Clinical Management / 1361Prognosis / 1362Liver Transplantation / 1362Emerging Technologies / 1362Cirrhosis and Portal Hypertension 1362Morphologic Classification of Cirrhosis / 1362Etiology of Cirrhosis / 1363Clinical Manifestations of Cirrhosis / 1364Laboratory Findings Associated With Cirrhosis / 1364Liver Biopsy / 1364Hepatic Reserve and Assessment of Surgical Risk in the Cirrhotic Patient / 1365Child-Turcotte-Pugh Score / 1365Model for End-Stage Liver Disease Scoring System / 1365Portal Hypertension / 1365Imaging of the Portal Venous System and Measurement of Portal Venous Pressure / 1366Etiology and Clinical Features of Portal Hypertension / 1366Management of Gastroesophageal Varices / 1367Prevention of Variceal Bleeding / 1367Management of Acute Variceal Hemorrhage / 1367Luminal Tamponade / 1367Transjugular Intrahepatic Portosystemic


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Surgery_Schwartz. / 1366Management of Gastroesophageal Varices / 1367Prevention of Variceal Bleeding / 1367Management of Acute Variceal Hemorrhage / 1367Luminal Tamponade / 1367Transjugular Intrahepatic Portosystemic Shunt / 1367Balloon-Occluded Retrograde Transvenous Obliteration / 1367Surgical Shunting / 1367Nonshunt Surgical Management of Refractory Variceal Bleeding / 1368Hepatic Transplantation / 1368Budd-Chiari Syndrome / 1368Infections of the Liver 1369Pyogenic Liver Abscesses / 1369Amebic Abscesses / 1369Hydatid Disease / 1370Ascariasis / 1371Schistosomiasis / 1371Viral Hepatitis / 1371Evaluation of an Incidental Liver Mass 1372Hepatic Cysts 1373Congenital Cysts / 1373Biliary Cystadenoma / 1373Polycystic Liver Disease / 1373Caroli’s Disease / 1374Benign Liver Lesions 1374Cyst / 1374Hemangioma / 1375Adenoma / 1375Focal Nodular Hyperplasia / 1376Bile Duct Hamartoma / 1376Malignant Liver Tumors 1376Hepatocellular Carcinoma / 1376Cholangiocarcinoma / 1377Gallbladder Cancer / 1378Metastatic


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Surgery_Schwartz. / 1375Adenoma / 1375Focal Nodular Hyperplasia / 1376Bile Duct Hamartoma / 1376Malignant Liver Tumors 1376Hepatocellular Carcinoma / 1376Cholangiocarcinoma / 1377Gallbladder Cancer / 1378Metastatic Colorectal Cancer / 1378Neuroendocrine Tumors / 1379Other Metastatic Tumors / 1379Treatment Options for Liver Cancer 1379Hepatic Resection / 1379Liver Transplantation / 1380Radiofrequency Ablation / 1380Ethanol Ablation, Cryosurgery, and Microwave Ablation / 1380Chemoembolization and Hepatic Artery Pump Chemoperfusion / 1381Yttrium-90 Microspheres / 1381Stereotactic Radiosurgery and Intensity-Modulated Radiation Therapy / 1381Downstaging / 1381Systemic Chemotherapy / 1381Hepatic Resection Surgical Techniques 1381Nomenclature / 1381Techniques and Devices for Dividing the Hepatic Parenchyma / 1382Steps in Commonly Performed Hepatic Resections / 1383Pringle and Ischemic Preconditioning / 1385Preoperative Portal Vein Embolization / 1385Staged Hepatectomy, ALPPS, and Repeat Hepatic


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Surgery_Schwartz. / 1382Steps in Commonly Performed Hepatic Resections / 1383Pringle and Ischemic Preconditioning / 1385Preoperative Portal Vein Embolization / 1385Staged Hepatectomy, ALPPS, and Repeat Hepatic Resection for Recurrent Liver Cancer / 1386Laparoscopic Liver Resection 1386Brunicardi_Ch31_p1345-p1392.indd 134520/02/19 2:36 PM 1346HISTORY OF LIVER SURGERYThe ancient Greek myth of Prometheus reminds us that the liver is the only organ that regenerates. According to Greek mythology, Zeus was furious with the Titan Prometheus because he gave fire to mortals. In return, Zeus chained Prometheus to Mount Caucasus and sent his giant eagle to eat his liver during the day, only to have it regenerate at night. Although this is folk-lore, the principles are correct that after hepatic resection, the remnant liver will hypertrophy over weeks to months to regain most of its original liver mass. It is interesting to note that the ancient Greeks seem to have been aware of this fact, because the


