Introducing diagnostic laparoscopy for patients with suspected acute appendicitis

Background: The diagnostic accuracy in patients with suspected acute appendicitis varies from 60% to 90% depending on age and gender. The aim of this study was to evaluate the use of diagnostic laparoscopy for diagnostic purposes in patients with suspected acute appendicitis to prevent unnecessary laparotomy and to leave a macroscopically normal appendix in place. Methods: For this study, 500 consecutive patients with suspected acute appendicitis admitted between January 1994 and October 1996 were included prospectively in a surgical training program set to provide diagnostic laparoscopy on a 24-h-a-day basis. Primary open operation was performed when no laparoscopically trained surgeon was available. Short-term outcome measurements were recorded, and a retrospective long-term follow-up evaluation was performed. Results: We succeeded in performing a diagnostic laparoscopy in 376 patients and a primary open operation in 124 patients. The overall appendicitis rate was 78%. A diagnostic laparoscopy alone was performed in 66 patients (56 of which were fertile women), with a median operating time of 36 min and a complication rate of 0%. The overall complication rate was 8.0%. During a median follow-up period of 19 months one patient returned on a later occasion with appendicitis. At completion of the study, 85% of the surgeons were skilled in diagnostic laparoscopy. Conclusions: Substantial education effort is needed to introduce diagnostic laparoscopy on a 24-h-a-day basis. Diagnostic laparoscopy has a high rate of accuracy, short operating time, and low associated morbidity, and prevents unnecessary laparotomy. It is possible to leave a macroscopically normal-appearing appendix in place. Received: 12 March 200/Accepted: 23 May 2000/Online publication: 9 August 2000     

Implications of removing a normal appendix

BACKGROUND: The diagnosis of acute appendicitis remains difficult, and therefore 15-30% of the removed appendices appear to be normal. The aim of this study is to investigate the morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis. PATIENTS AND METHODS: A retrospective study was performed on patients who underwent a negative appendectomy for suspected appendicitis in the period 1991-1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded. RESULTS: In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a reoperation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complication 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2,712. CONCLUSION: The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools as diagnostic laparoscopy should be used selectively in order to not further exceed costs.     

Implications of removing a normal appendix

BACKGROUND: The diagnosis of acute appendicitis remains difficult and therefore 15-30% of the removed appendices appear to be normal. The aim of this study was to investigate morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis. PATIENTS AND METHODS: Retrospective study of patients who underwent a negative appendectomy for suspected appendicitis in the period 1991-1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded. RESULTS: In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a re-operation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complications 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2712. CONCLUSION: The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools such as diagnostic laparoscopy should be used selectively in order not to further increase costs.     

Selective use of diagnostic laparoscopy in patients with suspected appendicitis

Background: Diagnostic laparoscopy has been introduced as a new diagnostic tool for patients with acute appendicitis. We performed diagnostic laparoscopy when the clinical diagnosis of appendicitis was in doubt. The aims of this study were to evaluate this strategy and to analyze the efficacy of diagnostic laparoscopy in patients with suspected appendicitis. Patients and Methods: All patients referred to our hospital with suspected appendicitis during the period 1994–1997 were evaluated prospectively. The clinical diagnosis was determined by the surgeon or resident on call based on the patient's history, physical examination, and leukocyte count. The patients were divided into three groups: group 1: appendicitis not likely. These patients were observed for 24 h or discharged. When they showed signs of appendicitis in 24 h, they were transferred to either group 2 or 3; group 2: doubt concerning diagnosis. These patients underwent diagnostic laparoscopy, and appendectomy was performed if indicated; group 3: In these patients the diagnosis appendicitis was felt to be certain. They were treated by primary appendectomy by an open procedure. In this study, 1,050 patients, 531 women (51%), 389 men (37%), and 130 children (12%) <11 yrs, were evaluated. Results: Altogether, 377 diagnostic laparoscopies were performed, leaving 109 healthy-looking appendices in place. This reduced the negative appendectomy rate from 25% to 14% in all surgically managed patients. The negative appendectomy rate for the women in group 2 was reduced from 49% to 14%, and for the men from 22% to 11%, so it also seemed worthwhile to perform diagnostic laparoscopy in men. Because the appendix sana was left in place in only three children, the benefit from laparoscopy is relatively small for children. In 48% of these patients a second diagnosis was obtained, most of them gynecologic in nature. There were no false-negative laparoscopies and no complications resulting from the laparoscopic procedure. Conclusions: Diagnostic laparoscopy is a safe procedure that reduced the appendix sana rate without increasing the total number of operations. It is a useful method for obtaining other, mostly gynecologic, diagnoses. To further reduce the appendix sana rate, better criteria for laparoscopic assessment of the appendix are needed. Received: 7 September 1999/Accepted: 21 February 2000/Online publication: 22 August 2000     

