Removing the appendix using the same laparoscopic incisions as used for cholecystectomy is very feasible and safe. At the same time, the right ovary (or both) can also be examined.
Surgery is not a supermarket! Every operation you perform must have a surgical indication. If you are in doubt that with laparoscopic cholecystectomy you treat the 'right disease' I think you should stopp and reconsider the indication! It is true that with laparoscopic surgery we can do a lot of things simultaneous, but it is not correct to enlarge in this way indications, because even the most experienced laparoscopic surgeon can have in simple operations like appendectomy really dangerous complications. If this rare situation happens then you have to justify your indication! And what do you do then? If you do a combined procedure as you mentioned, what will you do, if the appendix has no signs of inflammation, but you see some mor or less cystic process of the ovary and you take a small piece for histology and open up the cyst. Afterwars you will receive an histilogy report of borderline ovarian cancer! This is not only theoretical, this happened and you changed detrimentally the prognosis of the patient.
In this scenario, I should have mentioned that the patient needs cholecystectomy. The patient has either gallstones or chronic acalculous cholecystitis (positive cholecystokinin test) with the usual symptoms of biliary colic including right-upper quadrant pain/discomfort and which is also present on preoperative physical exam. But in this hypothetical case, the patient ALSO has unsuspected pain/discomfort in the right-lower quadrant on preoperative physical exam. My question is: should the appendix be removed?
I think in this case you should discuss this situation with the patient. If you have intraoperative signs of inflammation of the appendix - no question to remove it. But if you find no signs of inflammation, no endometriosis, no rupture of a follicular cyst,etc. then you should openly discuss this situation with the patient . There are 2 possibilities: 1. To remove a seemingly innocent appendix as an individual procedure after informed consent ( often right lower quadrant pain of unknown origin) or th 2 postpone elective cholecystectomy to have a complete diagnostic workup, which depends on the clinical signs, the individual/family history etc.
I agree that the appendix should not be removed for convenience. The two surgeries should have separate considerations. Appendectomy would be indicated for inflammation or tumour and it would be unusual, though not impossible, for symptoms to be orverriden by those of the gall stones.
Perhaps the questions should rather be, "Is the RIF pain caused by the appendix?"; and if so, "Should a diseased gallbladder be removed when an appendectomy is indicated?"
I appreciate your comments.
more than 20 years ago, a female patient was scheduled for elective cholecystectomy several weeks ahead. In short order she suffered acute onset of right-lower quadrant abdominal pain and underwent emergency operation for acute appendicitis. Did I miss this? On her initial pre-operative examination did she have, in addition to discomfort over the gallbladder, definite discomfort albeit somewhat subclinical over the appendix area.? Did I make a careful enough examination? That case made me realize that I probably had missed the co-existing appendiceal problem - and should have scheduled her earlier to remove both organs.
Anyway, since that time I have been careful to address a possible "problem" appendix - since disease of the gallbladder and of the appendix are two of the most common surgical problems of the abdomen and could co-exist. So far I have encountered several cases of early acute disease (one carcinoid) and a preponderance of fecalith-filled and fibrosed appendixes - both the latter may cause discomfort. In each case I open and photograph the appendix in the OR since pathologists (or their assistants) rarely report these benign entities. Family history for appendicitis is over 70% in this series.
Any ovarian pathology is left intact - and demands an immediate or, if not available, a post-operative consultation with gynecology. Here, any images are very helpful.
Finally, treating any other source of abdominal discomfort (such as RLQ) should help to assure a pain-free postoperative result after patients undergo elective cholecystectomy.
I don't remove a normal looking appendix in patients with RLQ pain, while doing laparoscopic cholecystectomy. Laparoscopy is a good diagnostic tool and it should be utilized during any procedure.
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