In such a situation, I would perform an appendectomy if only my preoperative diagnosis was acute appendicitis. Otherwise I do not add an appendectomy to any other procedure.

In case that the patient had multiple visits to the ER due to pain in the right abdomen, an appendicectomy could help in reducing the differential diagnosis problem. In other cases a normal appendix should be left in place.

In cases of surgery for gynecological cancer. There is a 10% risk of finding mets or primary appendicular cancer in a normally looking appendix. Our group have a paper in press about that, will attach it to this answer when I have it

In case of laparoscopy performed for abdominal pain (either acute or recurrent) with with no evidence of any intraperitoneal condition I would do appendectomy even if the appendix looks normal. In fertile female I would do appendectomy for a normal appearing appendix even if another peritoneal condition has been found

In case of performing laparoscopy for suspected acute appendicitis removal of the appendix should always be done. Critical review of the literature shows that removal of the appendix does not increase morbidity compared to simple diagnostic laparoscopy. Retrospectively about 17-19% of "normal" judjed appendix at operation were subsequently found to be inflamed on histological examination, sometimes with local inflammation. So my opinion is to perform appendectomy in case of clinically suspected acute appendicitis to decrease risks of misdiagnosis of an early stage ot the disease.

Tis easy in my mind: In a pt with RIF pain who proceeds to laparoscopy, in the absence of any pathology I always do an appendicectomy (esp if pre-op increased WCC/CRP). If there is other obvious pathology e.g. haemorrhagic ovarian cyst, then I leave the appendix.

The reason to remove it in the absence of other pathology pathology is:

a) there may be mucosal-only inflammation at that stage (esp if midgut pain only and hence in very early performed laps)

b) even if bloods are normal there may be a faecolith causing appendicular colic which may completely obstruct the lumen and progress to acute appendicitis.

If there is an obvious other pathology, I'd leave the appendix alone in a laparoscopic case. If conversion to open is done via a Lanz for another procedure e.g. Meckel's then naturally I'd take out the appendix to avoid future confusion.

This seems to be the mainstay of practice in the (generally conservative) UK.

BW,

John.

I agree with Feras Abu Saadeh, of course in metastatic cancer to ovaries (appendiceal mucinous adenocarcinoma) clearly appendicectomy is necessary. I was talking about emergency diagnostic lap cases for the acute abdomen.

I agree with John, in the presence of obvious other pathology then the appendix stays but if nothing, or just free fluid in the pelvis as we often see then it goes.

I explain to the patients this is for 3 main reasons.

1. Sometimes there is mucosal appendicitis without obvious serosal disease.

2. They can then never get appendicitis in the future - does this negate 'grumbling appendix/appendicular colic? I don't think we know

3. If they do return with RIF pain we can rule out appendicitis (although 1 in 25,000 people have a duplex appendix)

Cheers

Steve

Exactly, thanks Steve. Presumably if they are the rare 1 in 25, 000 we'd deal with the second appendix then and there.

Was interesting to hear the quite different management and increased use of CT scanning in young patients (mainly female) in the Netherlands at ASGBI last year (2012 in Liverpool).

Steve is also spot on, though it may be a touch cynical, for young frequent attenders to A&E with RIF pain, lap appendix often stops the problem becoming "surgical".

JB.

I agree with Doctor Massimo Chiarugi.

Especially in female patients, an appendectomy even in appendix that apparently is not inflamed, reduces the numbers of future surgical consults for abdominal pain, that in a half of cases are related to gynecological problems

I agree with others that in women with chronic, right lower quadrant pain, examination of the appendix is warranted at the time of laparoscopy. I favor removing the appendix in these patients, regardless of the presence of any pathology, due to the frequent pathologic evidence of inflammation or microscopic endometriosis. What isn't clear to me is whether these findings support a direct cause and relationship to the patient's presenting symptoms. Clearly some patients improve and it is nice to remove potential appendicitis from the differential if she returns with pain.

