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Outcomes of the Macroscopically Normal Appendix Left in Situ in Patients with Suspected Appendicitis
Sara Lee1, Tara M Connelly2, Jessica M Ryan2
1Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland. sara240398@gmail.com.
Background:
Right iliac fossa (RIF) pain is a common indication for laparoscopy to diagnose and treat appendicitis. When a macroscopically normal appendix is found, there is no standard consensus regarding excision. Some surgeons remove the appendix due to the risk of microscopic inflammation and to avoid a future, repeat laparoscopy for possible appendicitis. Alternatively, others leave the appendix in situ to avoid morbidity from a potentially unnecessary procedure. We aimed to evaluate the outcomes of patients with macroscopically normal appendices left in situ.
Methods:
All emergency laparoscopies without appendicectomy between January 1st 2010- December 31st 2020 were identified from theatre records. All operative notes were individually evaluated and comments on the macroscopic appearance of the appendix and any intra-operative pathology were recorded. Only patients undergoing laparoscopy for suspected appendicitis with macroscopically normal appendices were included.
Results:
A total of 120 patients [median age 21.68 (range 9-90.8) years] were included. The cohort was predominantly female (n=105, 87.5%). Forty-eight patients (40.0%) had a positive finding during index laparoscopy. During a median duration of 94.5 (range 8-131) months' follow-up, 16 patients (13.33%) underwent a repeat laparoscopy for recurrent RIF pain. Thirteen (10.8% of total cohort) subsequently underwent an appendicectomy. Histology confirmed acute appendicitis in six cases (4.17% of entire cohort). On subanalysis of smaller cohort, index laparoscopies with no positive findings (n=72), nine patients (12.5%) underwent appendicectomy with two (2.7%) appendices demonstrating appendicitis on histological examination.
Conclusion:
87% of the total cohort with a normal appendix at laparoscopy for RIF pain did not undergo further laparoscopy. Less than 5% of the total cohort and 2.7% of subanalysis cohort had an appendicectomy for histologically-proven appendicitis within the follow-up period. From the evidence in this study, we conclude that leaving the appendix in situ unless macroscopically inflamed is a viable alternative to excision.
Insights
Leaving a normal appendix in place after laparoscopy for right iliac fossa pain is safe. Most patients did not require repeat surgery, and few had appendicitis confirmed by histology.
Area of Science:
- Surgical outcomes
- Gastrointestinal surgery
- Diagnostic laparoscopy
Background:
- Right iliac fossa (RIF) pain is a common reason for laparoscopy to diagnose appendicitis.
- There is no consensus on whether to remove a macroscopically normal appendix during laparoscopy.
- Leaving the appendix avoids potential morbidity from unnecessary surgery, while removal prevents future appendicitis or repeat laparoscopy.
Purpose of the Study:
- To evaluate the outcomes of patients who had a macroscopically normal appendix left in situ after laparoscopy for RIF pain.
- To determine the rate of subsequent appendicitis or repeat laparoscopy in this patient group.
Main Methods:
- Retrospective review of emergency laparoscopies without appendicectomy (2010-2020).
- Inclusion criteria: suspected appendicitis with a macroscopically normal appendix.
- Data collected: macroscopic appendix appearance, intra-operative findings, and follow-up outcomes.
Main Results:
- 120 patients (predominantly female, median age 21.68 years) were included.
- 40% had positive findings during the initial laparoscopy.
- During median follow-up of 94.5 months, 13.3% had repeat laparoscopy for RIF pain, with 10.8% undergoing appendicectomy; histology confirmed appendicitis in 4.17% of the total cohort.
Conclusions:
- Leaving a normal appendix in situ is a viable alternative to excision.
- The majority (87%) of patients did not require further laparoscopy.
- Histologically confirmed appendicitis occurred in a small percentage of patients, suggesting conservative management is safe.
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