From the Guidelines
Incidental appendectomy is suggested if the appendix appears “normal” during surgery and no other disease is found in symptomatic patients, as stated in the 2020 update of the WSES Jerusalem guidelines 1. When considering incidental appendectomy, it is crucial to weigh the potential benefits against the risks, particularly in terms of morbidity, mortality, and quality of life. The decision should be made on a case-by-case basis, taking into account the individual patient's risk factors and the context of the primary surgery. Some key points to consider include:
- The incidence of unexpected findings in appendectomy specimens is low, and routine histopathology is necessary to identify any potential issues 1.
- Intra-operative grading systems can help identify homogeneous groups of patients and determine optimal postoperative management, but the surgeon’s macroscopic judgment of early grades of acute appendicitis can be inaccurate and highly variable 1.
- The procedure should only be performed when the primary operation is clean or clean-contaminated, and when it won't significantly increase operative time or risk.
- Specific patient populations, such as those with planned long-term immunosuppression, ventriculoperitoneal shunts, or conditions that might mask appendicitis symptoms, may benefit from incidental appendectomy due to their high risk of future appendicitis or challenges in diagnosing appendicitis.
- Routine incidental appendectomy is not recommended for the general population due to the low lifetime risk of appendicitis compared to the additional surgical risks, including infection, bleeding, and prolonged operative time. The 2020 update of the WSES Jerusalem guidelines provides a framework for decision-making, but the ultimate decision should be based on the individual patient's needs and circumstances, prioritizing their morbidity, mortality, and quality of life outcomes.
From the Research
Indications for Incidental Appendectomy
- The decision to perform an incidental appendectomy is based on various factors, including the patient's age, health status, and the primary surgical procedure being performed 2, 3.
- In general, incidental appendectomy is considered beneficial in young patients (< 35 years old) who are undergoing other abdominal surgeries, as it can prevent future morbidity and mortality associated with acute appendicitis 2, 3.
- In patients between 35-50 years old, the decision to perform an incidental appendectomy is left to the discretion of the surgeon, taking into account the patient's individual circumstances and the potential risks and benefits 2, 3.
- Incidental appendectomy is not recommended in patients over 50 years old, as the risk of acute appendicitis decreases with age, and the risks associated with the procedure outweigh the potential benefits 2, 3.
Contraindications for Incidental Appendectomy
- Incidental appendectomy is contraindicated in patients with unstable conditions, previous diagnosis of Crohn's disease, inaccessible appendix, planned radiation treatment, immunosuppression, vascular grafts, or other intraabdominal foreign material 3, 4.
- Patients with certain medical conditions or who are undergoing specific surgical procedures may also be at increased risk for complications from incidental appendectomy, and the decision to perform the procedure should be made on a case-by-case basis 3, 4.
Special Considerations
- In patients undergoing laparotomy for abdominal trauma, incidental appendectomy may be considered to prevent future development of appendicitis, especially in young patients 5.
- In mentally handicapped patients less than 50 years old who are physically healthy, incidental appendectomy may be recommended to prevent future morbidity and mortality associated with acute appendicitis 3.
- The use of prophylactic antibiotics may be considered in certain cases where incidental appendectomy is anticipated, especially in otherwise clean cases 3.