Management of Macroscopically Normal Appendix During Appendectomy in Children
In cases of negative appendicitis during appendectomy in children, the appendix should be removed if it appears normal during surgery and no other disease is found in symptomatic patients. 1
Evidence-Based Rationale for Appendix Removal
The 2020 World Society of Emergency Surgery (WSES) Jerusalem guidelines provide a weak recommendation (2C) supporting appendix removal when the appendix appears normal during surgery for suspected appendicitis in symptomatic patients 1
Intra-operative macroscopic distinction between a normal appendix and acute appendicitis can be challenging, with studies showing 19-40% of visually normal appendices are actually pathologically abnormal 1
Risks of leaving an apparently normal appendix in situ include:
- Later acute appendicitis development
- Subclinical or endo-appendicitis with persisting symptoms
- Missed appendiceal malignancy 1
Clinical Evidence Supporting Removal
A study by Tartaglia et al. found that 90% of normal-looking appendices removed during laparoscopy for abdominal pain harbored inflammatory changes on histopathological examination 1
Grimes et al. demonstrated that fecaliths may cause right iliac fossa pain without obvious appendiceal inflammation, and routine removal of normal-looking appendices was effective for preventing recurrent symptoms 1
A survey of Canadian pediatric surgeons showed 100% agreement on removing a normal-appearing appendix during laparoscopy for suspected acute appendicitis in children 2
Evidence Against Routine Removal
Sørensen et al. found that among 271 patients who underwent diagnostic laparoscopy where the appendix was not removed, only 20.7% were readmitted with right iliac fossa pain after 10 months, and only one of the subsequently removed appendices showed histological signs of inflammation 1
Allaway et al. reported no significant difference in complication rates (6.3% vs 6.9%) or length of stay (2.3 vs 2.6 days) between negative appendectomy and uncomplicated appendicitis groups 1
Surgical Society Recommendations
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2010 guidelines state that if no other pathology is identified, the decision to remove the appendix should be considered based on the individual clinical scenario 1
The European Association of Endoscopic Surgery (EAES) 2016 guidelines recommend performing an appendectomy when the appendix appears normal during surgery for suspected acute appendicitis 1
Important Considerations for Clinical Practice
Routine histopathology after appendectomy is strongly recommended (1B) to identify unexpected findings 1
Operative findings and intra-operative grading correlate better than histopathology with morbidity, overall outcomes, and costs in children 1
The negative appendectomy rate can be as high as 36% in some series, highlighting the diagnostic challenges 1, 3
Increasing the use of preoperative CT and incorporating imaging into the overall assessment may reduce the incidence of negative appendectomy without increasing perforation rates 3, 4
Pitfalls and Caveats
Surgeon's macroscopic judgment of early grades of acute appendicitis is inaccurate and highly variable 1
Young women are particularly at risk for negative appendectomy 3
Consider the risk-benefit balance prior to performing an appendectomy during diagnostic laparoscopy showing a macroscopically noninflamed appendix, as negative appendectomy carries a non-negligible morbidity 3
The decision to remove a normal-appearing appendix should weigh the risk of leaving a potentially abnormal appendix against the risk of appendectomy in each individual scenario 1