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17 Prophylactic Appendectomy
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Fig. 17.2 Amyand hernia (arrow) is seen in the CT coronal section
to intestinal malrotation, IA is added to the
procedure.
Some authors suggest appendectomy in cases
with appendix (De Garengeot hernia) in the inguinal hernia sac (Amyand hernia, Fig.
17.2) or the
femoral hernia sac during inguinal hernia surgery
[24]. IA is also performed during hernia surgeries.
Dens adhesions occur after the wide abdominal
defects are covered with mesh, and it may makes
difcult for subsequent surgical entries. Dilek et al.
considering that the intense brosis that will occur
after mesh applications for the repair of giant incisional hernia would make subsequent operations
difcult, they performed IA in 23 incisional hernia
cases in their series of 64 IA (2001) cases [25].
However, some authors do not recommend appendectomy especially in cases with mesh application
and in cases with normal appendix [26].
There are some studies that incidental appen-
dectomies are performed in addition to laparo-
185
scopic cholecystectomy, bariatric surgery, cardiac
surgery, urological procedures, trauma surgery,
and transplantation [
14, 27, 28]. While there are
authors that encourage appendectomy during
bariatric procedures for obesity, there are also
those who do not recommend it in cases where it
is difcult to dissect the appendix in super obese
[29]. Akbulut etal. (2020) reported that they did
170 incidental appendectomies in 1910 cases
performing living donor hepatectomy, as a result
of histopathological examination, they found
normal appendix in 137 cases, brotic changes in
13 cases, acute appendicitis in 6 cases, Enterobius
vermicularis in 5 cases, lymphoid hyperplasia in
4 cases, and various types of neoplasia in 7 cases.
They also concluded that inspecting the appendix
and seeking morphological changes could contribute to making an appendectomy [30].
The appendix is often removed during oncological surgery. In patients with Wilms tumor,
appendectomy is performed together with
nephrectomy. Especially in pediatric oncology
cases, it is recommended to remove the appendix
during surgery due to the risk of developing an
acute abdomen due to chemotherapy and neutropenic enterocolitis [12]. However, IA is not recommended for patients with severe comorbidity,
using immunosuppressants, vascular grafts and
over 60years of age [3, 25].
It has been reported in many studies that incidental appendectomies have no negative effects
on perioperative morbidity and mortality. It was
reported that there was no signicant difference
in morbidity after inguinal hernia surgery, incisional hernia, and hysterectomy operations [
13,
19, 31, 32]. While there was no signicant differ-
ence between Pollock and Evans’s series that
underwent laparotomy, cholecystectomy, and IA,
and antibiotics were used, the risk of infection
was found to be higher in the series that did not
use antibiotics [33]. However, there are also
series that undergo laparoscopic cholecystectomy and IA and report that there is no signicant
difference [34]. Strom et al. (1983) found that
incidental appendectomies in patients undergoing laparotomy due to trauma and without surgical pathology signicantly increased morbidity.
In another prospective study of the same author
186
and colleagues, they reported that there was no
signicant difference in morbidity between the
appendectomy group and the non-appendectomy
group during the laparotomy [28]. Morris etal.
(1987) reported that 210 patients who underwent
laparotomy due to Hodgkin’s disease, IA were
added to procedure in 130 patients and there was
no signicant difference in terms of morbidity.
On the other hand, there are also publications
reporting that the addition of IA prolongs wound
infection and hospital stay while performing laparoscopic cholecystectomy [35].
There is a general opinion that IA prevents
future appendicitis and complications. In many
epidemiological studies in the literature, it has
been reported that 20–25 IA prevents one future
appendicitis and its possible complications [1, 3].
In the literature, abnormal pathological ndings
were found in 16–73% of the cases in histopathological examination of the patients who were
considered to have normal appendix during laparotomy [3, 13, 36]. With the IA, as expressed in
the Turkish statement of “shooting two birds with
one stone” the patient will be free from two problems: single anesthesia, single hospitalization,
one laparotomy, and the risk of appendicitis in
the future and associated complications.
17.3.2 Prophylactic Appendectomy
Prophylactic appendectomy (PA) can be dened
as the removal of the appendix without any further action. Indications and risks should be determined in patients for PA. Decisions should be
made by talking to the patient or relatives for
diagnosis and surgery. Morbidity and mortality
are undesirable. PA is performed for many reasons (Table17.1).