Macroscopic assessment of the appendix at diagnostic laparoscopyis reliable

Background: Healthy-looking appendixes are often removed at laparoscopy for suspected appendicitis. This practice may have adverse secondary effects. Methods: We reviewed the literature for the years 1978 to 1998 to analyze the negative appendectomy rates, complication rates, the accuracy of laparoscopic appendix assessment, and the incidence of false negative diagnosis of appendicitis at surgical and gynecological laparoscopy. Results: The respective negative appendectomy rates were 22% and 15% in studies that compared laparoscopic with open appendectomy. The appendix was left in situ in 37% of 4,281 surgical diagnostic laparoscopies. There were instances of missed appendicitis among the 3,367 gynecological diagnostic laparoscopies performed on women for lower abdominal pain, and there were 188 appendectomies in this group. Studies comparing the macroscopic appearance of the appendix at operation with microscopic findings from the excised specimen had a false negative error rate of 3%. Conclusions: Contrary to general opinion, there is no substantial evidence to support the assumption that the macroscopic diagnosis of appendicitis is unreliable. High rates of conflicting diagnoses of excision specimens suggest that endoappendicitis has little clinical significance. At present, negative appendectomy rates are considerably higher for laparoscopic appendectomy than for the open approach. The role of diagnostic laparoscopy in suspected appendicitis should be reconsidered. It may be useful in particular subgroups of patients, but it is no substitute for good clinical judgment. Furthermore, it is not always necessary to perform an incidental appendectomy. Received: 7 September 1999/Accepted: 21 October 1999/Online publication: 30 May 2000     

LAPAROSCOPIC APPENDICECTOMY A PROSPECTIVE ANALYSIS

The potential advantages of laparoscopic surgery for a number of abdominal operations including appendicectomy have been heralded. In this study the aims were to assess prospectively the role of routine diagnostic laparoscopy in the diagnosis of acute appendicitis and determine the efficacy of laparoscopic appendicectomy. Patients with suspected acute appendicitis had diagnostic laparoscopy. When the diagnosis was confirmed laparoscopic appendicectomy was performed. Where an alternative diagnosis was made the appropriate treatment was instituted. If no diagnosis could be made the macroscopically normal appendix was removed by laparoscopic appendicectomy. Eighty-one patients (50 female, 31 male) had an initial diagnostic laparoscopy; 53 had appendicitis and proceeded to laparoscopic appendicectomy. A diagnosis could not be established at diagnostic laparoscopy in six patients and they also proceeded to laparoscopic appendicectomy. An alternative diagnosis was made in the remaining 22 patients (19 female and 3 male), with five proceeding to laparotomy and one patient with mesenteric adenitis having laparoscopic appendicectomy. Seven patients having laparoscopic appendicectomy required conversion to an open operation due to a retrocaecal³ or perforated⁴ appendix. The median operating time for successful laparoscopic appendicectomy was 55 min (range 30–95). Morbidity occurred in five of 53 patients having a successful laparoscopic appendicectomy. The median postoperative hospital stay was 2 days. The median time before return to normal activities was 8 days. Diagnostic laparoscopy is a useful diagnostic technique in women with suspected acute appendicitis, as it improves diagnostic accuracy, reduces the negative appendicectomy rate and avoids unnecessary laparotomy. Laparoscopic appendicectomy is a significant technical advance in the management of acute appendicitis. Preliminary results reveal similar morbidity to open appendicectomy with the potential advantages of a reduced postoperative hospital stay and a more rapid return to normal activities. Randomized trials are required to confirm this.     

