In a patient with equivocal clinical diagnosis of acute appendicitis, and underwent diagnostic laparoscopy, what will you do if the appendix is normal looking ( white) , and assuming no other pathologies identified ( no Meckel's diverticulitis, no gynaecological pathology, etc ).
Will you perform appendicectomy? Or stop at diagnostic laparoscopy?
- Does grossly normal looking appendix mean there is no appendicitis on histology?
- Will this patient be labelled as having ' Non specific abdominal pain(NSAP)' postoperatively?
- Does the small risk of appendiceal stump leak/blowout and adhesion justify for appendicectomy , against the risk of future appendicitis if left intact ?
Perform appendicectomy
When open grid-iron and found normal appendix, and no another pathology, remove it or not?
In absent of others condition appendicectomy should be performed with the respective biopsy of the appendix
In open appendicectomy (grid iron or Lanz), we will perform appendicectomy although grossly normal. Isn't it to avoid future confusion? As the operative scar strongly imply that the person's appendix has been removed?
Diagnostic laparoscopy scar has no strong association with any specific surgery.
No, don't remove appendix as it is now recognized that appendix isn't just a vestigial organ. You should revise your diagnosis and treat it accordingly. You just say, "... equivocal clinical diagnosis of acute appendicitis ..." Why do you say, equivocal and then also admit it a white normal-looking appendix? Histology is never a confirmatory examination because the pathologist invariably reports some degree of non specific inflammation. I have often wondered, is that biopsy report trustworthy? Say it with due respect to the pathologists, because our surgical handling inflicts non specific trauma during our removal technique. Could that not cause some pathological changes? I have often discussed it with my path colleagues with no clear answer.
During the last more than three decades, GI practice is undergoing tremendous revolutionary conceptual changes and most of our surgical colleagues seem to be unaware of these "Functional Gastro-Intestinal Disorders", now further classified as "Disorders of Gut Brain Interaction". Every RIF pain "must" not be consigned to ""Appendicular pain" lest we miss the real cause and the patient is ultimately labeled as a psychiatric case!
Dilap has already ruled out appendicitis; Do a meticulous examination exit Pneumoperitoneum reverse the patient and re investigate for the other differentials. I agree the body has no superfulous structures.
First of all: avoid to be in this situation by performing preoperatively, when available, US or CT-scan. If such examinations are unavailable, and if laparoscopy is precisely defined as diagnostic (and not as therapeutic), you have to explain preoperatively to the patient that it appears logical to not remove the appendix if appendix eventually appears normal.
Of course, however, take into account the context and preoperatively choose the strategy with the patient.
In a scenario like this, a diagnostic lap would suffice. Before embarking on a diag lap, investigations baseline bloods, urine exam, imaging (US, CT as appropriate) to be reviewed carefully. Presence of an appendicolith on imaging would push for Appendicectomy even in case of 'normal looking' Appendix.
If the patient had received antibiotics, the possibility of finding a 'normal looking' Appendix is high.
Recurrent bouts of pain abdomen in this scenario can justify Appendicectomy.
In a child enlarged mesenteric nodes, transient Intussusception, malrotation, worms are possible causes of a 'normal abdomen' on diag lap.
NSAP is justified, provided all other investigations do not reveal anything abnormal.
Both (stump blow out/ adhesion and risk of appendicitis) are minuscule.
Om Prakash Sudrania Dear Sir, I thought pathologists will look for transmural inflammatory cell infiltrates ( neutrophils ) ,to diagnose appendicitis. Will these cells be significantly seen due to instrument crushing and manipulation trauma during that brief episode ? Quite unlikely I guess.
Philippe Guillem , Totally agreed about the strategy, which should be well planned preoperatively. Patient takes part in the decision making, after giving options to deal with the various possible intraoperative outcomes.
Krishna Kumar Govindarajan , Interesting point on 'normal looking' appendix after given antibiotics. Probably in a delayed surgery setting after a few doses? Those cases could identify the patients who would be successfully treated with non-operative management. Appendicectomy probably not needed after all.
Cheah Sin Dee Thank you for your feedback. I'm a surgeon and often I have discussed this issue with my pathologist colleagues and argued with them. We never came out with a conclusion on this score. Having said, I personally feel that in the era of current developments in Gastroenterology and newer incites, such appendices "must" not be removed for no reason because it is no longer regarded as a vestigial 'useless' organ. Further, I have often treated such cases who ultimately respond very well with functional problems. This must be treated with a "holistic approach".
Secondly, we shall miss the actual pathological cause for the pain in tummy with continued maltreatment and labelling the patient ultimately as a 'nut case' and send to a psychiatrist. This is a sad story of such patients. We need to educate ourselves better in the incite of etiopathology of such obstinate patients.
I recall a saying by a renowned English Surgeon, "It is the doctor who is difficult than the innocent patient".
I hope it might help you.
Regards
I think like spleen used to be called "Plenum mysterie organum" - an organ full of mysteries which ultimately turned out to be one and lead to splenic preservation strategies.
Likewise Appendix may turn out to be the same and as such appendicular preservation in grossly normal appendix on laproscopy is not a bad idea!
Though if u go by book around 25% of grossly normal appendices are actually harbouring inflammation on HPE.
The bottom line wud be It z rightly a debatable question whether to take it out or leave it to show some mysterious functions in future!!!
:)
Naveed Nabi Very well put and thanq.
As you say, "... around 25% of grossly normal appendices are actually harbouring inflammation on HPE ..." But the reverse is also true. About 25% of appendicectomies done in 'emergency' for acute appendicitis are reported histologically normal and this figure rises in higher the medical institution, higher is this percentage.
Regards,
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