Fecalith or appendicolith formed within the
appendix are among the most common causes of
appendicitis (Fig. 17.3). In clinical studies, the
risk of recurrence of appendicitis has been
reported to be 72% in patients with appendicolith. Interval appendectomy is recommended for
patients who previously had attacks due to fecalith or appendicolith [37]. In the retrospective
computed tomography scan of 2913 patients of
O. N. Dilek et al.
Fig. 17.3 Fecalitis is seen (Arrow) in the appendix
18years or younger of age, Rollins etal. (2010)
revealed appendicoliths in 75 cases (2.6%) [38].
Appendix foreign bodies are very rare entities. Peristaltic strength of the appendix may not
be enough to push foreign bodies into the cecum.
Metal and similar objects more massive than the
gravity of the appendix content settle in the channel. However, foreign bodies rarely (0.0005%)
can cause appendicitis [39]. Foreign bodies rarely
show symptoms, and most are detected by chance
during examinations. There is no need to remove
foreign bodies in the appendix routinely.
However, long, thin, and sharp-edged foreign
bodies should be initially removed endoscopically. In cases that cannot be removed, PA should
be recommended [40]. There are also authors
suggesting routine appendectomy on foreign
bodies detected in young children [41]. In cases
where mercury taken with mercury poisoning
accumulates in the appendix, symptoms of
chronic poisoning may be encountered. In the
case of mercury poisoning, a medical and endoscopic approach can be treated as well as authors
are recommending PA [42]. It has been reported
that the barium meal used during radiological
examinations may accumulate in the appendix
and cause appendicitis. Patients undergoing such
radiological procedures should be informed that
appendicitis and PA are recommended in symptomatic patients [43].
17 Prophylactic Appendectomy
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187
a
Fig. 17.4 Normal (a) and complicated (b) cecum diverticulum (arrow) and normal appendix (arrowhead) are seen in
two different patients’ abdominal CT images
b
Although appendix diverticulum is very rare,
PA is recommended in clinical series due to the
risk of malignancy ranging from 7.1 to 47.8%
and high risk of confusion with mucocele (9.8%–
33%) [44–46]. Right colon diverticula often confuse clinically with appendicitis (Fig. 17.4).
Abdominal tomography is useful in the differential diagnosis. In the right colon diverticulitis
series of 113 cases of Yang et al. (2008), 56
patients were diagnosed correctly, and medical
treatment was performed, while 51 patients were
operated with the diagnosis of acute appendicitis.
There are also studies suggesting PA after medical treatment in patients diagnosed with right
colon diverticulitis [
47].
In recent years, the removal of luminal
pathologies endoscopically and by the mucosal
Fig. 17.5 The abdominal CT axial section shows the
clips in the radix and congested appendix (arrow) of our
patient who underwent endoscopic resection for the lesion
in the cecum
resection has started to be made increasingly. In
such a case, we performed PA in a patient with
edema and inammation in the appendix due to
the clips placed on the control computed tomographies taken after the EMR performed close to
the appendix radix (Fig.17.5).
There are many studies on whether the para-
sites cause appendicitis in the appendix. The
most common parasites found in the appendix
are helminths (Enterobius vermicularis,
Schistosoma spp, Taenia spp, Trichuris trichiura,
and Ascaris lumbricoides) and protozoa
(Entamoeba histolytica, Balantidium coli, and
Cryptosporidium parvum). The parasites are
thought to cause appendicitis by blocking the
lumen, leading to lymphoid hyperplasia or
inammation. The frequency of parasites in the
appendix varies depending on the countries’
socioeconomic levels and eating habits. Parasites
were detected in 0.5% of cases in a study from
Hong Kong, 5.5% of cases in Oman, and 16% of
188
O. N. Dilek et al.
cases in Malaysia [48, 49]. The most common
parasite in the appendix is Enterobius vermicu-
laris, and its incidence has been reported between
0.2% and 41.8% (average 4.5%) [50, 51]. The
incidence of appendicitis in appendixes with parasites is very different in clinical series. In the
literature, Zakaria et al. (2013) reported the
appendicitis rate as 5.5% of their 1600 cases
series. It was reported as 14.6% in Hong Kong
series, 42.5% in Malaysia, and 81.3% in Pasupati
series [48–50]. It has been reported in many
series that the incidence of parasites in the lumen
of the appendix and the risk of appendicitis is
very low, and the main cause of appendicitis is
not. There is no consensus on performing PA due
to the presence of parasites in the appendix.
Anti- parasitic therapy should be initiated in those
with or without appendectomy.
