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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 23
| Issue : 2 | Page : 99-102 |
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Evaluating the benefit of incidental appendectomy
Ikponmwosa Obahiagbon, Mojisola Udoh
Department of Histopathology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
| Date of Submission | 25-Aug-2017 |
| Date of Decision | 07-Oct-2017 |
| Date of Acceptance | 27-Feb-2018 |
| Date of Web Publication | 10-Jul-2020 |
Correspondence Address:
Dr. Ikponmwosa Obahiagbon
Department of Histopathology, University of Benin Teaching Hospital, Benin City, Edo State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/smj.smj_62_17
Background: Surgeons sometimes perform appendectomies during abdominopelvic surgeries for surgical conditions unrelated to the appendix. A retrospective study of the histopathological diagnoses of incidental appendectomy specimens was performed to see the value of this practice. Materials and Methods: Records of incidentally resected appendices submitted to the Histopathology Department of the University of Benin Teaching Hospital from January 2005 to December 2014 were reviewed retrospectively. Results: A total of 129 histopathological reports of incidental appendectomy were retrospectively reviewed; 67 (51.9%) of the patients were male and 62 (48.1%) were female, giving a male-female ratio of about 1.1:1. Fifty-four cases (41.9%) had histologically normal appendices, while 75 cases (58.1%) had various histopathologically demonstrable lesions ranging from acute appendicitis (the most frequent with 27%) to neoplasia (one case of mucinous adenocarcinoma). Conclusion: Significant pathology can be uncovered on histopathological examination of the clinically normal appendix. Incidental appendectomy is thus a useful procedure.
Keywords: Appendectomy, appendicitis, appendix, histopathological, incidental
How to cite this article:
Obahiagbon I, Udoh M. Evaluating the benefit of incidental appendectomy. Sahel Med J 2020;23:99-102 |
| Introduction | |  |
Incidental appendectomy is elective appendectomy performed while undertaking abdominal and/or pelvic surgery for other conditions.[1] Whether the grossly “innocent” appendix should be left alone or prophylactically removed has been a cause for controversy for a long time.[2],[3] Proponents believe it is expedient and safe and does not significantly increase the patients' risks. It could be beneficial, even when no incidental pathology is discovered since it permanently removes the risk of any appendiceal disease or future appendectomy.[2] Those not in favor of incidental appendectomy argue that the lifetime risk of even the most common appendiceal pathology, acute appendicitis, is rather low to warrant a prophylactic surgery; moreover, the concern of an extended duration of anesthesia and surgery, as well as an increased risk of postoperative complications beyond those already posed by the main surgery, has also been put forward.[4],[5],[6] Both sides of the divide are supported by various articles – case reports and retrospective reviews – in the literature.
We undertook a 10-year retrospective study to examine the evidence in favor of incidental appendectomy.
| Materials and Methods | | |
Study design
This is a retrospective study analying the pathology of the incidentally removed appendix over a 10-year period, at the University of Benin Teaching Hospital, Benin City, Edo state, Nigeria.
Data collection and handling
The records of all the incidentally resected appendices (these were appendices that were removed without any pre or intra operative diagnosis of appendiceal pathology) were reviewed. Histopathological data were retrieved from departmental records and reviewed.
Statistical analysis was done using the Statistical Package for Social Sciences, version 16 (SPSS16, SPSS Inc. Chicago, Illinois, United States of America). Categorical data are recorded as percentages. Data generated are presented using frequency tables.
Ethical consideration
Ethica approval was obtained from Uniersity of Benin Health research Committee (ADM / 22 / A / VOL. VII / 14794) on 4th October 2018. All studies conformed with 2013 guidelines of Geneva declaration.
