257 Incidental Appendectomies During Total Laparoscopic Hysterectomy

Abstract

This retrospective observational report analyzes the demographics, blood loss, length of surgical duration, number of days in the hospital, and complications for 821 consecutive patients undergoing total laparoscopic hysterectomy over a 11-year period stratified by incidental appendectomy.
A retrospective chart abstraction was performed. ANOVA and chi-square tests were performed with significance preset at P<0.05.
Of 821 consecutive patients undergoing total laparoscopic hysterectomy, 257 underwent elective appendectomy with the ultrasonic scalpel, either as part of their staging, treatment for pelvic pain, or prophylaxis against appendicitis. Comparing the 2 groups, no difference existed in mean age of 50+/-10 years or mean BMI of 27.6+/-6.7. Both groups had a similar mean blood loss of 130 mL. Surgery took less time (137 vs 118 minutes, P<0.0012) and the hospital stay was shorter in the appendectomy group (1.5 vs 1.2, P<0.0001) possibly because it was performed incidentally in most cases. No complications were attributable to the appendectomy, and complication types and rates in both groups were similar. Though all appendicies appeared normal, pathology was documented in 9%, including 3 carcinoid tumors.
Incidental appendectomy during total laparoscopic hysterectomy is not associated with significant risk and can be routinely offered to patients planning elective gynecologic laparoscopic procedures, as is standard for open procedures.

Full text

257 Incidental Appendectomies During Total
Laparoscopic Hysterectomy
Katherine A. O’Hanlan, MD, Deidre T. Fisher, MD, Michael S. O’Holleran, MD
ABSTRACT
Objective: This retrospective observational report analyzes the
demographics, blood loss, length of surgical duration, number
of days in the hospital, and complications for 821 consecutive
patients undergoing total laparoscopic hysterectomy over a 11-
year period stratified by incidental appendectomy.
Methods: A retrospective chart abstraction was per-
formed. ANOVA and chi-square tests were performed
with significance preset at P⬍0.05.
Results: Of 821 consecutive patients undergoing total laparo-
scopic hysterectomy, 257 underwent elective appendectomy
with the ultrasonic scalpel, either as part of their staging, treat-
ment for pelvic pain, or prophylaxis against appendicitis. Com-
paring the 2 groups, no difference existed in mean age of
50⫾10 years or mean BMI of 27.6⫾6.7. Both groups had a
similar mean blood loss of 130 mL. Surgery took less time (137
vs 118 minutes, P⬍0.0012) and the hospital stay was shorter in
the appendectomy group (1.5 vs 1.2, P⬍0.0001) possibly be-
cause it was performed incidentally in most cases. No compli-
cations were attributable to the appendectomy, and complica-
tion types and rates in both groups were similar. Though all
appendicies appeared normal, pathology was documented in
9%, including 3 carcinoid tumors.
Conclusions: Incidental appendectomy during total
laparoscopic hysterectomy is not associated with signifi-
cant risk and can be routinely offered to patients planning
elective gynecologic laparoscopic procedures, as is stan-
dard for open procedures.
Key Words: Incidental appendectomy, Laparoscopy, To-
tal laparoscopic hysterectomy.
INTRODUCTION
Incidental appendectomy during gynecological proce-
dures has been reviewed in the literature since 1967 and is
considered safe and reasonable during both abdominal
and vaginal surgeries.
1–8
Nezhat and Nezhat
9
reported on
therapeutic laparoscopic appendectomy for the treatment
of pelvic pain and concluded the benefits outweigh the
minimal risks. It is not known whether incidental laparo-
scopic appendectomy can be done safely and routinely in
gynecologic surgery. We reviewed our database of 821
cases of total laparoscopic hysterectomy (TLH) in which
257 patients had elective appendectomy and report on the
safety of this procedure.
METHODS
We have maintained an anonymous database of TLH
cases performed on consecutive patients in each of the
following diagnostic categories: benign gynecologic indi-
cations and early malignancies limited to Stage IA2 or less
cervical cancer, occult ovarian cancer, and clinical Stage
IIIA or less endometrial cancer. Investigational Review
Board approval is maintained at Sequoia Hospital in Red-
wood City, CA, USA. In all of these patients, a simple
hysterectomy was performed alone or with other proce-
dures as indicated by the patient’s history, physical exam-
ination, and radiological examinations. Every surgery was
performed by the author (KAO’H) from September 5, 1996
to April 4, 2007, at 4 California hospitals. A categorical
obstetrics and gynecology resident, a gynecologist, or a
general surgeon assisted all surgeries.
The technique used for TLH is described elsewhere in the
gynecologic literature.
10
After the hysterectomy, an ap-
pendectomy was performed in 257 patients, incising the
mesoappendix with a 5-mm Harmonic scalpel or LigaSure
(Covidian, Boulder, CO, USA) (Ethicon Endo-Surgery,
Cincinnati, OH, USA), to the base at the cecum, then
ligating the base with a 0-Vicryl EndoLoop (Ethicon
Sutures, Piscataway, NJ, USA). The appendix was then
incised across the base with the Harmonic scalpel or
LigaSure (Figure 1). A ring forceps was passed through
the vagina to grasp the appendix at the open base and
remove it from the abdominal cavity.
Gynecologic Oncology Associates, Palo Alto, California, USA (Dr. O’Hanlan).
Atlanta Center for Special Pelvic Surgery, Atlanta, Georgia, USA (Dr. Fisher).
General Surgery Associates, San Carlos, California, USA (Dr. O’Holleran).
Drs O’Holleran and Fisher have no conflict of interest. Dr. O’Hanlan is a consultant
for Novare Surgical Systems and is a speaker for Ethicon EndoSurgery. No financial
support was received for this article. No off-label use of any product is discussed
or described.
Address reprint requests to: Kate O’Hanlan, MD, Gynecologic Oncology Associates,
4370 Alpine Road, Suite 104, Portola Valley, CA 94028, USA. Telephone: 650 851
6669, Fax: 650 851 9747, E-mail: ohanlan@AOL.com
© 2007 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
JSLS (2007)11:428–431428
SCIENTIFIC PAPER