17.4 Miscellaneous Conditions
Chronic appendicitis is an entity characterized
by chronic inammation in the appendix wall,
which is shown as the cause of chronic abdominal pain in the clinic. Occasionally, an acute
abdomen was held responsible for intestinal
obstruction and perforations [52]. However, due
to the difculties in its diagnosis, it can be
accepted as an entity that has not been consensus.
It is frequently encountered as a histopathological diagnosis in prophylactic appendectomy
series in the clinic. In their series of 748 cases by
Schumacher and Schwartz (1986), they reported
chronic appendicitis in 27% of cases and normal
appendix in 73% [36]. In another PA series,
appendectomy was performed due to chronic pelvic pain in 15 cases, and their histopathological
analysis demonstrated that chronic appendicitis
in 4 cases, malignancy in one case, acute appendicitis in one case, and normal appendix in 9
cases [13]. In 269 cases of appendectomy series
of Leardi et al., chronic appendicitis was diagnosed in 38 cases (14.2%). In their postoperative
follow-up, they observed that 33 of the patients’
abdominal pain disappeared. They concluded
that chronic appendicitis might have a role in
recurrent abdominal pain, and PA may be
effective [53].
Plastron appendicitis may occur when the
omentum surrounds the appendix in cases of
appendicitis that progresses towards the perforation and abscess formation. As a complication of
appendicitis, more than 90% of cases improve
with medical treatment and drainage performed
in plastron appendicitis cases. Acute appendicitis
recurs again in 5–26% of the recovered cases.
While the risk of recurrence of appendicitis
increases in the rst 6months, it decreases after
the rst year. In such cases, two approaches are
recommended. Mentula etal. (2015) recommend
surgery in the early period (acute phase) as a
fewer follow-up, fewer hospital admissions,
fewer patients are admitted, and fewer interventional procedures will be performed [54]. There
is also more risk of malignant neoplasia in 0.7%
to 3% of patients with plastron appendicitis, and
the risk of malignancy is higher than 40years of
age. In the early stages, this risk can be eliminated with therapeutic appendectomy [55–58]. A
group of authors suggests that the medical
approach should be preferred in the early period,
and the interval appendectomy should be performed after 3months because it contains fewer
complications. It is also recommended to perform MRI before surgery [55, 57]. Besides, some
authors stated that follow-up with MRI would be
sufcient.
There are some speculations and many research
about the increased risk of cancer in patients
who have undergone appendectomy in the past,
and their relationship with cancer has not been
found [3]. However, in a retrospective cohort
study with broad participation from Taiwan in
recent years, it has been reported that developing
colon cancer is 1.14 times higher in people who
underwent an appendectomy and followed for
14 years (12.8 times). In the same study, they
reported that the risk of developing colorectal
cancer is much higher in the follow-up of patients
undergoing an IA.Interestingly, it is known that a
colon carcinoma should take about 10 years to
develop from a polypoid lesion; this period was
found between 1.5 and 3.5years postoperatively
17 Prophylactic Appendectomy
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189
after appendectomy [59]. Age-related changes in
the intestinal ora and the immune system are
known to be weakened due to age, and there is
insufcient clinical data on the relationship of the
event to appendectomy. It is known that genetic,
nutritional, and environmental factors play an
important role in the development of colon cancer. Prospective clinical studies with broad participation are needed to reveal the relationship
between appendectomy and colorectal cancer.
Although the appendix is thought to play a
role in the immune system due to its lymphoid
tissue content, there is insufcient data on the
negative effect of appendectomy on the immune
system and homeostasis [60]. There are also
studies on the natural and dense microbiota in the
appendix, which is a “safe house,” that it plays an
important role in the regulation of the ora
(microbiota and biolm) in the colon, and
changes occur in the colon ora after appendectomy [61]. In the literature, there are studies
reported that the risk of developing Crohn’s disease increases 1.6–2.1 times in individuals who
underwent appendectomy, or a decrease in the
incidence of inammatory bowel diseases, especially ulcerative colitis [2, 62]. There are even
studies reporting that patients with ulcerative
colitis have decreased immunosuppressive medication needs, and relapses and symptoms
decrease after appendectomy. However, all these
data need to be investigated with large prospective series [63]. While there are more than 500
types of bacteria in the intestines, studies are
reporting that there are genomic links between
Fusobacterium nucleatum/necrophorum found in
most acute appendicitis and the development of
inammatory bowel disease and subsequent
colorectal cancer [12, 64].