Laparoskopie bei Verdacht auf akute Appendizitis

The question whether an appendix found to be macroscopically normal at laparoscopy for suspected appendicitis should be removed remains open to debate. Potential advantages of appendicectomy in all cases include early diagnosis of neoplastic lesions that cannot be detected macroscopically, diagnosis and cure of neurogenic appendicectomy, avoidance of diagnostic confusion in later episodes of abdominal pain, and prevention of appendicitis developing later in life. Therefore, adopting a strategy of always removing the appendix even if it is found to be uninflamed at laparoscopy seems justified as long as it does not imply an increase in postoperative morbidity. We retrospectively studied all patients undergoing laparoscopic appendicectomy in which a ?normal appendix“ was found and all patients undergoing diagnostic laparoscopy in our hospital during a 7-year period. Our data as well as a critical review of the literature show that removal of the appendix does not increase morbidity compared to simple diagnostic laparoscopy and should always be done when performing laparoscopy for suspected acute appendicitis.     

The utility of laparoscopy in the diagnosis of acute appendicitis in women of reproductive age

Aim: To see whether laparoscopy improves the accuracy of a clinical diagnosis of acute appendicitis in women of reproductive age, and to determine what the long-term sequelae are of not removing an appendix deemed at laparoscopy to be normal. Method: The initial part of the study was undertaken during 1991–1992. Female patients between 16 and 45 years were eligible for inclusion once a clinical decision had been made to perform an appendicectomy for suspected acute appendicitis. Following consent, patients were randomized into two groups. One group had open appendicectomy, as planned. The other group had laparoscopy, followed by open appendicectomy only if the appendix was seen to be inflamed or was not visualized. The end points for the study were the clinical outcomes of all patients, and the results of histology, where appropriate. An attempt was made to contact all patients at 10 years to determine whether they had had a subsequent appendicectomy, or had been diagnosed with another abdominal condition that might be relevant to the initial presentation in 1991–1992. Results: Laparoscopic assessment was correct in all cases in which the appendix was visualized. Diagnostic accuracy was improved from 75% to 97%. Laparoscopy was associated with no added complications, no increase in hospital stay in patients who went on to appendicectomy, and a reduction in hospital stay for those who underwent laparoscopy alone. No patients developed a problem over the 10-year follow-up period from having a normal-looking appendix not removed at laparoscopy. Conclusion: Laparoscopic assessment of the appendix is reliable, and to leave a normal-looking appendix at laparoscopy does not appear to cause any long-term problems.     

Changing management of suspected appendicitis in the laparoscopic era

INTRODUCTION

The aims of this study were to examine the trends in performance of open and laparoscopic appendicectomy at a district general hospital, and to compare the diagnostic outcomes in the two patient groups.

PATIENTS AND METHODS

Data were collected prospectively from patients undergoing an open or laparoscopic procedure for cted appendicitis in an 8-year period between January 2000 and December 2007.

RESULTS

A total of 1700 patients (873 women, 827 men) with a median age of 24 years underwent surgery for suspected appendicitis in the study period. There were 1357 patients (group A) who underwent an open procedure for presumed appendicitis (610 women and 747 men [F:M ratio, 1:1.2]). There were 343 patients (group B) who underwent laparoscopy with or without laparoscopic appendicectomy (82 men and 261 women [F:M ratio, 1:0.31]). Over the study period, there was an increasing trend towards the performance of laparoscopic procedures for suspected appendicitis, increasing from 4% to 39% of the total per year. In group A, 1172 (86%) patients had appendicular pathology, while the appendix was normal histologi-cally in 178 (13%). Other pathologies were diagnosed intra-operatively in 1%. In group B, 193 patients (56%) had appendicular pathology while in 150 (44%) the appendix was normal. In the subgroup with a normal appendix, 56 patients (37%) had another cause for their symptoms identified.

CONCLUSIONS

Laparoscopic appendicectomy is increasingly being performed. Laparoscopy is often used as a diagnostic tool in general surgical patients, particularly women, with lower abdominal pain. In effect, these patients are undergoing diagnostic laparoscopy, with or without appendicectomy. This has resulted in a lower positive appendicectomy rate, but a higher yield of diagnoses other than appendicitis, in the laparoscopic group. Overall appendicectomy rates, however, have remained unchanged.     

Laparoscopy in patients admitted for acute abdominal pain

In 81 patients with acute abdominal pain, laparoscopy was performed because of diagnostic doubt. Diagnosis by clinical methods proved to be correct in 42 of the patients and laparoscopy gave correct diagnosis in 70. Appendectomy revealed acute appendicitis in 19 patients and normal appendix in five. Failure to establish a diagnosis by laparoscopy was due to incomplete visualization of appendix in nine patients, pelvic adhesions in one patient, and failure to enter the peritoneal cavity in another. A clinical diagnosis of acute appendicitis could be invalidated by laparoscopy in 17 of 40 patients. Negative laparotomy is potentially avoidable by use of laparoscopy when a diagnosis of appendicitis is questionable. Laparoscopy may therefore be warrantable in such cases.     

