I am generally very reluctant but have a few cases where an appendectomy for chronic appendicitis alleviated the symptoms.

I am agree with De Castro. In addition, during a diagnostic laparoscopy for chronic right iliac fossa pain, appendectomy is useful for improving or resolving symptoms in absence of another abnormal findings (bowel adherences or gynecological diseases for ex)

As a urogynecologist and a laparoscopic surgeon I would refrain from appendectomy. I am sure that appendectomy could have a placebo effect leading to pain alleviation. However, I also believe that there may be some other causes for this chronic pelvic pain or chronic right iliac fossa pain as you decleared it (e.g. endometriosis, lumbal sy). Usually, the osteomuscular pain is a under-diagnosed cause.

I would suggest a vaginal examination and palpation of pelvic floor muscles and pelvic trigger points to rule out tendernes of the L4-S1 region. From my experience, the scoliosis or fibromyalgia should also be taken into consideration....

In my opinion, the next step would be the X-ray diagnostics (or lumbar spine MRI), NSAIDs treatment, and only eventually laparoscopy...

If appendix is total normal , mobile , without sclerosis and any signs of past infiammatory, i don't remove. Otherwise yes, i perform an appendectomy.

I think I would perform an appendectomy to avoid future RLQ pain confusions.

very practical question,in the present era of excellent cect scans the role of diag lap is becoming smaller.Hence incidental appendectomy in a territory care hospital are not that common as before.But if i am performing a diag lap for chronic RIF pain,I would perform Appendicectomy,whenever I feel that I am justified.

There is no convincing evidence for the existence of a "grumbling appendix". Thus to perform an appendicectomy for undiagnosed pelvic pain is at best mumbo-jumbo, and at worst clinically wrong. That some patients may "recover" from their pain after appendicectomy does not validate this approach in any way, being of very low evidence value. Furthermore, the risks of incidental appendicectomy must not be ignored: short-term problems of faecal leakage and long-term problems of adhesions have been well documented.

The message is: don't do what you don't have to do!

Dr. Cotton, the question is not about "incidental" appendicectomy.

The approach of leaving macroscopically normal appendix may truely be construed as treating laparoscopy as diagnostic only.(that may also involve instrument port for retraction). Whoever in the past was opening abdomen via RLQ incision have never left a "macroscopically" normal appendix 'in' - have they? In other words, advent of laparoscopy should not alter one's threshold to taking a patient to surgery. But if the threshold remains high, (there was RIF guarding for instance ) preop, i will be reluctant to leave the appendix "in" - since serosal side examination does not rule out mucosal pathology or luminal pathology like fecalith, worms etc...

Our policy is to remove it if no other cause of the RLQ pain is found at laparoscopic exploration. Unsuspected mucosaĺ ulceration and infiltration with. PMN leucocytes is often found at microscopicaĺ examination even if the appendix looked normal.

I seriously doubt whether a normal appendix can cause right iliac fossa pain.

On the contrary, "normal appendix vermicularis" can be used for access or reconstructive purpose at any age, as you may agree.

With due respect to Dr Kumaran's view, it does nonetheless look like, "now I've gone along the wrong route, I may as well finish the course.." Why not treat a "normal-looking possibly serosally inflamed (whatever that may mean) appendix" with antibiotics?

As a surgical registrar in the UK, I often am in the position where I encounter a normal looking appendix during laparoscopy for acute admissions for RIF pain. This is because laparoscopy is used (somewhat incorrectly in my view) as a diagnostic test which has lowered the threshold for surgery. I take out the normal-LOOKING appendix if there is no other pathology I can see that would cause right iliac fossa pain. This is because multiple studies have shown early appendicitis may not be macroscopically visible (this has been shown in many studies!). The risk of complications from appendicectomy exists but should be negligible, since the technical requirements for laparoscopic excision of a normal looking appendix should be minimal with adequate laparoscopic training. For that reason I consent my patients that I will take out their appendix to prevent future episodes of appendicitis if everything else looks normal. Finally, in response to Dr Cotton, I have some problems with antibiotics in appendicitis due to the very high risk of recurrence (up to 1 in 3) documented in previous studies.

