Page 15 - World Journal of Laparoscopic Surgery

E Jane H Turner, Robin Lightwood

In a patient undergoing laparoscopy for right iliac fossa When asked whether there were sufficient guidelines on
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pain with an uncertain diagnosis, if the appendix appears normal this topic 68% said no, 6% said yes and 5% were unsure. 16%
and there is no other pathology do you remove the appendix? said that it was a matter for common sense rather than guidelines
If yes, is this for any of the following reasons? and felt that clinical judgment was needed as opposed to
• To prevent future appendicitis guidelines. 5% felt that the evidence was contradictory making
• For possible endoluminal appendicitis (inflammation of the it difficult to issue guidelines.
mucosa of the appendix with an externally normal appendix)
• To avoid future confusion for the patient as to whether or DISCUSSION
not they have an appendix Of those who responded to the questionnaire 98% were
• Other (please specify). currently performing laparoscopic appendicectomy. However
Do you feel that there are sufficient clear guidelines on this only 23% of the population surveyed responded to it. Most
topic? If so from what source? often laparoscopy for right iliac fossa pain is performed in women
who may have gynecological conditions which can mimic
RESULTS appendicitis.
61% of surgeons always remove the appendix and the most
135 (23%) responded to the questionnaire. 134 answered all common reason given was the possibility of endoluminal
questions, of which 98% currently perform laparoscopic appendicitis followed by the avoidance of future confusion as
appendicectomy. 62% perform laparoscopy for right iliac fossa to whether the patient has an appendix. Both these arguments
pain mostly in females and 4% only in females. 4% perform are backed up by data in the literature. However 44% remove an
laparoscopy mostly in males and for 28% sex does not affect appendix to prevent future appendicitis for which there is no
the decision. 2% were unsure of the sex distribution of their evidence.
patients. 68% felt there were no adequate guidelines for surgeons to
61% of surgeons remove a macroscopically normal appendix follow. However since the available evidence is contradictory it
at laparoscopy for right iliac fossa pain of unknown origin and does not at present allow the formulation of clear guidelines.
26% do not. 13% of surgeons do not commit either way. The 16% who said that clinical judgment was more important
Of those removing a normal appendix the most common are justified in their view.
reasons given were the possibility of endoluminal appendicitis This leaves the question of what should be done to satisfy
(87%) and to avoid future confusion as to whether the appendix the demand for clear guidelines found in this survey. A large
had been removed (64%). Some (44%) remove a normal appendix prospective randomized multicenter clinical trial would provide
to prevent future appendicitis and 38% gave various other the evidence but would prove logistically difficult and if patients
reasons (Table 1). were to be blinded to their operation an accessible data base
would be mandatory. Possibly a more feasible study (admittedly
Table 1: Reasons for removing a ‘normal’ appendix in the groups with a lower level of evidence) would be a large multicenter
that always remove or sometimes remove the appendix study on the long-term follow-up of all patients who have had
a normal appendix left in situ after diagnostic laparoscopy for
Reason Percent
right iliac fossa pain as previous similar studies have low
Endoluminal appendicitis 87 numbers of patients making it difficult to form conclusions. 18-20
To avoid future confusion as to whether it was 64 Meanwhile it is suggested that in the absence of guidelines the
removed options are discussed with the patient before the procedure
Prevention of future appendicitis 44 and that they are made fully aware that there are arguments for
Recurrent pain to clarify diagnosis 7 both removing and leaving the appendix.
To remove as a future diagnosis of nonspecific 6 In conclusion, this study shows that there is a lack of
abdominal pain consensus in the management of a normal appendix found at
Continuing pain 6 laparoscopy for right iliac fossa pain and most surgeons feel
Ease of procedure/Doesn’t add to morbidity 5 that guidelines would be useful. In the absence of guidelines
Patient satisfaction 3 the options may be discussed with the patient before their
Fecolith giving rise to colic 3 operation as part of the consent procedure.
To exclude other pathology 3
Same rationale as open 2
Training of juniors 1 ACKNOWLEDGMENTS
Surgeon more content 1 We would like to thank Jenny Treglohan and Michael Parker
Possible missed diagnosis 1 (ALSGBI) for their invaluable assistance with the questionnaire.

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