Is the appendix removed during a right-sided renal auto transplant?

Appendectomy During Right-Sided Renal Autotransplantation

The appendix is typically removed prophylactically during right-sided renal autotransplantation to prevent future diagnostic confusion and surgical complications, though this is based on surgical practice patterns rather than formal guidelines specific to this procedure.

Rationale for Prophylactic Appendectomy

The decision to remove the appendix during right-sided renal autotransplantation is driven by several practical considerations:

Altered Anatomical Relationships

• The transplanted kidney fundamentally changes the anatomical position of the appendix, making future diagnosis of appendicitis significantly more challenging 1
• Radiologic studies in kidney transplant recipients show various locations of the appendix relative to the grafted kidney, complicating imaging interpretation 1
• The appendix may be displaced or incorporated into surgical fields, including potential herniation into incisional defects 2

Diagnostic Challenges Post-Transplantation

• Only 20-50% of kidney transplant recipients with appendicitis present with typical migrating pain, compared to the general population 1, 3
• The Alvarado score performs poorly in this population, with 30% of confirmed appendicitis cases scoring ≤3 points (rule-out range) 3
• Immunosuppression masks typical inflammatory signs, making clinical diagnosis unreliable 1, 4
• CT scan, while superior to ultrasound, still has an 11% false-negative rate in transplant recipients 3

Increased Morbidity Risk

• Complication rates for appendicitis in kidney transplant recipients reach 50%, substantially higher than the general population 1
• Delayed diagnosis is common, with 40% of patients not diagnosed until day 5 of symptom onset 3
• Longer time from symptom onset to operation (69±48 hours in complicated cases) correlates with significantly increased complications and hospital stay (15.4±15 days vs 5.4±1.8 days) 1
• Complications include intra-abdominal abscess, small bowel obstruction, and prolonged hospitalization averaging 7 days 4

Surgical Practice Considerations

Supporting Evidence for Removal

• The European Association of Endoscopic Surgery (EAES) recommends performing appendectomy when the appendix appears normal during surgery for suspected acute appendicitis 5
• Studies demonstrate that 19-40% of visually normal appendices are pathologically abnormal on histopathology 6, 5
• 90% of normal-looking appendices removed during abdominal surgery harbor inflammatory changes on pathological examination 5
• Risks of leaving the appendix include subclinical inflammation with persistent symptoms and missed appendiceal malignancy 5

Surgical Access and Timing

• During right-sided renal autotransplantation, the surgical field provides direct access to the appendix without additional incisions
• Prophylactic appendectomy adds minimal operative time and morbidity when performed during the primary procedure, compared to the substantial risks of future appendicitis diagnosis and treatment in an immunosuppressed patient with altered anatomy 1, 4

Clinical Pitfalls

Common Errors to Avoid

• Do not rely on clinical examination alone in transplant recipients—the immunosuppressive state and anatomical changes make physical findings unreliable 1, 3
• Do not delay imaging—CT scan should be obtained promptly for any abdominal pain in transplant recipients, as early diagnosis is essential to reduce complications 1
• Do not assume a negative Alvarado score rules out appendicitis in this population 3

Post-Operative Considerations

• If the appendix is left in situ, maintain a high index of suspicion for appendicitis with any right-sided or periumbilical abdominal pain 1, 3
• Routine histopathology is strongly recommended (1B) after any appendectomy to identify unexpected findings 6, 5