When to perform a laparoscopic appendectomy on an incidentally encountered normal appendix during suspected acute appendicitis (inflammation of the appendix)?

From the Guidelines

When encountering a normal appendix during laparoscopy for suspected appendicitis, removal is generally recommended due to the potential risks of leaving a potentially abnormal appendix in place, including later acute appendicitis, subclinical or endo-appendicitis with persisting symptoms, and missed appendiceal malignancy. According to the 2020 update of the WSES Jerusalem guidelines 1, the decision to remove the appendix should be considered based on the individual clinical scenario. Several studies have shown that intra-operative macroscopic distinction between a normal appendix and acute appendicitis can be challenging, with a 19% to 40% rate of pathologically abnormal appendix in the setting of no visual abnormalities.

The risks of leaving in situ an apparently normal appendix are significant, and the benefits of removal may outweigh the risks in many cases. For example, a retrospective study by Grimes et al. found that routine removal of a normal-looking appendix at laparoscopy in the absence of any other obvious pathology appeared to be an effective treatment for recurrent symptoms 1. Additionally, Tartaglia et al. supported an appendectomy in patients undergoing laparoscopy for acute right lower quadrant abdominal pain even when the appendix appears normal on visual inspection, based on the results of a study in which 90% of the removed normal-looking appendices at laparoscopy for abdominal pain and no other intra-abdominal acute disease harbored inflammatory changes at the definitive pathology 1.

Some studies have suggested that not removing a macroscopic normal appendix during laparoscopy for clinically suspected acute appendicitis may not be necessary, as the rate of readmission with right iliac fossa pain is relatively low 1. However, the potential risks of leaving a potentially abnormal appendix in place must be weighed against the risks of appendectomy in each individual scenario.

Key considerations in the decision to remove a normal appendix include:

• The patient's individual clinical scenario and risk factors for future appendicitis
• The presence of any other explanatory pathology
• The potential risks and benefits of appendectomy
• The surgeon's expertise and experience with laparoscopic appendectomy. Ultimately, the decision to remove a normal appendix during laparoscopy for suspected appendicitis should be individualized based on patient factors, surgical findings, and a thoughtful risk-benefit analysis, as supported by the 2020 update of the WSES Jerusalem guidelines 1.

From the Research

Decision to Perform Laparoscopic Appendectomy on a Normal Appendix

• The decision to perform a laparoscopic appendectomy on an incidentally encountered normal appendix, when the initial diagnosis was suspected acute appendicitis, depends on various factors, including the patient's overall health, the presence of any complications, and the surgeon's professional judgment 2.
• Studies have shown that laparoscopic appendectomy is a safe and effective procedure for treating acute appendicitis, with benefits including less postoperative pain, shorter hospital stays, and faster recovery times 2, 3.
• However, the use of antibiotic treatment as an alternative to surgery for uncomplicated appendicitis has also been explored, with some studies suggesting that it may be a viable option for selected patients 4, 5.
• The presence of a normal appendix during laparoscopy does not necessarily mean that the patient does not require treatment, as the appendix can still be at risk of future inflammation or rupture 6.

Considerations for Performing Laparoscopic Appendectomy

• The patient's symptoms, medical history, and overall health should be taken into account when deciding whether to perform a laparoscopic appendectomy on a normal appendix 6.
• The surgeon's expertise and experience with laparoscopic procedures, as well as the availability of adequate facilities and equipment, are also important considerations 2.
• The potential risks and benefits of the procedure, including the risk of complications, should be carefully weighed against the potential benefits of removing the appendix 4, 5.

Current Evidence and Recommendations

• The current evidence suggests that laparoscopic appendectomy is a safe and effective procedure for treating acute appendicitis, but the decision to perform the procedure on a normal appendix should be made on a case-by-case basis 6, 2, 3.
• Further research is needed to fully understand the benefits and risks of antibiotic treatment versus surgery for uncomplicated appendicitis, and to determine the optimal treatment approach for patients with a normal appendix 4, 5, 3.