Surgery_Schwartz

Surgery_Schwartz. the remnant liver will hypertrophy over weeks to months to regain most of its original liver mass. It is interesting to note that the ancient Greeks seem to have been aware of this fact, because the Greek word for the liver, h¯epar, derives from the verb h¯epaomai, which means “mend” or “repair.” Hence h¯epar roughly translates as “repairable.”1 The importance of the liver dates back to even biblical times, for the Babylonians (c. 2000 b.c.) considered the liver to be the seat of the soul. There are scattered reports of liver surgery for battlefield injuries, but the first recorded elec-tive hepatic resection was done in 1888 in Germany by Langen-buch. There followed reports of liver resections in the United States (Tiffany, 1890) and Europe (Lucke, 1891), as well as the first large series of hepatic resections by Keen in 1899.2,3 In 1908, Pringle described in Annals of Surgery the “arrest of hepatic hemorrhage due to trauma” by compression of the porta hepatis, a maneuver that now


Surgery_Schwartz

Surgery_Schwartz. of hepatic resections by Keen in 1899.2,3 In 1908, Pringle described in Annals of Surgery the “arrest of hepatic hemorrhage due to trauma” by compression of the porta hepatis, a maneuver that now bears his name.4 Possibly due to the potential for massive hemorrhage during liver surgery, very little progress in surgical techniques was recorded for the next half-century. Work by Rex, Cantlie, and others laid the groundwork for experimental and clinical reports in the 1950s by Couinaud, Hjortsjo, Healey, Lortat-Jacob, and Starzl.5,6 These seminal contributions paved the way for the modern era of hepatic resection surgery.LIVER ANATOMYThe liver is the largest organ in the body, weighing approxi-mately 1500 g. It resides in the right upper abdominal cavity beneath the diaphragm and is protected by the rib cage. It is reddish brown and is surrounded by a fibrous sheath known as Glisson’s capsule. The liver is held in place by several ligaments (Fig. 31-1). The round ligament is the remnant


Surgery_Schwartz

Surgery_Schwartz. by the rib cage. It is reddish brown and is surrounded by a fibrous sheath known as Glisson’s capsule. The liver is held in place by several ligaments (Fig. 31-1). The round ligament is the remnant of the obliterated umbilical vein and enters the left liver hilum at the front edge of the falciform ligament. The falciform ligament separates the left lateral and left medial segments along the umbilical fissure and anchors the liver to the anterior abdominal wall. Deep in the plane between the caudate lobe and the left lateral segment is the fibrous ligamentum venosum (Arantius’ ligament), which is the obliterated ductus venosus and is covered by the plate of Arantius. The left and right triangular ligaments secure the two sides of the liver to the diaphragm. Extending from the trian-gular ligaments anteriorly on the liver are the coronary liga-ments. The right coronary ligament also extends from the right undersurface of the liver to the peritoneum overlying the right kidney, thereby


Surgery_Schwartz

Surgery_Schwartz. ligaments anteriorly on the liver are the coronary liga-ments. The right coronary ligament also extends from the right undersurface of the liver to the peritoneum overlying the right kidney, thereby anchoring the liver to the right retroperitoneum. These ligaments (round, falciform, triangular, and coronary) can be divided in a bloodless plane to fully mobilize the liver to facilitate hepatic resection. Centrally and just to the left of the gallbladder fossa, the liver attaches via the hepatoduodenal and the gastrohepatic ligaments (Fig. 31-2). The hepatoduodenal ligament is known as the porta hepatis and contains the com-mon bile duct, the hepatic artery, and the portal vein. From the right side and deep (dorsal) to the porta hepatis is the foramen of Winslow, also known as the epiploic foramen (see Fig. 31-2). This passage connects directly to the lesser sac and allows com-plete vascular inflow control to the liver when the hepatoduode-nal ligament is clamped using the Pringle


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Surgery_Schwartz. foramen (see Fig. 31-2). This passage connects directly to the lesser sac and allows com-plete vascular inflow control to the liver when the hepatoduode-nal ligament is clamped using the Pringle maneuver.Segmental AnatomyThe liver is grossly separated into the right and left lobes by the plane from the gallbladder fossa to the inferior vena cava (IVC), known as Cantlie’s line.5 The right lobe typically accounts for 60% to 70% of the liver mass, with the left lobe (and caudate lobe) making up the remainder. The caudate lobe lies to the left and anterior of the IVC and contains three subsegments: Key Points1 When operating on the liver, gallbladder, pancreas, or adjacent organs, recognition of the normal or variant vas-cular and biliary anatomy is essential to avoiding surgical complications.2 The liver is the largest gland in the body and performs a diverse spectrum of functions.3 Computed tomography and magnetic resonance imaging with contrast enhancement constitute the mainstays for