Exactly my point: "now I've gone along the wrong route, I may as well finish the course.." Once you commit to a laparoscopy (an invasive procedure) you are psychologically committed to "doing something"..

The adage that "complications should be negligible" does not hold water! The trouble is that complications do arise, and if they do for a procedure that was unnecessary, you have no leg to stand on. Those complications may be late (adhesions) and so not necessarily immediately apparent. Furthermore, it now appears appendicectomy leads to a higher risk of C. difficile. Also, what's wrong with treating appendicitis with antibiotics if there is a possibility of recurrence? Do you not treat early uncomplicated diverticulitis with antibiotics and reserve surgery for complicated & recalcitrant cases? Or tonsillitis likewise? This practice has evolved once it was realized that surgery was harmful and unnecessary for early uncomplicated cases. The same is almost certainly true of appendicitis, but dogmas die hard. Actually a meta-analysis & systematic review by Liu & Fogg (Surgery. 2011 Oct;150(4):673-83) supports my view. So put your laparoscope back in its drawer and get out the ultrasound for a diagnostic test instead!

If the appendix is normal, I don't remove it.

There is an extra issue in Belgium concerning this interesting problem and the value of " exploratory appendectomy" : a cost issue . The Belgian government monitors the cost of a number of procedures per hospital. One of these procedures is the appendectomy. All hospitals where an appendectomy costs more than the Belgian average amount plus 10 % are forced to pay back the extra costs to the government. All medical expenses going back as far as one month before the appendectomy are taken into account to calculate the cost of the procedure, in-hospital, ambulatory, related to the RLQ pain or not. Every single euro spent for the care of any problem of the patient one month prior to the procedure . This completely absurd repressive measure does undoubbtely raise the treshhold to perform preop US or CT scan and might lower the treshold for exploratiry laparoscopy......unethical indeed, but a reality I'm afraid. In our institution we are far from the " danger zone" , but I gather surgeons who already had to refund fees to the goverment will think twice before asking a preop CT In cases of suspected appendicitis, and probably will end up with a higher number of macroscopically normal appendices at laparoscopy.

I have been a gynecologist for over 40 years.My main interest and most of my practice has been female pelvic pain.My findings suggest that recurrent low grade appendicitis or grumbling appendicitis may be an entity, I have performed over 13000 diagnostic laparoscopies and the commonest finding is endometriosis,however if there is a history of recurring or chronic RIF pain I will very often see caecal and pericaecal adhesions in the presence of a healthy looking appendix.Histology of these after appendectomy will usually reveal lymphoid hyperplasia or increased lymphoid tissue indicative of previous inflamation . More importantly the patient usually has the RIF pain relieived or diminished

During laparoscopy for Right Iliac Fossa (RIF) pain,If no pathology is seen to account for patient's symptoms then there will be two options ,no one is completely right or wrong:

1.Go ahead with appendectomy: evidence from a study of 200 patients showed that normally looking appendix on laparoscopy has 20% chance of being inflammed on histology!!

Please see our study in Singapore Med J. 2009 Dec;50(12):1145-9.

What is positive appendicitis? A new answer to an old question. Clinical, macroscopical and microscopical findings in 200 consecutive appendectomies.

Hussain A1, Mahmood H, Singhal T, Balakrishnan S, El-Hasani S.

2.Do nothing and accept the 20% chance of inflammation and iv antibiotics for three days will sort it out.

The need for interval appendicectomy is not very much supported by literature as the chance for the appendicitis in the future is minimum (less than 10%) and does not out weight the risk and cost of the surgery.

Having said that the practice in the UK is variable and dictated by personal experience.

At the moment no solid evidence from research to support either way ,however the case should be taken on its merits .Factors such as age,sex,history and clinical examination blood test plus evidence from ultrasound [if available to exclude other causes] will direct the management when facing normal appendix on laparoscopy.