If the appendix has endomtriosis implants

In pediatric surgery, a prophylactic appendicectomy is indicated only in bowel malrotation but it is common to do this in patients that have been operated on because of abdominal diseases 2 or more times.

From a GYN perspective there are additional considerations for the removal of the appendix. The following recommendations are suggested.

1. Appendectomy is indicated in cases of epithelial ovarian cancer, mucinous ovarian neoplasms and pseudomyxoma peritonei. (II-3A)

2. Appendectomy may be considered in cases of anticipated abdominal or pelvic radiation or where extensive pelvic or abdominal surgery may incur severe postoperative adhesions (III-B).

3. Removing the normal or abnormal appearing appendix may be considered in patients with chronic pelvic pain and/or right lower quadrant pain as appendiceal pathology is common in this patient population (III-B).

4. Appendectomy may be considered in cases of endometriosis irrespective of a normal or abnormal appearing appendix due to the high association of pathology. (II-1A)

5. Appendectomy at the time of ovarian endometrioma resection should be considered as this finding is associated with deeper intestinal disease (II-2B).

6. Appendectomy may be performed in a safe, timely and cost effective manner in the hands of a properly trained gynaecologic surgeon or alternatively by a consultant general surgeon(II-3B).

Table 1: Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventative Health Care

Quality of Evidence Assessment* Classification of Recommendations‡

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in the category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

A. There is good evidence to recommend the clinical preventive action

B. There is fair evidence to recommend the clinical preventive action

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D. There is fair evidence to recommend against the clinical preventive action

E. There is good evidence to recommend against the clinical preventive action

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making

Thank you Dr Aanning for raising an important question, which is always a subject of dispute.

In a patient presenting with right iliac fossa pain, when no other cause to account for the pain can be identified, I will remove the appendix even it appears macroscopically normal.

The paper published by Wang et al. in The Lancet is very useful in understanding the pathology of appendicitis at the cytokine level.

Wang Y, Reen DJ, Puri P. Is a histologically normal appendix following emergency appendicectomy alway normal? Lancet. 1996 Apr 20;347(9008):1076-9.

Best wishes

BM Shrestha

.

Dr Leyland,

Some very interesting points.

I would bet however, you could count one hand the gynaecological surgeons in the entire UK who would remove an appendix. For essentially legal reasons. So much so, I have been called, whilst 'on call', to a gynaecological laparotomy, just to remove an appendix which had become mangled in a pyosalpinx. In fairness I would equally never perform an unexpected ovarian procedure without seeking OBGYN consult

Appendicoliths are a clear indication even if incidental for removing the appendix

Article Appendicoliths and appendectomy in the pediatric population

Here in Canada many Gynaecologists can and do remove the appendix when indicated if they have been trained to do so. Our national guidelines are designed not so much to push them to perform the procedure but to be aware when appendectomy should be considered during GYN procedures. As noted, there are a number of indications and we would hope that an appropriately skilled surgeon of any specialty should be enlisted to perform the procedure when indicated.

All your responses are very appreciated! Older published reports of "en passant" appendectomy studies appear to suggest an increased incidence of abnormalities in incidentally resected appendixes. Kelly, in his treatise (1905) on the appendix, said, "Not infrequently gall-stones and cholecystitis have existed independently of the appendiceal disease....When the association of the two ailments is not recognized, and only one is cured at the first operation, a second operation has sometimes been necessary for the complete relief of symptoms." (p.426) Is there any study linking the tendency for gallbladder disease to disease of the appendix - familial or otherwise?

in my eyes incidental appendectomy has to be associated with the cause of laparoscopy if it looks like with somekind of disease has to be removed. If it is associated with a lengty or complicated primary procedure and looks normal has to be avoided. I fully aree with prof Leyland and his table. thanks to this nice discussion

I usually do it as rutine when I perform surgery on the lower quadrant, to prevent surgeries from causes related to it, for example in endometriosis or ovarian cyst.

All of the answers have been written in the above discussion. Thanks for the question and a really valuable answers from all physician around the world. God bless you all.

