Base-First Versus Tip-First Appendicectomy: A Retrospective Analysis of Surgical Technique, Pathological Yield, and...

Appendicectomy is a common emergency operation, but there is no consensus on the optimal operative technique. We defined and compared two approaches: the tip-first technique and the base-first technique. In the tip-first technique, dissection begins at the distal appendix and progresses toward the base, stripping the mesoappendix off the appendix and leaving it behind. In the base-first technique, dissection starts near the base of the appendix with division of the appendiceal artery near its origin, removing the appendix together with its mesoappendix. Because the mesoappendix contains lymphovascular structures essential for pathological assessment and oncological staging, its omission may compromise completeness. This study aimed to classify appendicectomy into tip-first and base-first techniques and compare their clinical, operative, and pathological outcomes. We hypothesised that the base-first technique would consistently include the mesoappendix, ensuring more complete staging.

A retrospective cohort study was conducted of 134 consecutive appendicectomies performed at a single United Kingdom institution from January to December 2022. Techniques were classified histologically as base-first (mesoappendix present) or tip-first (mesoappendix absent). Data collected included demographics, American Society of Anesthesiologists (ASA) grade, surgeon grade, operative details, specimen characteristics, incidental malignancies, and clinical outcomes. Statistical analysis used chi-square, t-tests, and Mann-Whitney U tests, with p<0.05 considered significant.

Of 134 patients, 94 (70.1%) underwent base-first and 40 (29.9%) tip-first appendicectomy. Demographics were comparable, although base-first patients were slightly older (mean 40.5 vs. 38.3 years; Student's t-test (t(132)=1.97), p=0.051). Consultant-led surgeries were more frequent in the base-first group (41.5% vs. 22.5%; chi-square test (χ²(1)=4.39), p=0.036). Median length of stay was similar (four vs. three days; Mann-Whitney U=1763, p=0.589). Incidental neoplasms were found in five patients: three (3.2%) in the base-first group and two (5.0%) in the tip-first group (χ²(1)=0.23, p=0.633). In tip-first cases, lack of mesoappendix hindered staging, requiring further right hemicolectomy.

This is, to our knowledge, is the first study to categorise appendicectomy techniques into tip-first and base-first groups with comparative outcomes. While overall clinical results were comparable, tip-first appendicectomy risks incomplete oncological staging due to the absence of the mesoappendix, occasionally necessitating further major surgery. Surgical training should emphasise the base-first technique to ensure pathological completeness and oncological safety.