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.