At first, I'd like to say thanks for a gorgeous article by Dr.Paya and co-workers on the matter of the discussion!

At second, the lack of theory gives rise to surplus of practice. Coincidence the acute appendicitis and appendicoliths is commonly known, but, to the best of my knowledge at any rate, I met no study of the nature of these appendicoliths, nor about the fate of them in uninflammated appendix during a some stretch of time. So, noone seemingly knows why, how, and with which velocity the appendicoliths are forming, and why and how these 'stones' cause the obstruction of the appendix lumen. Can they ('a-liths') be occured under the normal conditions?

Appendicoliths (fecaliths of the appendix) might simply be the result of decreased peristalsis of the appendix resulting in incomplete emptying of its mucosal secretions. Over a period of time these concretions grow in lamellar fashion that may lead to luminal obstruction of the appendix. Could appendiceal colic be the spasm of an appendix attempting to expel such a concretion(s)? Could this be familial?

Precisely!

But why does the decreased peristalsis of the appendix occur in one person and does not in others?

What qualitive and quantitive changes of the appendiceal peristalsis can lead to the appendicoliths development?

Can we assume that the appendicoliths are almost the same as gallstones in the gallbladder lumen (the appendicoliths=the irreversible pathological alteration), so that, if being detected, they are an indication for the appendix elective removement?

On the opposite way, can the appendicoliths be expelled and resolved by the appendix itself, so to say, naturally, are they reversible?

Can they be removed via the fibercolonoscopy, by an expirienced endoscopist?

How long it takes for the appendicolith to occur: hours, weeks, or years?

Who did investigate the appendicolith structure? Is it really lamellar like a gallstone?

What kind of mucous does the appendix secrete for the fecalith to make up?

Can the appendicolith development be prevented by medication or diet?

And so on, and so on..

Three additional comments:

1) Appendicoliths or fecal concretions are often rinsed away when the appendix is prepared for examination by the pathologists in our area. This means that appendicoliths are not always reported in the gross examination of the appendix and often fail to be documented in the final pathology report.

2) Some pathologists even feel that if a fecal concretion of the appendix can be crushed between the fingers it is not an appendicolith but merely extraneous fecal debris.

3) Virtually all surgeons in my area do not open the appendix at operation to document its luminal contents. They simply send the un-opened and un-examined appendix directly for pathological examination.

These three factors lead me to believe that the role of appendicoliths in acute appendicitis and in appendiceal colic (chronic right lower quadrant abdominal pain) is very under-appreciated and under-estimated.

Agreed completely as to each point of your remark. Seemingly, all is the same about the appendicoliths everywhere.

However,

1) Who did documented a putative connection between an appendicolith transient incarceration and appendiceal colic by the ultrasound investigation and other techniques? Without such image technique data, the likely connection is - alas! - not more that one of many probable (and speculative) explanations.

2) I have a strong feeling that the appendicoliths are waiting for their hour of investigations to come and exclude the acute appendicitis from everyday surgical activity, much as the same as the peptic ulcer disease novadays in the Western countries.

3) The appendix is one of the most unlucky organs that is ever 'under suspition' of a surgeon (and a gynecologist also). Nobody removes a healthy eye or finger looking forward 'possible alterations to come' in future years or decades, but anyone readily removed 'a lily white appendix', the important immune organ between the small and large intestines, at least once in his/her practice. Of course, the immediate consequences of the appendectomy are not so disasterous as ones of the papillosphincterotomy may be, but what may be the remote? Strangulation in the periceacal adhesions are commonly known; the colon cancer were described rarely, but it seemingly reliable data. As for alterations of the mucosal immunity of the intestine; bowel movements alterations; the small intestine bacterial overgrowth syndrome; and gallstone disease, who have eximined these after the 'incidental' appendectomy?

