Should an appendectomy be performed if a normal-appearing appendix is found during an indirect inguinal hernia repair in a patient with no history of appendicitis?

Incidental Appendectomy During Indirect Inguinal Hernia Repair

If a normal-appearing appendix is found during indirect inguinal hernia repair (Amyand's hernia), appendectomy should be performed in symptomatic patients or when the appendix is adequately exposed, as visual inspection is unreliable and 19-40% of normal-appearing appendices harbor pathologic abnormalities. 1

Clinical Context and Decision Framework

When to Perform Appendectomy

Appendectomy is recommended in the following scenarios:

• Symptomatic patients with right lower quadrant or groin pain: The World Society of Emergency Surgery (WSES) 2020 guidelines suggest appendix removal if the appendix appears "normal" during surgery and no other disease is found in symptomatic patients, as surgeon's macroscopic judgment is inaccurate and highly variable 1

• Adequately exposed appendix: When the appendix is well-visualized and can be safely removed without additional morbidity, appendectomy should be performed to prevent future complications 2

• Any degree of appendiceal inflammation: If there is any visual suggestion of inflammation, appendectomy is mandatory as studies show 90% of normal-looking appendices harbor inflammatory changes on histopathology 3

Rationale Supporting Appendectomy

The evidence supporting incidental appendectomy is compelling:

• Pathologic discordance: Between 19-40% of visually normal appendices are pathologically abnormal on histopathology, demonstrating the unreliability of intraoperative assessment 1

• Prevention of future symptoms: Retrospective data shows 20.7% of patients with retained normal-appearing appendices are readmitted with right iliac fossa pain, and 8.1% require subsequent laparoscopic procedures 1

• Risk of missed pathology: Leaving the appendix in situ carries risks of later acute appendicitis, subclinical endo-appendicitis with persistent symptoms, and missed appendiceal malignancy 1

• Historical evidence: Two documented cases of patients who developed acute appendicitis after inguinal hernia repair where the appendix was present in the sac but not removed support prophylactic appendectomy 2

Surgical Technique Considerations

When performing appendectomy during hernia repair:

• Use standard appendectomy technique with endoloops, suture ligation, or polymeric clips for stump closure 3

• Divide adhesions by sharp dissection if the cecum is adherent to the hernia sac 4

• Mesh placement: Prosthetic mesh repair can be safely performed if the appendix is non-inflamed or minimally inflamed, with appropriate antibiotic coverage for 3-5 days postoperatively 4, 5

• For inflamed appendices, consider Bassini suture repair without mesh to avoid infection risk, or use a two-stage approach with interval hernioplasty after recovery 6, 5

When Appendectomy May Be Avoided

Limited scenarios where appendectomy can be safely omitted:

• Asymptomatic patients with minimal appendiceal exposure: If the appendix is not adequately visualized and the patient has no abdominal symptoms, the risk-benefit ratio may favor leaving it in place 5

• Significant technical difficulty: When appendectomy would require extensive dissection or poses unacceptable risk of complications 7

However, these exceptions are narrow, as the WSES guidelines note that morbidity rates between negative appendectomy and uncomplicated appendicitis are equivalent (6.3% vs 6.9%, P=0.48), with no difference in complication severity or length of stay 1

Mandatory Histopathology

All removed appendices must undergo histopathological examination:

• Routine histopathology is strongly recommended (1B) to identify unexpected findings including early appendicitis, inflammatory bowel disease, and appendiceal neoplasms 1, 3

• The intra-operative diagnosis alone is insufficient for identifying unexpected disease 1

Common Pitfalls to Avoid

• Over-reliance on visual inspection: Do not assume a normal-appearing appendix is truly normal, as macroscopic judgment is highly inaccurate 1

• Inappropriate mesh use with inflammation: Avoid mesh placement if significant appendiceal inflammation is present; consider tissue repair or staged approach 6, 4

• Inadequate antibiotic coverage: When mesh is used with any degree of inflammation, ensure broad-spectrum antibiotics for 3-5 days postoperatively 4