The tell tale sign of previous appendicitis at laparoscopy is the presence of filmy adhesions around caecum and appendix in the presence of a normal looking appendix.,If there are no adhesions DONT remove the appendix. In cases with these adhesions lymphod hyperplasia of the appendix is nearly always present.If the histologist is asked ? previous appendicitis the answer is almost always positive. Reference JAMA 1919 The Clinical signifigance of Lymphoid Hyperplasia in Appendicitis. Douglas Summers MD Maurice Greenberg MD JAMA 1919 72[7] doi 1001/jam p 468-470

In India amoebic typhylitis is common.so adhesions around the caecum is a fairly common finding.This does not signify the previous episode of appendicitis.

if appendix is normal, i don`t remove it as Dr. Cotton said complications do arise and it is not justified to remove every normal appendix

I believe it should be removed in all instances because, grossly, no one can determine if there is or no focal recurrent Payers patch inflammation that may obstruct the appendicial lumen when it reinflames producing the colic.

This only answers the question partially however, because the premise to the question is too broad and is misleading! There are other diseases unrecognized that may be extant, see below for recommendation on what to read.....

The etiology of right lower quadrant (rt. Iliac fossa ?) pain may be the unrecognized congenital abnormality Recurrent Cecocolic Torsion. Please read the articles on the radiological and clinical diagnosis and treatment of this problem in the Journal of Society of Laparoendoscopic (JSLS circa 2005 etc.) and for colored pictures see Surgical Rounds circa 2003. Check the bibliography for more topics on it. These articles were published by reasoning 'a posteriori' and not by consensus.

The described adhesions in some of the answers above may be congenitally occurring Jackson's membrane, Parietocolic Membrane, Cecal folds, Lane's band Cecal volvulus can not be invoked as a cause because it can not and does not exist being only an eidetic overreach .

F.T.Tirol, M.D. PMHD, Brawley, CA. June 2014

I advice appendectomy

It is a pity that much practice is not associated with real medical evidence. The fact that the appendix is visibly not inflamed means that it is not likely top be seriously affected, and whatever is affecting it (if anything) is likely to resolve spontaneously.

This logic cannot be refuted.

To evoke weird radiological entities such as "caecololic torsion" (which seems unlikely to be a common problem) to justify appendicectomy is likewise illogical.

A physical torsion of the caecum would sure give rise to severe discomfort, and would not necessarily be resolved by appendicectomy.

By contrast, a torsion of the appendix itself could possibly meet these criteria, but the anatomy allowing such an entity has never been described.

I return to the famous adage: "Do not do what you don't have to do." You may regret it and you wqill probably not be able to justify it in the future in the courts!

MC

And so the controversy continues..............

I agree that practice should be associated with medical evidence. However, there is evidence that an appendix that appears normal at laparoscopy is inflamed on histological analysis. I'm not sure where the evidence for Dr Cotton's assertion that "whatever is affecting it (if anything) is likely to resolve spontaneously" originates from!

Medical evidence has its limitations. We have only been taking out appendices for less than 300 years. Is it not possible that a normal appendix on conventional histological analysis may cause RIF pain-- and we do not yet understand why? Today I operated on a young woman with persistent RIF pain. At laparoscopy 2 weeks ago, the registrar left her normal appendix in. I took it out today at re-laparoscopy-- normal, but widened/thickened at the base with a faecolith. She had no RIF pain post op. This is not atypical in my limited experience as a junior surgeon, having performed around 200 appendicectomies. A small but notable subset of patients with normal appendixes (that I remove in the absence of other pathology) feel better post-op. Have other surgeons not experienced this?!

The evidence that mild appendicitis can resolve on its own is evident by the hundreds of patients who suffered from this ailment in the 1920s-1930s before the advent of antibiotics. It is therefore reasonable to suppose that antibiotic treatment is successful in mild cases, for which the evidence is mounting. (This is not gainsaying those that require appendicectomy for severely inflamed, gangrenous or perforated appendicitis.)

Actually, the first appendicectomy was carried out by Amyaud in 1735, where the inflamed appendix was found inside an inguinal hernia, and therefore its extraction did not involve a laparotomy (hence Amyaud's hernia). Whilst it is known that some patients may improve after removal of a normal appendix, many suffer complications. Thus, as a general rule, it should not be done.

1. An indicated ( not incidental nor exploratory) laparoscopy under anesthesia with its own moirbidity is being peformed for a  2. specific  right iliac fossa pain ( recurrent? )  3. with "no" gross laparoscopic findings.