4) I can recollect rare, but remarckable cases of 'lily white gallbaldders' removement under various sophisticated reasons like 'possible syphonopathies', and so on, in the era before the ultrasound examination (and which completely disappeared after the medical ultrasound invention). The same may now going on with the appendix, and what I call "lack of proper theory'.

Preventive appendectomy is also indicated in Pediatric Surgery during intestinal Malrotation corrective procedure, to prevent appendicitis in atypical location and avoid disastrous consequences.

And when we find a Meckel's diverticulum?

we are discussing about incidental Appendicectomy,one of the very commonly performed procedure in the laparoscopic era.Though evidence has always been conflicting,but practice is going on.chronic right iliac fossa pain,malrotation and during Ladd's band release it is better to do incidental appendicectomy.

The most important factor to be considered is the reason for conducting a laparoscopy

in any case malrotation is an indication for apendicectomy during laparoscopy and it may also be considered in chronic pain in right iliac fossa to rule out apendicitis if the pain recurs

As It is believed that the Appendix serves no useful function but can create trouble at times. So it is always recommended to remove when you open the abdomen for any reason. This may be questionable from scientific view point but In developing countries like India this is economic too.

Sorry guys, I would not take out the appendix in any abdominaal surgery, but I would do it if I operate for an abdominal pain, even if it looks normal. I find no reason to add a morbidity factor in any operation perform, but I do think that it should be extracted to rule out its role in any present or future abdominal pain reccurence.

I think that even in the absence of strong evidence of literature, appendectomy during laparoscopy for other diseases, it is highly advisable in young women who have continuous access to emergency care for nonspecific pelvic symptoms. In my experience after an appendectomy performed for an apparently non-pathological appendix, in almost all of the patients with nonspecific pelvic symptoms, problem was definitively resolved without further access to the emergency room, in addition, in approximately 30% of appendices removed without grossly visible alteration, by microscopic examination some appendix alteration that justified a surgical excision were found

I will agree with Dimitrios Dardamanis.

"If a normal-appearing appendix is identified at the time of surgery, should it be removed? This question has been raised again after the introduction of the laparoscopic approach; consensus is lacking on this point. Although it is difficult to know how many patients benefit from this practice, removal of the appendix adds little morbidity to the procedure. In some cases, pathologic abnormalities that were not apparent on visual inspection are identified. Our practice is to remove the appendix and perform a thorough search for other causes of the patient's symptoms (CRUCIAL POINT - SYMPTOMS i.e. ABDOMINAL PAIN). We specifically examine the small intestine for Meckel's diverticulum and Crohn's disease, the mesentery for lymphadenopathy, and the pelvis for abscesses, ovarian torsion, and hernias. If findings of Crohn's disease are observed and the base of the appendix is not involved in the inflammatory process, appendectomy is advised to prevent future confusion. If, however, the base of the appendix is involved in the inflammatory ileitis process, it may be safer to avoid appendectomy to minimize fistula formation."

[Townsend: Sabiston Textbook of Surgery, 19th ed.]

The indications for elective incidental appendectomy are best described by the few contraindications: active Crohn's involvment, additional technical risk or compromise (e.g., beyond the surgical field, difficult dissection due to hostile abdomen, etc), time-constraints (e.g., unstable patient on the OR table), and likely a few others. The two main reasons to support the incidental appendectomy are: (1) low risk compared with future anesthesia for acute appendicitis episode (especially when patient reaches age greater than 70 years), and (2) the presence of abdominal or pelvic surgical scars will often lead physicians/surgeons in the future to assume that the appendix was removed during the previous operation (even it it wasn't)! In general, if you can reach it, remove it.

It is my opinion that there are no surgical school preventive interventions but you need to excision of a normal appendix in a context of diffuse abdominal pain without possibility of defining the cause morbidity without affixes sine causa with the high probability of not resolving the painful symptoms . during a laparoscopy is removed only if it is pathological

I agree with dr. Bowman, it should be removed if there are no contraindications for it.

I agree with Dr. Bowman. Additionally it is eliminated as a differential diagnosis in any future symptomatic puzzling diagnostic entities at the right lower abdominal quadrant.: e.g. Cecocolic torsion, Cecal Bascule, etc.