By using JMP statistical software (SAS, Cary, NC, USA),
continuous data were analyzed by ANOVA, and categor-
ical data were analyzed by chi-square and Fisher’s exact
test, with significance set at P⬍0.05.
RESULTS
Of 821 women undergoing TLH, 257 underwent concom-
itant appendectomy and 564 did not. The mean age of 50
(P⫽0.1404) and mean body mass index (BMI) of 27
(P⫽1823) were similar in both groups.
Surgical blood loss was similar in both groups, 130 mL
(P⫽0.0678). The mean duration of surgery was 19 minutes
shorter in the appendectomy group, (137 vs 122 minutes,
P⬍0.0012). Patients in the appendectomy group spent
fewer days in the hospital (1.5 vs 1.2, P⬍0.0001). If pa-
tients with long additional procedures performed, such as
node dissection, omentectomy, Burch colposuspension,
uterosacral ligament plication, cholecystectomy, hernior-
rhaphy, or posterior vaginal repair, were eliminated from
the analysis, leaving only 482 patients undergoing only
hysterectomy/BSO, appendectomy, lysis of adhesions,
and fulguration (not resection) of endometriosis, the ap-
pendectomy cases still were of shorter duration (133 vs
104 minutes, P⬍0.0001), and the duration of stay was still
shorter in the appendectomy group (1.5 vs 1.1,
P⬍0.0001).
Clinically, all 257 appendices appeared normal. Patho-
logic examination of the appendices revealed normal
anatomy in 135 (52%); fibrous obliteration in 98 (38%);
endometriosis in 8 (4%); 3 cases each of carcinoid tumor
(1.1%) and chronic appendictis (1.1%); 2 cases each of
serositis fatty metaplasia and mucinous cystadenoma
(1.1%); and one case each of mucosal melanosis, neuro-
philia, adhesions, and metastatic papillary ovarian cari-
noma (1.5%). Two of the three cases of carcinoid demon-
strated invasion to the serosal surface and required
subsequent staging ileoascending colectomy as treatment.
No complications were attributed to the appendectomy
procedure. Additionally, there was no difference in overall
(11.3 vs 7.4%, P⫽0.0813), or reoperative complications
(5.6 vs 2.7%, P⫽0.0654) in either group.
DISCUSSION
In patients 40 years and older, appendicitis occurs with a
frequency of about 30/100,000,
11
about the same as the
incidence of ovarian cancer in that age group.
12
After age
60, patients who develop appendicitis have a significantly
increased risk of perforation and postoperative complica-
tions.
13
This is because the diagnosis of appendicitis in
senior women is often difficult, making immediate open
surgical exploration appropriate in this population.
14
In
1981, Tranmer et al
6
reviewed 100 cases of appendicitis
among women over age 40 and found a 30% perforation
rate and a 31% risk of incisional abscess. Furthermore,
among these women, 13% had undergone previous elec-
tive hysterectomy or cholecystectomy, leading them to
conclude that some of these cases may have been pre-
vented by incidental appendectomy.
The earliest reports of incidental appendectomy in gyne-
cologic surgery were during Cesarean deliveries in 1959,
15
for management of ectopic pregnancy in 1962,
16
vaginal
hysterectomy in 1966,
8
with abdominal hysterectomy in
1967,
17
and during postpartum sterilizations in 1973.
18
The
routine performance of incidental appendectomy during
laparotomy for ovarian cancer staging had become stan-
dard by 1968 because 25% of normal-appearing appendi-
ces contained metastatic deposits.
6
In 1981, Tranmer et al
6
reviewed 200 cases of incidental appendectomy during
laparotomy for hysterectomy or cholecystectomy, noting
no complications, concluding that incidental appendec-
tomy was indeed routinely indicated with laparotomy.
Waters et al
19
concurred that incidental appendectomy
“should be performed with abdominal and pelvic surgery
whenever the opportunity is presented.” In a review of
5,369 incidental appendectomies, 8% of specimens dem-
onstrated acute appendicitis, 65% showed evidence of
chronic appendicitis with obliteration of the lumen, and
Figure 1. The appendix is held with the Realhand (Novare
Surgical Systems, Cupertino, CA, USA) in preparation for incision
of the mesentery.
JSLS (2007)11:428–431 429

