Page 14 - World Journal of Laparoscopic Surgery

Management of the Normal Appendix during Laparoscopy for Right Iliac Fossa Pain
World Journal of Laparoscopic Surgery, May-August 2009;2(2):15-17

Management of the Normal Appendix during

Laparoscopy for Right Iliac Fossa Pain

E Jane H Turner, Robin Lightwood
Department of Surgery, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, United Kingdom
Correspondence: E Jane H Turner, Department of Surgery, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH
United Kingdom, E-mail: ejhturner@btconnect.com

Abstract Many patients are unsure as to whether their appendix has
The advent of laparoscopic surgery raises the question of what to do been removed. Murphy et al 2001 reported that of 176 patients
with a normal appendix at laparoscopy for right iliac fossa pain of who had laparoscopy for right iliac fossa pain 61% were under
uncertain origin. We assess the views of all members of the Association the misapprehension that their appendix had been removed. 9
of Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI) via They suggest that the removal of a normal appendix adds little
means of a survey. Of 135 responses to the questionnaire 61% of to the morbidity of laparoscopy and that the appendix should
surgeons remove a macroscopically normal appendix and 26% do be removed regardless of its appearance at laparoscopy. This
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not. 13% of surgeons do not commit. Of those removing a normal
appendix the most common reasons given were the possibility of is supported by studies where incidental appendicectomy has
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endoluminal appendicitis (87%) and avoiding future confusion as to been performed during total abdominal hysterectomy and
whether the appendix had been removed (64%). When asked whether cystectomy. 12 However other studies report increased
there were sufficient guidelines on this topic 68% said no, 6% said yes complications following the removal of a normal appendix. 13-17
and 5% were unsure. 16% said that it was a matter for common sense Data on follow-up of patients who have not had their
rather than guidelines and 5% felt that the evidence was contradictory. appendix removed suggest that it is safe to leave a normal
This study highlights a lack of consensus in the management of a
normal appendix found at laparoscopy for right iliac fossa pain and appendix in place. Van den Broek et al 2000 reported a
demonstrates most surgeons feel guidelines would be useful. In the prospective study of 109 diagnostic laparoscopies for suspected
absence of guidelines the options may be discussed with the patient appendicitis where the appendix was left in place if it looked
before operation. normal. There were 9 readmissions with only one requiring an
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Keywords: Laparoscopic appendicectomy, normal appendix, appendicectomy. Van Dalen et al 2003 reported a prospective
diagnostic laparoscopy randomised study of 63 patients with 10 years follow-up.
Patients found at laparoscopy to have a normal appearing
INTRODUCTION appendix were randomised to laparoscopy + open
appendicectomy or laparoscopy only. No patients in the
The lifetime risk of developing appendicitis in the USA is 8.6% diagnostic laparoscopy group developed appendicitis
1
for men and 6.7% for women. In the era of open subsequently. Teh et al 2000 reported that of 41 patients who
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appendicectomy15-30% of appendices removed were normal. 2,3 had laparoscopy alone for a normal appendix 13 continued to
Scoring systems have been put forward as an aid to diagnosis. 4 have symptoms and 2 eventually had their normal appendix
Ultrasound is user dependent and while computed tomography removed. 20
may be diagnostic it involves exposure to radiation. In this study we assess the practice of members of ALSGBI
There is a lack of consensus in the literature over what to and their views on whether guidelines are desirable.
do with a normal appendix. The main argument for removing a
normal appendix is that endoluminal appendicitis may not be MATERIAL AND METHODS
recognized at operation leading to concern that an abnormal
appendix is left in place. This may result in the need for A literature review was performed using the Pubmed database
5,6
subsequent appendicectomy. Endoluminal appendicitis is and searching using the words laparoscopy and normal
reported in 11-58% of apparently normal appendices appendix.
removed. 5,7,8 Navez argues that since endoluminal appendicitis Following questionnaire was sent to 588 members of
is confined to the mucosa it does not cause localized pain and ALSGBI:
questions whether there is progression to suppurative Do you perform laparoscopic appendicectomies?
appendicitis. 7 Approximately what proportion of these are in females?

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