M1702 A Macroscopically Normal Appendix Should Be Removed At Laparoscopy for Abdominal Pain in the Absence of An Identifiable Cause

Abstract

Introduction: Some authors recommend leaving a ‘normal' appendix in situ during laparoscopy for abdominal pain (1,2). We question the safety of this rational following a case where we adopted such practice. Three days later an inflamed appendix was removed at open appendicectomy in the same patient.We therefore sought to correlatemacroscopic assessment at appendicectomy with that of reported histological findings. Method: All appendix samples over a three year period (1/1/2003-1/1/2006) were identified. Patient notes were then reviewed with patient age, sex, surgical approach, grade of surgeon(s), operative and histological findings recorded. For comparison with surgical findings the histological diagnosis was taken as being most accurate. Results: 972 appendicectomies were performed. We obtained 876 case notes (90.1%). There was 100% congruity between surgeons and pathologists when perforation, abscess or gangrene of the appendix noted (n=235). When inflammation was the sole recorded finding 8.3% of cases (37/445) were reported as histologically normal. This false positive value rose to 46.6% (26/57) when surgeons used vague terms to describe inflammation such as catarrhal inflammation or congestion. 33.1% (47/139) of appendixes perceived to be normal at appendicectomy demonstrated histological signs of inflammation. For both inflamed and normal appearing appendixes the choice of operative approach (laparoscopic vs. open) or seniority of operating surgeon had no effect on the correlation between surgical and pathological findings. Of 16 neoplastic lesions (12 carcinoid, 3 adenoma, 1 adenocarcinoma) only 3 were identified at the time of surgery. 2 were incidental findings at elective surgery the remainder presented as acute appendicitis. A mass was palpable in the caecum of the third case. Conclusions: The ability of surgeons to correctly diagnose a normal or mildly inflamed appendix is poor. At laparoscopy to investigate acute abdominal pain, in the absence of other identifiable pathology, a macroscopically normal appendix should be removed. The ability to detect features of neoplastic lesions of the appendix is also poor. Consequently it is essential that histological assessment is performed on all appendicectomy specimens. As follow up is not routine for the majority of patients who undergo appendicectomy must be vigilant when reviewing histology reports. 1. Teh SH, O'Ceallaigh S, Mckeon JG,O'DonohoeMK, TannerWA, Keane FB. Eur.J.Surg. 2000;166:3889. 2. van Dalen R, Bagshaw PF, Dobbs BR, RobertsonGM, Lynch AC, Frizelle FA. Surg.Endosc. 2003;17:1311-3.