DOI: 10.1097/SLE.0b013e3181b7196d
,
Issn Print: 1530-4515
Publication Date: 2009/10/01
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Excerpt
In the acute setting, there is a negative appendicectomy rate of 22% for laparoscopic and 15% for open procedures.1 The question in the literature remains, whether a “normal” appendix should be left at laparoscopy for acute appendicitis.1–3 Macroscopic assessment at laparoscopy has a false-negative rate of 3% in a predominantly pediatric population according to a large meta-analysis.1 Traditionally the appendix was always removed after a gridiron incision to avoid diagnostic confusion in the future. Laparoscopy has shifted the goalposts and has improved outcomes especially where diagnostic doubt exists. If a diagnostic laparoscopy is undertaken in the acute setting, it has been shown that patients mzay benefit from removal of a normal looking appendix, provided there is no increased morbidity or mortality.4 However, in this context, laparoscopic appendicectomy is not without risk and there is a reported 6.5% conversion and 4.7% complication rate.1
In patients with chronic right iliac fossa pain, the case for routine appendicectomy where no other pathology is found at laparoscopy seems to be stronger. Although a correlation between outcome and intra-appendiceal pathology has been demonstrated, the recommendation for routine appendicectomy is not yet standard practice.5
Confusion also remains over the significance of endoappendicitis and whether this represents evolving appendicitis. The fact that a significant number of macroscopically normal appendices are left intact without requirement for relaparoscopy/laparotomy is testament to the irrelevance of this finding. In a published necropsy study, 22% of infants who died of unrelated causes showed signs of subacute appendicitis.6
On the basis of current data, it would seem entirely reasonable to leave a macroscopically normal appendix behind. The only proviso is that a surgical team with adequate skill level make that decision and, if so, negative appendicectomy rates will be minimized as should relaparotomy for a missed appendicitis.
