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Original article

A normal appendix found during diagnostic laparoscopy should not be removed
W. T. van den Broek, A. B. Bijnen, P. de Ruiter and D. J. Gouma*
Departments of Surgery, Medical Centre Alkmaar, Alkmaar and *Academic Medical Center, Amsterdam, The Netherlands Correspondence to: Dr W. T. van den Broek, Department of Surgery, Medisch Centrum Alkmaar, Wilhelminalaan 12, 1815 JDAlkmaar, The Netherlands (e-mail: w.broek@wolmail.nl)

Background: Diagnostic laparoscopy has been introduced as a new diagnostic tool for suspected

appendicitis. While the normal appendix used to be removed routinely, laparoscopy allows us to leave a normal looking appendix in place. This latter strategy is, however, not generally accepted. The longterm results of not removing a normal lookingappendix were evaluated. Methods: This was a prospective evaluation of 109 diagnostic laparoscopies for suspected appendicitis in which a normal looking appendix was left in place. After a median follow-up of 4´4 years a telephone questionnaire was performed. Results: There were no false-negative laparoscopies. In 65 patients (60 per cent) another diagnosis was obtained (group 1). In 44 patients (40per cent) no diagnosis was obtained (group 2). After a median interval of 8 months, 15 patients presented to the emergency department for symptoms possibly involving the appendix, during the median follow-up of 4´4 years. This resulted in readmission of nine patients, of whom eight were reoperated. In only one patient (1 per cent) was a histologically proven appendicitis found and the appendixremoved. Some 105 patients were eligible for follow-up. Of the 100 patients interviewed (95 per cent), nine patients (9 per cent) (six in group 1 and three in group 2) still had recurrent pain in the right lower abdominal quadrant. There were no differences between patients with or without another diagnosis obtained during preceding laparoscopy. Conclusion: It is safe to leave a normal lookingappendix in place when a diagnostic laparoscopy for suspected appendicitis is performed, even if another diagnosis cannot be found at laparoscopy.
Paper accepted 4 September 2000 British Journal of Surgery 2001, 88, 251±254

Introduction

Clinical criteria used in the diagnosis of appendicitis lead to 15±30 per cent of normal appendices being removed at open operation1±3. New diagnostic tools suchas ultrasonography and computed tomography have been introduced and achieve sensitivity rates of 75±89 per cent and speci®city rates of 86±100 per cent for the diagnosis4±7. In the `laparoscopic era', diagnostic laparoscopy has also been used because it is usually a simple procedure with a high speci®city and has the possibility of con®rming other diagnoses8±11. In the `open era', the normallooking appendix found during exploration was removed routinely because the presence of the typical scar in the right lower abdominal quadrant might cause confusion about a future diagnosis. Since the introduction of diagnostic laparoscopy it has been
ã 2001 Blackwell Science Ltd

suggested that an apparently normal appendix should be left in place, even if another diagnosis is not found12,13.Others report that a normal looking appendix found during laparoscopy can be removed safely because this does not increase postoperative morbidity or hospital stay14. Furthermore, the presence of an `endoappendicitis', which might not be recognized during laparoscopy and could equally be missed at open operation, may lead to recurrent abdominal complaints and subsequent appendicectomy. This shouldjustify the removal of an appendix that appears normal15,16. On the other hand, besides a prolonged operation time and costs, an increased number of complications after removal of a normal appendix has been reported17±20. Rarely, a normal appendix might also be useful in future reconstructive urological operations21. Considering the above aspects, the decision was made not to remove a normal...