Acute appendicitis – is there still a place for active observation?

Abstract

We read the study of Akbar et al. with interest and have also noted the increasing enthusiasm for diagnostic laparoscopy in recent years amongst our colleagues. In a similar fashion to the authors, in clear-cut cases of appendicitis on initial presentation we leave the surgical approach (open or laparoscopic) to the discretion of the operating surgeon, but as a consultant firm we have generally employed the ‘active observation’1 approach (without computerised tomography) for the management of patients with suspected appendicitis with equivocal signs and symptoms, rather than performing diagnostic laparoscopy. Aware of our traditional approach in the face of the increasing use of diagnostic laparoscopy, we conducted a 9-month retrospective audit of patients admitted with suspected appendicitis under the care of the lead author (DJA) to assess our outcomes. In total, 38 patients underwent appendicectomy, performed via both open and laparoscopic approaches, resulting in a 5% negative appendicectomy rate (two patients). No additional or alternative diagnoses were made at the time of surgery, and no patients discharged with a diagnosis of non-specific abdominal pain were re-admitted with appendicitis. Bearing in mind reported re-admission rates of 33% in patients undergoing a negative appendicectomy,2 as well as the small but real risks of diagnostic laparoscopy, such as major vascular injury or significant port-site bleeding,3 we are happy to continue our approach to managing patients with suspected appendicitis without laparoscopy used solely as a diagnostic tool.