Acute appendicitis—a clear-cut case in men,a guessing game in young women

Background: The aggressive surgical approach to patients suspected of having acute appendicitis for fear of perforation, and the inaccuracy of available diagnostic methods lead to an unacceptably high negative appendicectomy rate, especially in young women, in whom gynecological disorders frequently mimic appendicitis. Our objectives were to determine the value of diagnostic laparoscopy in women of child-bearing age to reduce the number of negative laparotomies and establish the correct diagnosis to allow prompt and appropriate treatment. Methods: 161 consecutive adult female patients under 50 years of age with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy prior to the planned appendicectomy. If an inflamed appendix was found, appendicectomy was usually done through a muscle-splitting McBurney incision. Other diagnoses were treated accordingly. A normal appendix was not removed. Results were compared to a group of 42 similar patients in whom the laparoscopy was omitted for various reasons, to 23 postmenopausal women, and to all 137 male adults, directly operated by the McBurney approach. Results: After laparoscopy, 55% of the patients required appendicectomy for appendicitis while in 23% a gynecological diagnosis was made in spite of previous examination by a gynecologist. Fourteen percent had a negative laparoscopy. There were no false-negative results. The negative appendicectomy rate after laparoscopy was 5% due to two false positives and eight laparoscopy failures. In the group of fertile females who escaped laparoscopy the negative appendicectomy rate was 38%. The respective rates for postmenopausal women and men were 4% and 8%. Conclusions: All women of child-bearing age suspected of having acute appendicitis should undergo diagnostic laparoscopy prior to the planned appendicectomy, regardless of the certainty of the preoperative diagnosis. This is currently the only way to reduce the negative appendicectomy rate and establish a correct diagnosis allowing prompt and appropriate treatment. In male patients and postmenopausal women one may proceed directly to emergency appendicectomy.     

Improving the diagnostic accuracy of ultrasonography in suspected acute appendicitis by the combined transabdominal and transvaginal approach

Transabdominal ultrasound has a lower diagnostic yield in acute appendicitis than computed tomography (CT) scanning. The addition of transvaginal sonography in women with suspected appendicitis has shown improvement in the efficacy of diagnosis, potentially providing the option of selective CT use and reducing overall investigative cost and surgical delay. Two hundred ninety-two women who underwent combined transabdominal and transvaginal ultrasound for suspected acute appendicitis were evaluated. Patients were divided into two groups; Group 1 including patients with a positive sonographic diagnosis of appendicitis who underwent operation and Group 2 including patients with a negative sonographic diagnosis. Of the 157 women in Group 1, the diagnosis of appendicitis was histologically confirmed in 144 patients with five cases having a normal appendix in whom eight other pathologies were found. Of the 135 women with negative ultrasound examinations, 14 underwent surgery in which four cases of appendicitis were found. The sensitivity of the combined approach was 97.3 per cent, the specificity 91 per cent, the positive predictive value 91.7 per cent, and the negative predictive value 97 per cent. Combined ultrasound has a high predictive value for the diagnosis of appendicitis and may assist in reduction of the use of CT scanning for diagnosis and in the negative appendectomy rate.     

Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy

Background: Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy for suspected acute appendicitis may help in making the correct diagnosis in the absence of pathology of the appendix. Methods: Fourteen patients with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy through the right lower quadrant incision after open appendectomy to exclude further pathology in the case of a noninflamed appendix. Results: In 10 of the 14 patients, laparoscopy helped to correct the diagnosis. In two patients, the etiology of the acute right lower abdominal pain remained unclear. In two others, histological examination showed acute appendicitis despite a normal macroscopic appearance. Conclusions: Diagnostic laparoscopy through the right lower quadrant incision may help to correct the diagnosis in patients who are operated on for clinically acute appendicitis but in whom no acute appendicitis or other pathological findings are seen. Received: 10 September 1997/Accepted: 15 April 1998     