There are many studies on whether PA is cost-
effective or not. In studies conducted, it has been
reported that incidental appendectomies and prophylactic appendectomies performed before the age
of 30 have a positive and cost-effective contribution
[65]. The operation must be performed with minimal complications. Twenty years after a PA, a case
with ileus and intestinal necrosis due to regional
adhesions has been reported in the literature [14].
17.5 Conclusion
Prophylactic or incidental appendectomy can
ethically be performed with minor complications. PA should be recommended in patients
without comorbidity and at a younger age (<30).
IA should be performed in patients who are considered to have no adverse effects on morbidity
and mortality and thought that IA would be benecial. The surgery decision must be made with
the patient and family. In addition to preventing
future appendicitis and associated complications,
PA will also assist in the early diagnosis of appendix malignancies.
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Vascular Problems Related
toColectomy: Habitual andVariant
Anatomy, Prevention, andTactical
Aspects
AbeFingerhut , HayatoKurihara ,
andWilliamTzu-LiangChen
18
18.1 Introduction
While the normal vascular anatomy of the colon
and rectum is well documented [1, 2], variations
are highly prevalent and may be an underlying
cause of vascular failure after colonic resection
and anastomosis. Indeed, adequate oxygen supply is mandatory for the normal healing process
[3–5]. Insufcient blood supply, with its obvious
corollary, insufcient oxygen supply to the site of
healing (anastomosis), and thus a risk factor for
anastomotic breakdown, can be secondary to
inadvertent division (whether the vessel is in its
“normal” situation, or not), stretching or twisting
of the alimentary vessels of one of the enteric
segments, or division of vessels as necessary to
perform a procedure (high or low tie of the infe-
A. Fingerhut (*)
Department of Surgery, Section for Surgical
Research, Medical University of Graz, Graz, Austria
Department of General Surgery, School of Medicine,
Shanghai Minimally Invasive Surgery Center, Ruijin
Hospital, Shanghai Jiao Tong University,
Shanghai, People’s Republic of China
e-mail: abengerhut@aol.com
H. Kurihara
Istituto Clinico Humanitas, Emergency Surgery and
Trauma Section, General and Minimally Invasive
Surgery, Rozzano (Milan), Italy
e-mail: hayato.kurihara@humanitas.it
W. T.-L. Chen
Department of Colorectal Surgery, China Medical
University Hsinchu Hospital, Hsinchu, Taiwan
e-mail: wtchen@mail.cmuh.org.tw
rior mesenteric artery with its corollar interruption of the left colic artery), especially when there
is an insufcient anastomotic arc between the
superior and inferior mesenteric circulations at
the level of the marginal artery (of Drummond)
or Grifths’ point, absence of the middle colic
artery (MCA) or one of its branches, and last, but
not least, when vascular supply to the colon does
not take its normal course, notably when atherosclerosis or previous colectomy obstructs or
interrupts the normal vascularization.
Moreover, several anatomic regions along the
gastrointestinal tract are known to have a tenuous
vascular supply and after dissection and division
of adjacent vessels, the gastrointestinal segment
can become hypo-perfused, or even ischemic.
This is the case when small hypoplastic vessels
are present, notably at the level of Grifths’ point
[6]. Ischemia of the intestinal segment to be anastomosed can also be due to inadvertent ligation of
terminal vessels supplying the edges, incorrect
angle of division, or too generous trimming of the
mesenteric border [7].
In this chapter we will review the most commonly encountered vascular patterns and their
variations, highlighting how these variants may
inuence the vascular supply to the remaining
colorectal structure during the most commonly
performed colorectal resections and the consequences for the surgeon performing colorectal
surgery.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_18
193
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A. Fingerhut et al.
18.2 Normal (Traditional)
Anatomy
The most prevalent vascularization (approximately one-third of the population) of the terminal
ileum, colon, and rectum (main organs involved in
colorectal surgery) relies on vascular supply from
the superior and inferior mesenteric arteries (SMA
and IMA, respectively). The SMA runs off the
aorta opposite L1 and supplies blood to the terminal ileum, the cecum, the ascending colon, and the
proximal half to two-thirds of the transverse colon
by the main branches of the SMA (the middle
colic, the inconsistent right colic (less than 50%),
the ileocolic arteries and the terminal branches of
the SMA) [8]. The IMA runs off the aorta at the
level of L3 and supplies blood to left half to left
third of the transverse colon, the descending, the
sigmoid colon and the upper third of the rectum by
its main branches, namely the left colic, the sigmoid and the terminal, upper rectal artery.
