In a male patient with clinical appendicitis (abdominal rigidity and tenderness) whose appendix appears normal intraoperatively, should the appendix be removed and the abdomen closed?

Management of Normal-Appearing Appendix During Surgery for Suspected Appendicitis

Remove the appendix and close the abdomen (Option A), as recommended by the 2020 WSES Jerusalem Guidelines, which state that appendix removal is suggested even when the appendix appears "normal" during surgery if no other disease is found in symptomatic patients. 1

Rationale for Appendix Removal

The decision to remove a macroscopically normal appendix is based on several critical considerations:

• Surgeon judgment is unreliable: The WSES guidelines explicitly note that "surgeon's macroscopic judgment of early grades of acute appendicitis is inaccurate and highly variable," meaning what appears normal intraoperatively may actually harbor early pathology 1

• Histopathology reveals occult disease: Routine histopathology after appendectomy is strongly recommended because "the intra-operative diagnosis alone is insufficient for identifying unexpected disease," and microscopic appendicitis may be present despite normal gross appearance 1

• Prevents future diagnostic confusion: Removing the appendix eliminates it as a potential source of future right lower quadrant pain, avoiding diagnostic uncertainty if the patient presents with similar symptoms later 1

Why Not the Other Options?

Option B (Look for Meckel's diverticulum): While exploring for alternative pathology is reasonable, this should be done in addition to removing the appendix, not instead of it. The guidelines recommend appendix removal regardless of whether other pathology is found 1

Option C (Convert to open and explore): If already performing laparoscopy, conversion to open surgery is unnecessary unless technical difficulties arise. Laparoscopic exploration provides excellent visualization of the entire abdomen 1, 2

Option D (Close without doing anything): This is explicitly contraindicated by guidelines, as it leaves the patient at risk for recurrent symptoms and provides no tissue for histopathologic diagnosis 1

Clinical Algorithm

1. Confirm the appendix truly appears normal (no erythema, edema, exudate, or perforation)
2. Systematically explore the abdomen for alternative pathology:
   • Examine terminal ileum for Meckel's diverticulum (within 60-100 cm of ileocecal valve)
   • Inspect for gynecologic pathology in females (ovarian cysts, torsion, pelvic inflammatory disease)
   • Evaluate for mesenteric adenitis, Crohn's disease, or other inflammatory conditions
3. Remove the appendix regardless of findings 1
4. Send specimen for histopathology (mandatory) 1
5. Document operative findings using standardized grading system 1

Important Caveats

• The recommendation for appendix removal carries a weak strength (2C) due to low-quality evidence, but the clinical rationale remains sound 1

• Approximately 10% of appendectomy specimens reveal unexpected findings on histopathology that were not apparent intraoperatively, including early appendicitis, carcinoid tumors, or other neoplasms 1

• The patient presented with clinical signs of peritonitis (rigidity and tenderness), indicating significant intra-abdominal pathology that warrants both appendix removal and thorough exploration 3