Ultrasonography in the diagnosis of acute appendicitis

Ultrasonography with graded compression was performed in 525 patients with clinical signs of acute appendicitis. Of 207 patients with surgically proven appendicitis the inflamed appendix (diameter greater than or equal to 6 mm) had been visualized sonographically in 177 (86 per cent). The score for non-perforated appendicitis (91 per cent) was higher than for perforated appendicitis (55 per cent). Twenty-four patients in whom an inflamed appendix was seen on ultrasonography did not undergo surgery because of rapidly subsiding symptoms ('abortive appendicitis'). Four of these 24 developed recurrent appendicitis warranting surgery. Two underwent elective appendectomy and 18 have remained symptom-free. Of 155 patients with a subsequently confirmed alternative condition, ultrasonography made the correct diagnosis in 140: bacterial ileocaecitis (69), mesenteric lymphadenitis (eight), gynaecological conditions (34), urological conditions (eight), caecal diverticulitis (six), perforated peptic ulcer (six), Crohn's disease (two) and miscellaneous conditions (seven). Of 139 patients in whom no definite diagnosis was made ultrasonography showed no abnormalities in 138. In four patients a false positive sonographic diagnosis of appendicitis was made and in two patients with appendicitis an alternative condition was incorrectly diagnosed. During the last 3 years of the study the negative appendicectomy rate was 7 per cent and delay beyond 6 h after admission occurred in only 2 per cent of patients with surgically proven appendicitis. When used to complement the clinical diagnosis ultrasonography improves the diagnostic accuracy and patient management in those suspected of having acute appendicitis.     

Surgical validation of unenhanced helical computed tomography in acute appendicitis

BACKGROUND: Surgery for pain in the right lower quadrant of the abdomen remains a clinical dilemma. This prospective study assessed the accuracy of preoperative unenhanced helical computed tomography (CT) in the evaluation of patients with suspected acute appendicitis. METHODS: One hundred and three adult patients with suspected acute appendicitis underwent unenhanced helical CT of the abdomen. Subsequently, all patients underwent laparoscopic inspection of the abdominal cavity by a surgeon who was blinded to the diagnosis suggested by CT. Patients underwent appropriate surgical therapy accordingly. Follow-up was at least 6 weeks. RESULTS: Appendicitis was diagnosed by CT in 83 patients (80.6 per cent). Acute appendicitis was identified during laparoscopy in 87 patients (84.5 per cent). Prospective interpretation of CT images yielded a sensitivity of 95.4 per cent and a specificity of 100 per cent for the diagnosis of acute appendicitis. There were four false-negative scans. In 12 of 20 patients without signs of appendicitis on CT, the scan established the presence of other pathology. At operation no additional pathology was observed in this group and all other diagnoses proved to be correct. CONCLUSION: Plain helical CT in patients with suspected acute appendicitis provides an accurate diagnosis without the disadvantages of contrast enhancement.     

Laparoscopic evaluation of patients with suspected acute appendicitis

Background: High error rates are reported in the clinical diagnosis of acute appendicitis. This study was undertaken to discover what additional value laparoscopy has in the diagnosis of suspected acute appendicitis. Methods: From April 1995 to November 1996, a diagnostic laparoscopy, before open appendicectomy, was performed in 100 consecutive patients with suspected acute appendicitis. Appendicectomy was performed only if the appendix showed signs of inflammation at laparoscopy or if the appendix could not be visualized. Results: Twenty-four patients were spared an appendicectomy, and in half of them a new diagnosis was established during laparoscopy. The rate of misdiagnosis was 41% in female patients of reproductive age and 8% in male patients. There were no cases of missed appendicitis in this trial, and all removed appendices showed signs of inflammation at histology. Conclusions: It is safe to rely on the diagnosis made at laparoscopy. Its use for establishing diagnosis before appendicectomy in women of reproductive age is recommended. Received: 13 June 1997/Accepted: 24 October 1997     

Incidental laparoscopic appendectomy for acute right lower quadrant abdominal pain