There was a Lancet study (can't remember which) that actually showed that all surgeries involving laproscopy in the abdomen should end with an appendisectomy as the risk of an appendicites event after a surgery (clean-contaminated) is higher than those with a virgin abdomen.

Just thought I share with you guys.

Arvinder

Incidental appendicectomy used to be a routine during any major abdominal surgery in young and middle -aged patients. This recommendation fell out of favour in recent years and I feel there is no indication to remove a normal-looking appendix during any laparoscopic procedure. One exception is in diagnostic laparoscopy performed for chronic RIF pain (in young females usually) in absence of any gynaecological causes and gegative US, CT scan and colonoscopy. In such situation, the appendix is removed laparoscopically even if macroscopically looked normal.

I cannot locate the Lancet article mentioned by Dr Singh, but two recent informative reviews with full texts are available at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015983/pdf/jsls-13-3-376.pdf

http://www.jogc.com/abstracts/full/201301_Gynaecology_1.pdf

I think the only benefit of removing a grossly normal looking appendix would be in cases of chronic abdominal pain or extensive adhesions or in cases malrotated gut , otherwise it is best left alone.

I totally agree with Dr.Meshikhes comment. After all, the accepted negative appendectomy rate worldwide is about 15% (most studies quote 5-24%).

This is one of the typical situations in where most surgeons (me included) do not follow the scientific evidence. In fact, no papers advice for taking off a normal appendix, although the current practice is to do this in order to reduce future diagnostic dilemma. Moreover, it seems hard to me to justify some unnecessary laparoscopy in case of suspected appendicitis. However, this could lead to some malpractice claims in case of incidents. On the other hands, I strongly discourage to touch a normal appendix in course of surgery for different disease.

Addiss classic article "The Epidemiology of Appendicitis and Appendectomy in the United States" (Am J Epidemiology 1990 Vol 132 no 5 pp 910-925) reports the lifetime risk of acute appendicitis for adults (per 10,000 population) varies from 550 for age group 20-24 to about 100 for age group 60-64 (or 1 percent).The risk of death from general anesthesia is 1-2 in 10,000 for even healthy adults and higher in older adults with comorbid chronic conditions. The risk of complications/mortality from incidental appendectomy (at abdominal operation in patient already under anesthesia) is minimal compared with the lifetime risk of acute appendicitiis in the adult population. This quantification of benefit for incidental appendectomy does not account for potential confusion of future surgical consultants when faced with a patient with abdominal pain and abdominal surgical or laparoscopic scars.

Addiss article full text at:

http://us.venaxis.com/wp-content/uploads/2013/01/Epidemiology-of-Appendicitis.pdf

Normal appendix should not be excised if indication for surgery is other, than appendix or related disease. However, if the patient is operated for suspected appendicitis and appendix appears normal, it will have histological evidence of acute inflammation in up to 20 percent of cases

1. When an ovarian pseudomyxoma has been resected because primary ovarian PM does not exist. It comes usually form the appendix, even if looking normal.

2. If mesenteric or livers mets from carcinoid tumor is found when no primary tumor has been identified

Sorry but even if there is no clinical and scientific based indication for removing the appendix - I still remove it simultanly during total cystectomy - I have spent three nights in the OR repairing the ureter after surgical laparotomy.because of pain in the right lower abdomen. In fourteen years there was only one complication, which could have been avoided, if the coecum would has been mobiliced and properly fixed in the small pelvis.

To consider the reverse of this situation, I have been involved in the case of RIF pain in a young female 4 days post Caesarian section, with equivocal features on CT imaging. Laparoscopy revealed generalised fibrinous exudate over the peritoneal surface with subjectively more in the RIF and pelvis. The appendix was removed anyway, the histology if which did not show appendicitis. The diagnosis was thought to be vernix caseosa peritonitis from spillage during Caesarian section. The patient made a uneventful recovery.