Videos provided by Teresa Tam, MD, and Gerald Harkins, MD
CASE: Should appendectomy be included in total
A 39-year-old mother of two continues to experience severe dysmenorrhea and persistent menorrhagia despite undergoing endometrial ablation 2 years earlier. Her obstetric and gynecologic history is remarkable for a diagnosis of chronic pelvic pain, endometriosis, and failed endometrial ablation. Both her children were delivered by cesarean, and she has undergone tubal ligation. She requests hysterectomy to address the dysmenorrhea and menorrhagia once and for all.
A pelvic exam reveals an anteverted, 10-weeks’ size uterus with no adnexal masses or tenderness. After extensive discussion of the surgical procedure, the patient signs a consent for total laparoscopic hysterectomy.
Would you recommend appendectomy, too?
Prophylactic removal of the appendix during a benign gynecologic procedure is known as “elective incidental appendectomy.”1 Incidental appendectomy at the time of cesarean delivery was reported initially in 1959.2 Subsequent studies of removal of a normal-appearing appendix at the time of gynecologic surgery have met with considerable debate. Proponents argue that removal of the appendix at the time of abdominal hysterectomy does not increase operative time or postoperative morbidity. More important, it does prevent future appendicitis.3-5
Some surgeons disagree, citing an increase in operative time, hospital costs, and patient morbidity as reasonable concerns. They also note that appendectomy requires an additional surgical procedure, which could increase the risk of infection and other complications and lead to adhesion formation.
Advantages of incidental appendectomy include technical ease, low patient morbidity and mortality, and significant diagnostic and protective value.6 It also prevents conflicting diagnoses, especially in patients who have chronic pelvic pain, a ruptured ovarian cyst, or endometriosis. Other patients likely to benefit from elective incidental appendectomy are those who are undergoing abdominal radiation or chemotherapy, women unable to communicate health complaints, and those who are planning to undergo complex abdominal or pelvic procedures that are likely to cause extensive adhesions.1
In this article, we describe the rationale behind this procedure, as well as the technical steps involved.
The laparoscopic approach is preferred
Appendectomy is commonly performed laparoscopically. Semm first described this approach in 1983.7 Several studies since have reported that incidental laparoscopic appendectomy is safe, easy to perform, and should be offered to patients undergoing a concomitant gynecologic procedure.8-10 Laparoscopic removal of a normal appendix does not add morbidity or prolong hospitalization, compared with diagnostic laparoscopy. A large study drawing from the Nationwide Inpatient Sample (NIS) database found laparoscopic removal of the appendix to be associated with lower mortality, fewer complications, shorter hospitalization, and lower mean hospital charges, compared with open appendectomy.11 The same study found laparoscopic appendectomy to be the procedure of choice in both perforated and nonperforated appendicitis.
Overweight and obese patients also may benefit from the laparoscopic approach because it avoids problems associated with an open incision, such as the need for abdominal wall retraction, a longer hospital stay, and a risk of wound infection, compared with smaller incisions—especially in this high-risk population.12
Cost is another issue. Any prolonged surgical time and higher medical costs required for incidental appendectomy decrease as surgical proficiency and experience rise. The concomitant performance of endoscopic procedures can also reduce the risk associated with anesthesia for reoperations.
There is compelling evidence that elective appendectomy is beneficial in patients who have endometriosis. Endometriosis of the bowel has been reported in 5.3% of all histologically proven endometriosis cases, with appendiceal endometriosis found in approximately 1% of women with endometriosis.13 Despite the low prevalence (2.8%) of appendiceal endometriosis,14 some studies reported a high incidence of appendiceal endometriosis when incidental appendectomy was performed. Patients who report right lower quadrant (RLQ) pain, chronic pelvic pain, and ovarian endometrioma had the highest incidence of abnormal histopathologic findings.15-17 Because most women with endometriosis present with these symptoms, it is prudent to counsel patients preoperatively about the incidence of appendiceal endometriosis and to visually examine the appendix during gynecologic surgery to identify incidental appendiceal pathology.
Age may influence the appendectomy decision
The incidence of acute appendicitis is highest among people aged 10 to 19 years. The estimated lifetime risk of appendicitis is 6.7%.18 The surgical dilemma is whether to perform incidental appendectomy in the nonadolescent population, which is at lower risk for appendicitis, as a preventive measure.
We lack randomized trials on the benefit of incidental appendectomy. A retrospective study of open procedures supported incidental appendectomy in patients younger than 35 years; for patients 35 to 50, the decision was left to the clinical judgment of the surgeon, based on the patient’s clinical condition.4 The same study failed to support incidental appendectomy in women older than 50 years.