Is an appendectomy (removal of the appendix) necessary during a laparotomy if the appendix is intact?

Incidental Appendectomy During Laparotomy with Normal-Appearing Appendix

Remove the normal-appearing appendix during laparotomy when no other pathology explains the patient's symptoms, as visual assessment is unreliable and 19-40% of macroscopically normal appendices harbor pathological changes that can cause persistent symptoms. 1

Primary Recommendation

The European Association of Endoscopic Surgery (EAES) recommends performing appendectomy when the appendix appears normal during surgery for suspected acute appendicitis 1, and this principle extends to laparotomy scenarios where the abdomen is already open and the appendix is accessible.

Evidence Supporting Removal

Diagnostic Limitations of Visual Assessment

• Surgeons cannot reliably distinguish normal from abnormal appendices by appearance alone, with studies showing 19-40% of visually normal appendices are pathologically abnormal on histopathology 1, 2
• In one study, 90% of normal-looking appendices removed during abdominal surgery harbored inflammatory changes on pathological examination 2
• Another study found 29% of appendices judged macroscopically normal at laparoscopy were confirmed as appendicitis on histologic examination 3
• A Belgian study demonstrated that 58% of apparently normal appendices showed pathologic changes on microscopy, yielding only a 41% negative predictive value for visual assessment 4

Clinical Risks of Leaving the Appendix

• Leaving an apparently normal appendix risks subclinical or endo-appendicitis with persisting symptoms 1
• There is potential for missed appendiceal malignancy 1, 2
• The World Society of Emergency Surgery (WSES) provides a weak recommendation (2C) supporting appendix removal when it appears normal during surgery for suspected appendicitis in symptomatic patients 1, 5

Safety Profile

• No significant difference in complication rates or length of stay exists between negative appendectomy and uncomplicated appendicitis groups 1, 6
• In trauma patients undergoing laparotomy with incidental appendectomy, only 1 of 23 patients developed an appendiceal stump leak 7
• One study of 48 patients with normal-appearing appendices removed during diagnostic laparoscopy recorded no procedure-related complications, with mean hospital stay of 2.1 days and symptom resolution in all patients 4

Counterargument Evidence

• A Dutch prospective study found that among 109 patients who had normal-appearing appendices left in place during diagnostic laparoscopy, only 1% developed histologically proven appendicitis during 4.4 years follow-up 8
• Another study showed only 20.7% of patients were readmitted with right iliac fossa pain after 10 months when the appendix was not removed 1

Clinical Decision Algorithm

Remove the appendix if:

• The abdomen is already open for laparotomy
• No other pathology fully explains the patient's symptoms
• The appendix is easily accessible without additional morbidity
• The patient is hemodynamically stable

Consider leaving the appendix if:

• Another clear pathology fully explains symptoms
• The patient is hemodynamically unstable or critically ill
• Removal would require extensive additional dissection with significant risk

Essential Practice Points

• Always send removed appendices for histopathology (1B recommendation) to identify unexpected findings 1, 2, 5
• The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) states that when no other pathology is identified, the decision should be based on individual clinical scenario 1, but given the high false-negative rate of visual assessment and minimal additional morbidity during an already-open abdomen, removal is generally warranted
• Surgeon's macroscopic judgment of early grades of acute appendicitis is inaccurate and highly variable 1

Common Pitfalls

• Assuming a normal-appearing appendix is truly normal—this is incorrect in up to 40% of cases 1
• Failing to remove the appendix when the abdomen is already open, potentially subjecting the patient to future surgery through dense adhesions (particularly relevant in trauma patients) 7
• Not obtaining histopathology on removed specimens, missing unexpected pathology 1, 2