| Results | | |
One hundred and twenty-nine incidentally resected appendix specimens were received between January 2005 and December 2014. Of these, 67 (51.9%) were from male patients and 62 (48.1%) were from female patients, giving a male-female ratio of about 1.1:1. The ages of the patients ranged from 1 to 92 years, with a mean age of 37.75 years ± 20.02, a median age of 38 years and a modal age of 50 years. The incidental appendectomy rate was highest in the fourth decade (25 cases, 19.4%), but closely followed by the third, fifth, and sixth decades. It was much less common in the elderly. The rates were generally comparable between both sexes across the decades [Table 1]. Although the overall incidence of incidental appendectomy was higher in males, the peak was however found to be slightly higher in females aged 30–49 years than in men of any age group. | Table 1: Age group and sex distribution of cases of incidental appendectomy
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Fifty-four cases (41.9%) out of 129 incidental appendectomies had histologically normal appendices, while 75 cases (58.1%) had histopathologically demonstrable lesions ranging from acute appendicitis – 35 cases (27.1%) to neoplasia – one case of mucinous adenocarcinoma (0.8%). Other findings were periappendicitis/peritonitis – 17 cases (13.2%), reactive follicular hyperplasia – 20 cases (15.5%), and others such as chronic appendicitis and eosinophilic appendicitis – 1 case each (0.8%) [Table 2]. Acute appendicitis had an almost equal incidence in incidental appendectomies between males and females, at 14% and 13%, respectively [Table 2]. It was the most common in the third decade and rarest in the elderly. Follicular hyperplasia was more common in males than in females with 12 (9.3%) and 8 (6.2%) cases, respectively. Periappendicitis/peritonitis was more common in females than males with 11 (8.5%) and 6 (4.7%) cases, respectively. | Table 2: Histopathological findings in male and female patients who underwent incidental appendectomy
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The primary surgeries (general surgery and gynecological procedures) during which incidental appendectomy was performed are as outlined in [Table 3]. | Table 3: Primary surgeries during which incidental appendectomy was performed
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| Discussion | | |
The surgical removal of the clinically silent or normal appendix is an acceptable additional procedure to the major indication for the abdominal or pelvic surgery. The rationale for this is to permanently eliminate the risk of future appendicitis [3],[7] bearing in mind that acute appendicitis is the most common cause of the acute abdomen and the most common surgical emergency.[2] Clinically silent appendices that appeared normal at surgery have been found to harbor significant pathology. In a group of 202 incidental appendectomies reviewed by Waters 21 (10.4%) cases had acute appendicitis, 51 (25.2%) had chronic appendicitis, 5 (2.5%) had endometrioses, and 2 (1%) had carcinoids.[1] In a study conducted in California, United States, 3 cases (1.1%) of carcinoid tumor and 8 cases (4%) of endometriosis were diagnosed on histopathological examination. Two of the three cases of carcinoid tumor showed invasion as far as the serosa.[8] In our study of 129 cases, acute appendicitis was found in 35 cases (27.1%), reactive follicular hyperplasia in 20 cases (15.5%), and mucinous adenocarcinoma (0.8%) in one case. Other findings were periappendicitis/peritonitis – 17 cases (13.2%), and a case each of chronic appendicitis and eosinophilic appendicitis. No cases of endometrioses or carcinoids were found in this study.
The argument for incidental appendectomy is based on the rather high percentage of significant pathologies found in them on histopathological examination. The number of abnormal, incidentally resected appendices varies from 16% to 73% in different series.[9] The rate in our study is 44.9%. In a study in Lund, Sweden, 28% of the patients undergoing incidental appendectomy were found to have had significant pathological abnormalities.[3] Leibovitch et al. reported that 31.1% of their urology patients who had undergone incidental appendectomy were found to have had significant histopathological anomalies.[10] A study in Kansas, the United States, revealed that 23% of incidentally removed appendices had demonstrable pathology.[2] Melcher reported that only 12 out of 45 appendices electively removed at hysterectomy were histologically normal.[11] These high rates of significant pathology strengthen the case in favor of incidental appendectomy.
In this series of 129 cases of incidentally resected appendices, 41.9% of cases were histologically normal. Another 13.2% had periappendicitis/peritonitis, which may have been attributable primarily to pathologies in other organs. We, therefore, have not considered it as significant appendiceal pathology. However, 44.9% of cases were significantly abnormal. Thirty-five out of the 129 cases (27.1%) already had histopathologically demonstrable acute appendicitis diagnosed by the finding of neutrophils in the muscularis propria. It would, therefore, seem that incidental appendectomy had served them a useful purpose considering that acute appendicitis, although clinically latent as at the time of the surgery, might have earned them a second surgery sometime in the future. Moreover, even the 41.9% of cases in which the incidentally removed appendices were histologically normal, would still be spared the possibility of appendiceal pathology in the future. Some studies suggest that the postoperative infection and morbidity rates are significantly increased by incidental appendectomies [12],[13] but there is also evidence that with good surgical and aseptic techniques, there may be no additional increase in postoperative infection attributable to the incidental appendectomy.[14],[15]
The relative lifetime risk for appendectomy as quoted in different studies ranges from 9.6% to 20%.[16],[17] Appendectomy rates tend to be higher where laparoscopic evaluation of patients is not done before appendectomy. The gains of incidental appendectomies in such settings would be higher because once done and documented; it would exclude the appendix as the cause of acute abdomen.
