Should the macroscopically normal appendix be removed during laparoscopy for acute right iliac fossa pain when no other explanatory pathology is found?

BACKGROUND: Acute appendicitis remains the most common surgical emergency and although diagnosis should be made on clinical grounds, sometimes this can be difficult. Laparoscopy has gained increasing favour as a method of both investigating right iliac fossa pain and treating the finding of appendicitis. The aim of this study was to determine the accuracy of intraoperative diagnosis of appendicitis. PATIENTS AND METHODS: Records of all patients who underwent laparoscopy for possible appendicitis at the Norfolk and Norwich University Hospital over a 1-year period were reviewed. Notes of those patients who underwent an open appendicectomy were also reviewed for comparison. Intraoperative findings were recorded, as were the subsequent pathologic findings. RESULTS: Over the 1-year period from September 2005 to September 2006, 355 operations for suspected appendicitis were performed. In 277 (78%) cases, these were performed laparoscopically. Seventy-three out of 78 open appendectomies were confirmed as appendicitis. Only 1 of these was not macroscopically evident to the surgeon. The appendix was removed in 259 of the 277 laparoscopic procedures. Correct intraoperative diagnosis was made in 217 (84%) of removed appendices, 12 (29%) of the appendices thought to be macroscopically normal and removed were found to be appendicitis after histologic examination. Eighteen patients undergoing the laparoscopic procedure had their appendix left in situ due to normal appearance; none had represented at 6 months postsurgery. CONCLUSIONS: Laparoscopy may aid in the diagnosis of acute right iliac fossa pain. However, intraoperative diagnosis is not easy with almost one-third of apparently normal appendices being inflamed histologically. We would therefore advocate the removal of a normal looking appendix in the absence of other explanatory pathology.

The value of routine histopathological examination of appendicectomy specimens.

BACKGROUND: Appendicectomy specimens removed from patients with suspected acute appendicitis often appear macroscopically normal but histopathological analysis of these cases may reveal a more sinister underlying pathology. We evaluated histopathological reports of 1225 appendicectomy specimens at the Norfolk and Norwich University Hospital (NNUH) over the past three years. METHODS: Histopathology reports for all appendices analysed at the NNUH between March 2003 and March 2006 were reviewed by examination of the case notes. The analysis focussed on the confirmation of acute appendicitis, incidental unexpected incidental findings other than inflammation, whether these abnormalities were suspected on gross examination at the time of surgery, and the effect on patient management and prognosis. RESULTS: The histopathology reports disclosed a variety of abnormal incidental lesions. Of the 1225 specimens, 46 (3.75%) revealed abnormal diagnoses other than inflammatory changes. Twenty-four (1.96%) of these were clinically significant and affected further patient management. Only two of these (0.16%) were suspected on macroscopic examination intra-operatively. CONCLUSION: Twenty-four of the 1225 specimens (1.96%) had an impact on patient management or outcome and were not suspected on macroscopic examination at the time of surgery. These would have been missed had the specimens not been examined microscopically. The intra-operative diagnosis of the surgeon is therefore unreliable in detecting abnormalities of the appendix. This study supports the sending of all appendicectomy specimens for routine histopathological examination.