What is the treatment approach for a patient with acute appendicitis and an ovarian mass?

Treatment Approach for Acute Appendicitis with Ovarian Mass

Laparoscopic appendectomy is the preferred surgical approach for patients with acute appendicitis and an ovarian mass, with careful intraoperative assessment of both pathologies to determine appropriate management. 1, 2

Diagnostic Approach

• When a patient presents with symptoms suggesting appendicitis alongside an ovarian mass:
  • CT abdomen/pelvis is medically indicated for confirmation of suspected appendicitis and evaluation of the ovarian mass 2
  • Ultrasound may be particularly useful for characterizing the ovarian mass

Surgical Management Algorithm

Step 1: Appendicitis Management

• Laparoscopic appendectomy is strongly recommended over open appendectomy due to:
  • Less postoperative pain
  • Lower incidence of surgical site infections
  • Decreased length of hospital stay
  • Earlier return to work
  • Better quality of life scores
  • Lower overall costs 1, 2

Step 2: Intraoperative Assessment of Ovarian Mass

• During laparoscopy, thorough inspection of the ovaries is essential 3
• Decision points for ovarian mass management:
  1. If benign-appearing ovarian cyst/mass: Consider cystectomy or ovarian-sparing approach
  2. If hemorrhagic ovarian cyst: Manage using bipolar cautery and ligatures 3
  3. If complex mass or suspicion of malignancy: Obtain gynecology consultation intraoperatively
  4. If ovarian torsion is present: Perform detorsion and assess ovarian viability

Timing Considerations

• Appendectomy should be performed within 24 hours of hospital admission for uncomplicated cases 2
• For complicated appendicitis, surgery should be performed within 8 hours 2
• Do not delay appendectomy to complete extensive workup of the ovarian mass if appendicitis is acute

Special Considerations

For Complicated Appendicitis with Abscess

• If laparoscopic expertise is available, proceed with laparoscopic appendectomy and assessment of the ovarian mass 1
• If abscess is present and percutaneous drainage capability exists, consider image-guided drainage as an adjunct to antibiotics 1
• Non-operative management may be considered in high-risk patients, but surgical treatment shows fewer readmissions and additional interventions 1

For Pregnant Patients

• Laparoscopic appendectomy is safe and preferred over open appendectomy even during pregnancy 1
• Special attention to port placement based on gestational age

Antibiotic Management

• Single preoperative dose of broad-spectrum antibiotics is recommended for all patients 1
• For uncomplicated appendicitis: No postoperative antibiotics needed 1
• For complicated appendicitis: Continue postoperative antibiotics, especially if complete source control has not been achieved 1
• Recommended regimens include:
  • Amoxicillin/clavulanate
  • Ceftriaxone + metronidazole
  • Cefotaxime + metronidazole 2

Postoperative Follow-up

• For patients with incidental finding of ovarian mass:
  • Arrange follow-up with gynecology for further evaluation and management
  • Consider imaging studies to further characterize the mass if not fully assessed during surgery
• For patients ≥40 years old with complicated appendicitis treated non-operatively: Consider colonoscopy and interval full-dose contrast-enhanced CT scan 1

Pitfalls to Avoid

• Failing to properly assess both the appendix and ovaries during laparoscopy, especially when one pathology seems obvious 3
• Attributing all symptoms to appendicitis without considering the contribution of the ovarian pathology
• Delaying appendectomy beyond recommended timeframes while investigating the ovarian mass
• Overlooking the possibility of synchronous pathologies like Meckel's diverticulum when both appendicitis and ovarian pathology are present 3