Background: Removing the normal appendix when operating for suspected acute appendicitis is the standard of care. The use of laparoscopy should not alter this practice. Methods: Retrospective review of 72 patients found to have grossly normal appendices while undergoing laparoscopy for suspected appendicitis. Twenty-eight patients underwent diagnostic laparoscopy (DL) alone while 44 patients underwent diagnostic laparoscopy with incidental laparoscopic appendectomy (ILA). Results: There was no difference in length of hospitalization (DL = 44 h, ILA = 43 h, p= 0.49) or morbidity (DL = 11%, ILA = 5%, p= 0.37). One patient required appendectomy 11 days after diagnostic laparoscopy for recurrent acute right lower quadrant abdominal pain. Five percent of resected appendices (2/44) demonstrated acute inflammation upon pathologic review. Conclusions: Laparoscopic removal of the normal appendix produces no added morbidity or increase in length of hospitalization as compared to diagnostic laparoscopy. It demonstrates cost effectiveness by preventing missed and future appendicitis. Incidental laparoscopic appendectomy is the preferred treatment option. Received 3 April 1997/Accepted: 3 July 1997     

A prospective evaluation of the combined use of the modified Alvarado score with selective laparoscopy in adult females in the management of suspected appendicitis

BACKGROUND: A diagnostic scoring system such as the modified Alvarado score, combined with selective laparoscopy in adult females, can be used in the assessment of acute abdominal pain suggestive of appendicitis. METHOD: A total of 84 consecutive patients presenting to our surgical team with suspected appendicitis were assessed prospectively using the modified Alvarado score. The definitive management of this study group was instigated according to a set algorithm based on the score. The algorithm included the use of diagnostic laparoscopy in adult female patients with scores suggestive of appendicitis. A negative appendicectomy rate was obtained from those undergoing appendicectomy using this approach and compared to that obtained from the 97 patients that had undergone appendicectomy under the care of the other surgical teams in our unit during the study period. RESULTS: The rate of negative appendicectomy in the study group was 0% compared to 18% in the control group (P < 0.05); 10% of adult female women had negative diagnostic laparoscopies for appendicitis thus saving this group an unnecessary appendicectomy. This was achieved without an increase in total in-patient stay. CONCLUSION: An algorithm combining the modified Alvarado score with selective laparoscopy is recommended for widespread use in the management of suspected acute appendicitis.     

Our experience with selective laparoscopy through an open appendectomy incision in the management of suspected appendicitis

BACKGROUND: An accurate preoperative diagnosis of suspected appendicitis at times can be extremely difficult. We report our experience with a simple strategy of selective laparoscopy through an open appendectomy incision after finding a noninflamed appendix in the management of suspected appendicitis. METHODS: Patients presenting with suspected appendicitis after regular office hours (6 pm to 8 am weekdays and weekends) were recruited prospectively from January 2002 to December 2003. Laparoscopy through an open appendectomy incision was performed only when the appendix was found to be normal. RESULTS: Twenty-five (18.5%) of 135 patients underwent laparoscopy through an open appendectomy incision because of a normal-looking appendix. Laparoscopy through an open appendectomy incision helped to identify additional intra-abdominal pathology in 13 (52%) of the 25 patients; thus improving the overall detection rate of underlying pathology from 81.5% (110 of 135) to 91.2% (123 of 135). CONCLUSIONS: Selective laparoscopy through an open appendectomy incision in patients with a noninflamed appendix is a simple technique that can identify potentially fatal pathology and also maintains a valuable training opportunity for young surgeons to perform open abdominal surgery. We recommend using this technique in the management of suspected appendicitis.     

Role of leukocyte count, neutrophil percentage, and C-reactive protein in the diagnosis of acute appendicitis in the elderly

Leukocyte count, neutrophil percentage, and C-reactive protein (CRP) have been shown to give valuable information in the diagnosis of acute appendicitis. However, whether these laboratory tests have the same clinical applicability in the elderly as in young patients remains unclear. This retrospective study aimed to clarify the role of these tests in the diagnosis of acute appendicitis in patients aged 60 years or over. Eighty-five consecutive elderly patients underwent appendectomy for suspected acute appendicitis during a 30-month period. Histologically verified appendicitis was found in 77 of the 85 patients (90.6%). There was no significant difference in leukocyte counts or CRP values between patients with acute appendicitis and those with a normal appendix. The sensitivities of leukocyte count, neutrophil percentage, and CRP in the diagnosis of acute appendicitis were 71.4 per cent, 88.3 per cent, and 90 per cent, respectively, while the specificities were 37.5 per cent, 25 per cent, and 37.5 per cent, respectively. Of 77 patients with acute appendicitis, only two had all three tests simultaneously normal. In conclusion, patients with normal results in all three tests are highly unlikely to have acute appendicitis and should be evaluated with extra caution before surgery.