Studies indicate that the risk of acute appendicitis is higher before the age of 50 years, and declines thereafter,[16],[18],[19] leading to the thinking that incidental appendectomy might be less beneficial for older subjects.[3] However, in our study, 7 (20%) of the 35 cases of incidentally discovered acute appendicitis were aged 50 years and above, indicating that incidental appendectomy could still be of benefit to those over 50 years of age, a point supported by studies that show that acute appendicitis in the elderly is associated with a higher likelihood of complications, for example, perforations, leading to severe morbidity, prolonged hospital stay, and increased mortality compared to nonperforated appendicitis.[20] Moreover, Leibovitch et al.,[10] in their analysis of 122 incidental appendectomies, found that the rate of abnormal appendices was higher in the elderly.
A case of mucinous adenocarcinoma of the appendix was discovered in an incidental appendectomy specimen in this study. Although a lone case, the early diagnosis of such sinister pathology for that patient could prove to be lifesaving. Jones et al. had two cases of primary adenocarcinoma and one case of metastasis to the appendix.[21]
The appendix is said to be a vestigial organ; nevertheless, the normal appendix has important surgical uses. For instance, it can be incorporated in urinary tract reconstruction. It is useful as an intermittent catheterization route to empty a competent urinary reservoir.[10] Incidental appendectomy means forfeiture of such potential benefit. It should, however, be remembered that the appendix that has been used for reconstructive purposes is not exempt in its new location from the development of known pathologies of the appendix.[10]
Limitation
This study being retrospective might have been limited by loss of or incomplete data.
| Conclusion | | |
Incidental appendectomy in the context of related or unrelated abdominal and pelvic surgery may be useful procedure in identifying unsuspected pathological condition.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Waters EG. Elective appendectomy with abdominal and pelvic surgery. Obstet Gynecol 1977;50:511-7.  |
| 2. | Snyder TE, Selanders JR. Incidental appendectomy – Yes or no? A retrospective case study and review of the literature. Infect Dis Obstet Gynecol 1998;6:30-7. |
| 3. | Arnbjörnsson E. Incidental appendectomy: Risks versus benefits. Curr Surg 1983;40:194-7. |
| 4. | Gordon CA. The maternal and perinatal mortality of caesarean section. Am J Surg 1951;82:485. |
| 5. | Marshall HK, Macer G. Gynecologic mortality lessons. West J Surg Obstet Gynecol 1949;57:365-87. |
| 6. | Cosgrove RA. Comments on appendectomy at the time of caesarean section. Clin Obstet Gynaecol 1958;1:1940. |
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| 8. | O'Hanlan KA, Fisher DT, O'Holleran MS. 257 incidental appendectomies during total laparoscopic hysterectomy. JSLS 2007;11:428-31. |
| 9. | Silvert MA, Meares EM Jr. Rationale of incidental appendectomy. Urology 1976;7:129-34. |
| 10. | Leibovitch I, Avigad I, Nativ O, Goldwasser B. The frequency of histopathological abnormalities in incidental appendectomy in urological patients: The implications for incorporation of the appendix in urinary tract reconstruction. J Urol 1992;148:41-3. |
| 11. | Melcher DH. Appendicectomy with abdominal hysterectomy. Lancet 1971;297:810-1. |
| 12. | Cruse PJ. Incidence of wound infection on the surgical services. Surg Clin North Am 1975;55:1269-75. |
| 13. | Komorn H, Kaufman LW. Incidental appendectomy during gall bladder surgery. Bull Sinai Hosp Detroit 1963;11:103-6. |
| 14. | Bogart JN, Sebesta DG. Incidental appendectomy and its effect on the incidence of wound infection in cholecystectomy. Am Surg 1969;35:650-2. |
| 15. | Lowery CH, Lenhart HF. Incidental appendectomy during gall bladder surgery. Arch Surg 1962;85:476. |
| 16. | Ludbrook J, Spears GF. The risk of developing appendicitis. Br J Surg 1962;52:11. |
| 17. | Lee JH, Park YS, Choi JS. The epidemiology of appendicitis and appendectomy in South Korea: National registry data. J Epidemiol 2010;20:97-105. |
| 18. | Ashley DJ. Observations on the epidemiology of appendicitis. Gut 1967;8:533-8. |
| 19. | Hewitt D, Milner J, Le Riche WH. Incidental appendectomy: A statistical appraisal. Can Med Assoc J 1969;100:1075-81. |
| 20. | Peltokallio P, Tykkä H. Evolution of the age distribution and mortality of acute appendicitis. Arch Surg 1981;116:153-6. |
| 21. | Jones AE, Phillips AW, Jarvis JR, Sargen K. The value of routine histopathological examination of appendicectomy specimens. BMC Surg 2007;7:17. |
[Table 1], [Table 2], [Table 3]
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