0.6% contained carcinoid tumors, mucoceles, or endome-
triosis.
20
These data are reconfirmed by our findings.
Incidental appendectomy has been recommended for
routine use with all abdominal hysterectomies by Salom et
al,
1
who also observed no additional complications and
confirmed a 31% rate of appendiceal pathology.
2
By 1988,
routine incidental appendectomy during laparotomy was
accepted as safe and protective,
4,20
with some hospital
programs enforcing a policy of routine incidental appen-
dectomy during all open gynecologic surgery.
21
They re-
ported 97% compliance with the policy with no increase
in complication rates attributed to the appendectomy.
21
Initially, in the late 1970s, laparoscopy for appendicitis
was used solely to confirm the diagnosis and to facilitate
the planned laparotomy for appendectomy.
22–24
After the
1987 separate reports of laparoscopic therapeutic appen-
dectomies by Gangal and Gangal
25
and Schrieber,
26
the
laparoscopic approach for therapeutic appendectomy be-
came standard.
27
A laparoscopic approach for incidental appendectomy in
elective gynecologic surgery was first reported in 1982 by
Semm
28
and then in a 1990 series of 388 gynecologic
procedures by Gotz et al,
29
and in a 1991 series of 100
procedures by Nezhat and Nezhat,
9
with no complications
attributable to the procedure. In 1996, Pelosi and Pelosi
30
performed 12 vaginal incidental appendectomies during
laparoscopic-assisted vaginal hysterectomies and found
that an additional 12 minutes was needed for the proce-
dure. Incidental laparoscopic appendectomy is specifi-
cally recommended in cases of right pelvic pain because
22 of 53 patients had appendiceal inflammation, even
though removal did not relieve the pain in all patients.
31
Many patients having laparoscopic surgery for endometri-
osis have been found to have endometriosis on the ap-
pendix.
32
Neither fertility concerns
33,34
nor pregnancy
35
are contraindications for incidental or indicated appen-
dectomy in young women.
33,34
Today, laparoscopic ther-
apeutic appendectomy is part of the gynecologic surgical
standard for treatment of pelvic pain and endometrio-
sis,
36,37
and staging of ovarian and tubal carcinoma.
38
In this series of total laparoscopic hysterectomy patients
with many diverse gynecological indications, no detri-
ment was observed that was attributable to the appendec-
tomy. The longer surgical duration and postoperative hos-
pital stay in the group not having appendectomy are likely
due to the fact that appendectomy was variably offered
and variably performed. This is a significant weakness in
this report, but it reflects the reality of surgical practice
standards. Although appendectomy was recommended to
every patient under age 40, we did not document the rate
of acceptance or refusal. Additionally, we did not uni-
formly offer or document the response for appendectomy
to every patient over age 40. Early in the series, appen-
dectomy was rarely offered to patients over age 40. When
a case seemed overly long or difficult, the appendectomy
was sometimes abandoned. These data, however, are still
useful in confirming that laparoscopic incidental appen-
dectomy is low risk when the appendix is accessible and
when the prior portions of the case have gone well.
CONCLUSION
This series of 199 cases is the largest series of laparoscopic
incidental appendectomies in gynecology and confirms
an equal and low complication rate whether appendec-
tomy was performed or not. These data concur with the
literature findings of safety from routine incidental appen-
dectomy during open or laparoscopic approaches. Gyne-
cologists should consider offering prophylactic appendec-
tomy to their patients when open or laparoscopic
procedures are planned.
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