Question
Asked 21st Mar, 2015

Any role of prophylactic appendectomy in patients with incidental appendicolith on CT scans?

Should we offer prophylactic appendectomy to patients?

Most recent answer

23rd Oct, 2016
Sohaib Khan
University of Texas Southwestern Medical Center
I had asked the above question around 18 months back and it reallymade me understand that prevailing practices are based mainly on expert opinions and experiences with their being a lack of scientific evidence. I have therefore conducted a Retrospective matched cohort study of patients found to have Appendicoliths incidentally on CT scans. We recently presented our findings at the American college of surgerons clinical congress held in Washington DC. You can all find it below.
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All Answers (14)

21st Mar, 2015
Katherine A O'Hanlan
Laparoscopic Institute for Gynecology and Oncology (LIGO)
I am a Gyn Oncologist, and I offer incidental appy to every patient i operate on. Takes 90 seconds to incise through the mesoappendix, and tie off the appendix at the base with one Endoloop (by Ethicon, order EJ10G , a single use, preloaded on plastic knot pusher, pre-tied lasso, with an 18" 0-vicryl), and I pass it out the vagina on a ring forcep. I give Cefoxitin instead of Cephazolin to cover gi bugs, but I can say that I have never had a complication attributable to the appy. Have now done over 1300 incidental appys in my gyn surgeries since 1996,
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23rd Mar, 2015
Francis Oliver Cunningham
Royal College of Surgeons in Ireland
I would say 1300 unnecessary apps. There is old literature which says that SSI rattles go up doing it
23rd Mar, 2015
Edin Husaric
University Clinical Center Tuzla
If there is no recurrent abdominal pain, I think there is no sense to do appendectomy, just because we can see appendicolith on CT scan, especially if we are talking about children.
25th Mar, 2015
Ossama Mohamed Zakaria
Suez Canal University
As long as it is asymptomatic, there will be no role for performing an unnecessary surgery with its morbidity even if it will be of  a very low percentage. I totally disagree with what Dr. K A O'Honlan mentioned regarding her 1300 incidental appendectomy during the hysterectomy procedure as it seems to be of non sense.
The rational of performing an appendectomy in females may be attributed to the decrease of post inflammatory adhesion that may influence the female fertility potentials. So how about an already hysterectomized females??  
26th Mar, 2015
Ognyan Georgiev Brankov
Tokuda Hospital Sofia
An accidentally finding of appendicolyths in asymptomatic children is not necessarily indication for appendectomy. However one must consider a possible perforation by pressure with subsequent local peritonitis.
1 Recommendation
26th Mar, 2015
José Gustavo Olijnyk
Hospital Militar de Área de Porto Alegre, Brasil
If there is no semiological sign of apendicitis, surgery at this moment has no role. However, the patient should be monitored.
2 Recommendations
26th Mar, 2015
Ossama Mohamed Zakaria
Suez Canal University
I do agree with Jose Gustavo Olijinyk that the key for surgery here is the clinical signs and symptoms, yet, monitoring the patient is mandatory.
26th Mar, 2015
Goran Augustin
University Hospital Centre Zagreb
I would consider appendectomy when appendicolith is found on CT:
1. If the patient is operated for other intraabdominal  (intraperitoneal) disease
2. If the patient has chronic pain in the right lower quadrant 
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26th Mar, 2015
Sohaib Khan
University of Texas Southwestern Medical Center
Thank you all. The consensus of the majority seems that prophylactic appendectomy is not indicated but monitoring the patient is needed. This question came up in my mind when I had read in Bailey and Love's Short Practice of Surgery, 26th Edition that "The incidental finding of a faecolith is a 'relative indication' for prophylactic appendicectomy" However, I could not find any research articles in support of this statement.
27th Mar, 2015
Ossama Mohamed Zakaria
Suez Canal University
It was written a relative!!
So go linguistically for the meaning of relative and measure the relativity in this case.
Another point that we never diagnose and perform surgery based on investigations per-se.
i.e . The clinical examination and history is the main stone for any diagnosis; CT should be an assist and not the main tool for diagnosis
2 Recommendations
27th Mar, 2015
Andrey Borodach
Novosibirsk State Medical University
It is a good question, Dr.Khan, but similar topics have already existed at the Researchgate (see the links below). I would be happy if you keep us kindly informed about further fate of the patient. It is utterly interesting.
According to what were written there, the incidental appendectomies during any elected laparoscopic procedures are commonly accepted worldwide. The majority of practising surgeons seemingly share the motto "Good appendix is removed appendix", and the best candidate among the 'lily white appies' for removement is that one contained appendicoliths as has been presented here by Dr.O'Hanlan.
Which and when and how the appendicoliths may play their role? Are they the same in health and disease, or different? And so on, and so on...
There is a huge gap in the existing concept of the acute appendicitis' pathogenesis, and all these discussions about the needness or needless of so called 'prophylactic, or incidental appendectomy' and of the role of the appendicoliths will never end untill the mechanism of the acute appendicitis becomes clearer. As for now, it remains as obscure as it was at the time of Reginald Heber Fitz who discovered this common and dangerous disease in the year of 1886. The appendectomy is relatively cheep and simple to perform. And any fundamental investigations of the pathogenesis to do are always difficult and expensive, and their results are usually not very impressive. It is the hard and very long way to go still.
27th Mar, 2015
Goran Augustin
University Hospital Centre Zagreb
Dear Andrey you said it well.
And i must add something. For example some studies showed that patients with prior appendectomy had higher incidence of severe C. difficile colitis leading to colectomy. Also, similar observation was found with ulcerative colitis saying that appendix could have protective role. These are small numbers but should always be kept in mind when trying to make complete picture of some disease, procedure etc...
1 Recommendation
27th Mar, 2015
Andrey Borodach
Novosibirsk State Medical University
Yes, indeed. It is the matter of millions of appendectomies each year performed worldwide, so even the lowest mortality and morbidity rates turn to be very large in reality. Nobody has just studied this in the modern time yet. The appendicitis is out of the scientic fashion for long.
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