18.2.1 Branches oftheSMA
The MCA, usually the second branch of the SMA
(after the inferior pancreaticoduodenal artery),
normally gives rise to two branches, a right (relative to the patient) branch that anastomoses with
the right colic (when present) or the ascending
branch of the ileocolic terminal division, and a
left (relative to the patient) branch that anastomoses with the ascending or right divisional branch
of the left colic artery, forming Drummond’s
arcade or anastomosis, also called the peripheral
arterial arcade [9] (Fig.18.1).
The watershed of marginal blood ow between
the SMA and IMA lies somewhere near the splenic
exure and has been called the Grifths’ point [6,
9] (circle in Fig. 18.1). Of note, this watershed
anastomosis can be absent or insufcient in up to
40% of patients. The marginal artery of Drummond
is absent in 5% of patients or can sometimes either
be replaced or complemented by other arcades
such as the so-called Riolan or the meandering
artery of Moskowitz, often when Grifths’ point is
absent or insufcient. These complementary connections are called the proximal mesenteric
arcades. Likewise, there is another critical secondary watershed area between the vascular supply
coming from the most distal sigmoid artery and
the most proximal branch of the superior rectal
artery called Sudeck’s critical point [9] (dotted
circle in Fig. 18.1). This anastomosis is insufcient or absent in up to 15% of patients.
The right colic artery, when present, gives rise
to two pericolic marginal branches, one ascending, connecting with the right branch of the
Fig. 18.1 Normal
colonic vascularization
[9]. Grifths’ (full
circle) and Sudeck’s
(dotted circle) points are
critical watershed
vascular connections
that warrant attention
during colonic resection:
(a) middle colic artery;
(b) right colic artery; (c)
ascending branch of the
ileocolic artery; (d) left
colic artery; (e) sigmoid
arteries; (f) superior
rectal artery; full circle:
Grifths’ point (no
vascular connection in
up to 53% of patients);
dotted circle: Sudeck’s
critical point (no
vascular connection in
up to 15% of cases)
a
b
c
d
e
f
Right external
n
18 Vascular Problems Related to Colectomy: Habitual and Variant Anatomy, Prevention, and Tactical…
195
MCA, the other descending, connecting to the
ascending branch of the ileocolic artery.
The ileocolic artery divides into an ascending
branch that irrigates the cecum and appendix, and
anastomoses with the right branch of the middle
colic or right colic artery and a descending branch
that goes to the terminal ileum.
18.2.2 Venous Circulation
Right colon: Normally all arteries have their
nominal venous counterparts (middle colic vein,
right colic vein (more consistent than its arterial
equivalent), ileocolic vein). While the ileocolic
veins usually drain directly into the superior mesenteric vein, the middle colic and right colic
veins drain into a common trunk called the Henle
trunk that usually runs directly into the superior
mesenteric vein [8] (Fig.18.2).
Left colon: Normally all nominal venous
counterparts (left colic vein, sigmoid veins, and
superior rectal vein) drain directly into the inferior mesenteric vein (Fig.18.2).
18.2.3 Most Frequent Variants
Variations can be due to different congenital or
acquired anatomic congurations (after colectomy, gastrectomy, pancreatic resection, or sometimes even radical nephrectomy) or changes
induced by chemo/radiation therapy or disease
(atherosclerosis).
The MCA can be completely absent (25%) [7,
11], the two branches can arise directly from the
SMA (without a common trunk), one or the other
can be absent, or there is no communication
between the two branches (5–10%) (Fig.18.3).
The right colic artery is absent in up to 1/3 of
cases. The communication between the SMA and
IMA at the splenic exure (Grifths’ point connection) can be absent or inadequate in 43 to 53%
of cases [6, 12–14].
The ileocolic artery can pass in front of
(≈30%), or behind (≈60%) the superior
mesenteric vessels (Fig.18.3) [15]. This has its
importance when lymph node dissection of the
origin of the ileocolic vessels is envisioned, notably in complete mesocolic excision.
Fig. 18.2 Right and left
colonic venous networks
[10]
Portal vein
Superior mesenteric vein
Right colic
vein
IIeocolic vein
Common
iliac vein
iliac vein
Internal
iliac vein
Middle rectal vein
Inferior rectal vein
Splenic vein
Inferior mesenteric vein
Left colic vei
Sigmoid vein
Middle
sacral vein
Superior
rectal vein
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