Absence of  gross findings may mean nonrecognition of a disease.  Appendicitis generally starts as an obstruction of this blind organ and the mucousal inflammation eventually spreads to the serosa, then you get visible and positive peritoneal  or retroperitoneal signs with the stress effect  of  WBC elevation and shift, etc.  Right iliac fossa location suggests retrocecal irritation so  where is the appendix ?  retrocecal, retrocolic? Kinked?    If there is mild appendicitis, "who" can pontificate that it will not proceed into a full blown appendicitis?  Take out the appendix!

Doctor Cotton, my  suggestion was:  When confronted  with absence of recognizable findings, be aware that there are other right iliac fossa pathologiy involved like cecal bascule, (cecal volvulus is an anatomical overreach), recurrent cecocolic torsion and its "not weird variants"  that are evidence based ( read  and see pictures in the articles recommended) ureteral and psoas irritations, etc.  These are but a few problems to sleuth  for if the pain ever recurs.

Amyand's Hernia is a congenital cecocolic hyperrotation because the normally developed  cecum should rest at the right iliac fossa.  I had a case of an incarcerated cecum at the left inguinal canal ( with pictures also in the recommended article - weird?) . I was lead to  diagnose, cecopex, and relieve a patient with symptomatic mobile cecocolon seventeen years after a normal appendectomy because I searched for an alternative diagnosis for her continuing symptoms.

I think you are exposing the patient to increased surgical morbility risk (laparoscopy vs laparoscopic appendectomy) withou a patology to treat.

I would not recommend appendectomy hence the threshold for a diagnostic laproscopy for RIF pain needs to be increased as subjecting a patient to a surgical procedure may have morbidity if not mortality.

You should only do dx laparoscopy for RLQ pain if you think there is pathology there on imaging or H&P. Once you're in there, if you don't take out a normal looking appendix, you'll be back to take it out later. I've been surprised at the number of appendixes that looked normal at surgery that had PMN infiltrates on pathology-"early appendicitis."

I tend to agree with Dr. D'Souza's comments. You can not completely rule out appendicitis if the appendix looked grossly normal because there is enough data to support the microscopic evidence of appendicitis in a normal looking appendix. 

The same problem  is encountered in open abdomen also!. One literature referred to two groups of appendicitis - obstructive appendicitis which will come back for surgery. There was another non obstructive group which didn't go for recurrence and didn't require surgery. i have not taken out a normal looking appendix and never repented for it!

At times one is faced with the situation that there will be a need to remove even a normal looking appendix however that brings us back to clinical examination and also the CBC and to further add our threshold to operate should be high in case of women.

I  will remove the appendix if there is tenderness in the right iliac fossa,more especially if the symptoms has being recurrent .

Whilst the arguments for removing a normal-looking appendix are understandable, this undermines the logic for a diagnostic laparotomy. It must be explained to the patient that the appendix will be removed, unless other significant pathology is found, regardless of its appearance. Many patients may not wish to accept this logic. 

Furthermore the reported high risk of recurrence still does not mandate surgery. The same argument used to be made for diverticulitis, but now indications for sigmoid colectomy are very much more stringent. The difference, of course, lies in the relative simplicity (and lack of complication) of appendicectomy. No studies have been made on the application, however, of Sod's Law! If appendicitis recurs (but inflammation remains clinically localized, and not complicated by bacteraemia, constitutional upset or other factors are at play, a second, or even third course of antibiotics may still be reasonable.

It is important to involve the patient in this discussion, because it is ultimately him or her that will carry the consequences. The drawback of this approach is that social reasons for or against intervention may then predominate. 

I remember well, as an SHO in UK, how a well-to-do patient persuaded the consultant to perform surgery, which was strictly not necessary, because he had an important up-coming business job interview in Cape Town. He had been on a boat holiday in the Mediterranean and no-one noted that in fact he had a tinge of jaundice. He died of the post-operative consequences of liver failure induced by halothane used for his GA.

For RIF pain without obvious clinical and laboratory signs of inflammation, of course, antibiotics are probably not indicated, and a wait-and-see policy entirely appropriate. There is rarely need for an instant confirmatory diagnosis, as has been proven by institutions which have abandoned appendicectomy operations at night.

