Incidental Appendectomy

1
Incidental Appendectomy

• Amanda Hutchinson
• 9/2005

2
The Debate(take it or leave it)

• Timeless Debate spanning the past century.
• Acute appendicitis is most common cause of
  hospitalization in the US
• Incidence most common between 15 and 30 yrs.
• Cumulative lifetime risk of acute appendicitis is
  7
• Morbidity and Mortality increase with age

3
Take it

• Technically easy procedure
• 5-15 minute procedure
• Less morbidity
• No statistically significant data support
  increase in postoperative infection
• No additional anesthesia risk
• Risk of future anesthesia completely eliminated
  by incidental appendectomy
• Cost savings in future hospitalization and
  operation

4
Take it

• High incidence of dz in incidental appendectomy
  specimens
• Pathology found in 5-73 of specimens from
  appendectomies
• Most frequent was fibrosis of appendix
• Decreased morbidity and mortality associated with
  acute appendicitis
• Excision of a potential site of disease
• Elimination of confusion in future DDx of RLQ
  pain in females
• Ovarian torsion
• Tubal pregnancy
• Rupture of ovarian cyst
• PID
• Mittelschmerz

5
Leave it

• Technically difficult procedure
• Appendix not easily accesible
• Intra-operative time increased
• Morbidity (no statistically significant data to
  support increased risk)
• Stump blowout
• Wound infection
• Hemorrhage
• Post-op ileus and phlebitis
• Path specimensspeculative data
• Is fibrosis the natural course for an aging
  appendix?
• Would fibrosis lead to future episode of acute
  appendicits?

6
Leave it

• Future Morbidity and Mortality
• Incidence of morbidity and mortality in incr. in
  older pts, however rate of death from ruptured
  appendix in elderly is decreasing.

• Incidence of acute appendicitis drops off after
  third decade of life

7
ACOGs Recommendation

• Preventative value is relatively low
• MM not significant when compared with cost of
  incidental appendectomies aimed at prevention
• Only routinely indicated for certain select
  groups of patients, the benefits of eliminating
  future emergency appy/simplification of Ddx for
  pelvic pain outweigh cost concerns.

8
ACOGs Recommendations

• Certain Select groups for prophylactic incidental
  appendectomy
• Pts. With fixation of appendix to ovary or tube
• Apppendiceal fecalith or calculus
• Women in whom abdominal radiation is anticipated
• Mentally handicaped/unable to provide clear hx
• Women undergoing major surgery in whom major
  adhesions are anticipated postoperatively
• Women in whom future contraindications to
  abdominal surgery are anticipated

9
ACOGs Recommendations

• Groups where contraindicated
• Crohns Disease
• Inaccessible appendix
• Hx of prior abdominal radiation tx
• Vascular grafts
• Material in Abdomen
• Unstable medical condtion

10
References

• CB Lynch. Incidental appendectomy durning
  gynecological surgery. Int J Gynaecol Obstet.
  1997 Dec 59 (3)261-2
• KS Fisher. Guidelines for therapeutic decision
  in incidental appendectomy. Surg Gynecol Obstet.
  1990 Jul 171 (1) 95-8
• Incidental Appendectomy. ACOG Compendium.
  1995-2003 Dec.
• EM Salom et al. The safety of incidental
  appendectomy at the time of abdominal
  hysterectomy. Am J Obstet Gynecol. 1993 Dec 189
  (6) 1563-1567.