Leaving a normal appendix at diagnostic laparoscopy led to a repeat laparoscopy in 3.5%

Design

Retrospective multicentre cohort, four Danish university hospitals

Population

1,145 patients aged over 2 with normal findings at laparoscopy for suspected appendicitis

Primary outcome

Repeat diagnostic laparoscopy for suspected appendicitis

Effect

3.5% (95% CI 2.0 to 4.9) after appendix left; subsequent appendicitis 0.96%

A Danish multicentre retrospective cohort study in the World Journal of Surgery, published on 19 September, compared 627 patients whose macroscopically normal appendix was left in place at diagnostic laparoscopy for suspected appendicitis with 518 who had it removed. Median follow-up was more than five years.

In the group who kept the appendix, 3.5% (95% CI 2.0 to 4.9) had a second diagnostic laparoscopy for suspected appendicitis, a median of 1.7 years later, and about 1% went on to have appendicitis. In the main analysis there was no difference in later abdominal surgery, endoscopy or surgical complications. In sensitivity analyses, complications were more frequent after removal (3.7% vs 1.6%).

Many guidelines advise removing a normal-looking appendix when no other cause is found, to avoid future diagnostic confusion. This study suggests the cost of leaving it is small. It is observational, and the choice to leave or remove was the surgeon's, so the groups may differ.

• If the appendix looks normal and no other cause is found, discuss in advance with the patient whether it will be removed.
• Document clearly in the operation note and discharge letter whether the appendix was left in place.
• Explain to patients who keep a normal appendix that a later episode of right iliac fossa pain may still be appendicitis.
• Inspect the pelvis and terminal ileum before deciding the laparoscopy is negative.

Why it matters

It questions the routine removal of a normal appendix, which adds operative risk for a small diagnostic benefit later.

Don't overread it

Observational and surgeon-selected; it has not changed guidelines that favour removal.

The statistics, in plain English

3.5% with a confidence interval of 2.0% to 4.9% means roughly 1 in 30 patients returned for a second look over about five years. The complication difference appeared only in sensitivity analyses, so it is weaker than the main result.

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