All this said, it is dangerous to be fixed in a belief. Learned opinion in 1900 was that 5 days should elapse to allow inflammation to settle before intervening to perform an appendicectomy. Sir Frederick Treves had become the authority on the subject, having performed over 2000 appendicectomies by 1902. In that year, Kind Edward VII fell ill and developed an appendicular abscess; two days before his scheduled coronation, Treves insisted on drainage, despite  the fact that many guests had already arrived. The big event had to be postponed several weeks. Treves had learnt how conservative treatment of his daughter two years earlier, when she was suffering flagrant appendicitis, led to her death. He did not want the guests to be attending a royal funeral... 

= A feather in your cap, Doctor Cotton.

Reading all the replies, I am as confused as I started.

The answers reiterate 2 things - better not to be in the position (a high threshold in doubtful cases. ) - while I wait I do not give antibiotics, ... ( in children that is); 

No one answer satisfy all patients, thorough history and examination with lab results make us tilt to one side or the other over years. Individualisation of treatment is inevitable in that situation.

I tend to follow the line of thought mentioned by Dr.Nigel D'Souza. However, I enjoyed reading Dr.Cotton's detailed discussion and interesting anecdotes from history !!

 EARLY APPENDICITIS:  Anatomically the appendix is layered like the small intestine except that that it has one end closed. Any obstruction can only be relieved one way because of this blind end. Viability is maintained and necrosis per strangulation  is difficult because it has its own mesentery. Obstructing it at any point will not immediately compromise its viability hence the colicky pains  do not abate until viability is completely lost. The superior mesenteric nerve reflects its prodromal symptoms until the colics become prominent.. After the inflammation [penetrates the serosa you now have physical peritoneal signs and may now see signs of serosal inflammation. .. So... If the appendicitis is caused by inflammation, you may have nonspecific  prodromal symptoms of indigestion (?) nausea, anorexia, epigastric discomfort, etc. but the patients do not consult  for this as  yet unless their threshold for complaining is low. Then comes the colicky pains when the stage of  the inflammation or obstruction is intruding and obstructing the  appendiceal lumen, then the appendix will try to expel it. If the inflammatory obstruction bursts and drains into the lumen or the obstructing fecalith ( whatever) is expelled, the pain subsides.  If at this time  antibiotics is given (it would have been equivalent to  not have given it) you  get the false impression that you cured the appendicitis!  Exploring at this time, you may not see gross changes on the appendiceal surface as yet unless the appendix is deformed by an obstructing lump. The WBC may be normal (early, aged. relative adrenal insufficiency, etc), CT scan may see a fecalith or obstructing body, No periappendiceal collection for the Sonogram. 

Who can diagnose with exclusive specificity an early inflammatory appendicitis that can spontaneously resolve without treatment or define an intraluminal obstructing appendiceal body?  One does not explore open or laparoscopically at this stage of a reversible appendiceal obstruction.  I do not give antibiotics because I may mask signs and symptoms but I watch the evolution of the symptoms. .

I always wait for the peritoneal signs (rebound tenderness) before I decide to operate. This means that the inflammation has proceeded through the wall and is now serosal.  I observe and examine this patient every four to six hours and watch exacerbating peritoneal signs.. After peritoneal signs appear there will be surface changes and when the colicky abdominal pains start to subside with the exacerbating rebound  tenderness, it means that the appendix is losing viability.

How can one know if a normal looking appendix is normal?  I have encountered "weird" materials and conditions like: paper clip, wooden toothpick, carcinoid, Meckel's, constricting Lane's band, intussusception of the appendix, and other non appendiceal conditions like Cecal Bascule, cecocolic torsion, diverticulitis of the cecum, etc etc etc.

All this hair splitting is tedious but all of you  trained surgeons must have a good reason to explore that right lower abdominal quadrant, so if you are already in, you will not raise the morbidity any much more. Perform that appendectomy because that the abdomen is "a temple of surprises", furthermore a  non-appendicitis etiology can be defined easier if the right lower iliac pain recurs in the future. .                                                               

We need not, if we have a clear consent from a well informed patient.