The Role of Appendectomy in Gynaecologic Surgery: A Canadian Retrospective Case Series

Transcription

1 GYNAECOLOGY The Role of Appendectomy in Gynaecologic Surgery: A Canadian Retrospective Case Series Jennifer A. Jocko, BScN, MD, Hassan Shenassa, MD, FRCSC, Sukhbir S. Singh, MD, FRCSC Department of Obstetrics and Gynecology, The Ottawa Hospital, The University of Ottawa, The Ottawa Hospital Research Institute, Ottawa ON Abstract Objective: To review the indications for, and the associated pathology and complications of, appendectomy performed during gynaecologic surgery in a tertiary academic health sciences centre. Methods: We performed a retrospective review of appendectomy cases performed from September 2007 to December 2011 in a tertiary level gynaecologic surgical practice. Cases were reviewed using a standardized intake sheet with surgical reports, history, and pathologic findings. Results: A total of 71 appendectomies were performed during gynaecologic surgery in the study period. All cases were primary gynaecologic surgical cases; the most common diagnoses were endometriosis, pelvic pain, and pelvic mass. Overall, 42 (59%) of the study cases had abnormal histopathology in the appendix. Of the 44 women with a primary diagnosis of endometriosis, 28 (64%) had positive appendiceal pathology. In women with chronic pelvic pain, three of eight (38%) had pathology within their appendix. Of all appendixes removed that appeared normal on gross inspection, irrespective of diagnosis, 44% had positive pathology. Conclusion: When a structured approach is taken towards assessment of the appendix during gynaecologic surgical cases, with removal when indicated, a high rate of pathology may be found. In this series, there were no complications directly related to the appendectomy, providing support for the contention that appropriately trained gynaecologists can safely perform appendectomy. The findings in this Canadian series are in keeping with previous reports and support the need for evaluation and removal of the appendix when indicated at the time of gynaecological surgery. Key Words: Appendix, appendectomy, gynaecologic surgery, endometriosis, chronic pelvic pain, pelvic mass Competing interests: None declared. Received on June 5, 2012 Accepted on June 28, 2012 Résumé Objectif : Analyser les indications, la pathologie connexe et les complications de l appendicectomie menée au cours d une chirurgie gynécologique au sein d un centre de santé universitaire tertiaire. Méthodes : Nous avons mené une analyse rétrospective des cas d appendicectomie ayant eu lieu entre septembre 2007 et décembre 2011 au sein d une pratique chirurgicale gynécologique de niveau tertiaire. Les cas ont été analysés au moyen d une fiche d accueil standardisée comptant les rapports de chirurgie, l anamnèse et les constatations pathologiques. Résultats : Au total, 71 appendicectomies ont été menées dans le cadre d une chirurgie gynécologique au cours de la période d étude. Tous les cas étaient des cas chirurgicaux gynécologiques primaires; les diagnostics les plus courants étaient l endométriose, la douleur pelvienne et la présence d une masse pelvienne. En tout, 42 (59 %) des cas de l étude présentaient une histopathologie anormale en ce qui concerne l appendice. Chez les 44 femmes qui avaient obtenu un diagnostic primaire d endométriose, 28 (64 %) présentaient une pathologie appendiculaire positive. Chez les femmes qui connaissaient une douleur pelvienne chronique, trois femmes sur huit (38 %) présentaient une pathologie appendiculaire. Quarante-quatre pour cent de tous les appendices retirés qui semblaient normaux au moment de l inspection macroscopique, sans égard au diagnostic, présentaient une pathologie positive. Conclusion : Lorsque l on adopte une approche structurée envers l évaluation de l appendice dans le cadre de cas chirurgicaux gynécologiques (s accompagnant d un retrait lorsque cela s avère indiqué), un fort taux de pathologie peut être constaté. Dans le cadre de cette série, aucune complication directement associée à l appendicectomie n a été constatée, ce qui soutient l hypothèse selon laquelle les gynécologues disposant d une formation appropriée peuvent mener des appendicectomies en toute sûreté. Les résultats obtenus dans le cadre de cette série canadienne sont conformes à ce qui a été signalé auparavant et soutiennent la nécessité de procéder à une évaluation et au retrait de l appendice lorsque cela s avère indiqué au cours d une chirurgie gynécologique. J Obstet Gynaecol Can 2013;35(1): JANUARY JOGC JANVIER 2013

2 The Role of Appendectomy in Gynaecologic Surgery: A Canadian Retrospective Case Series INTRODUCTION Appendectomy is one of the most common surgical procedures performed globally. 1 The appendix may be removed as an emergency because of acute inflammation, as part of a procedure with related pathology, in cases of chronic pain, or in cases of abnormal appearance during non-related abdominal or pelvic surgery. Incidental removal of a normal appendix during laparoscopy or laparotomy has also been performed in an attempt to prevent future appendicitis. 2,3 Appendectomy during gynaecologic surgical cases has been reported in several large case series, 2,4 8 but there is a paucity of reported Canadian experience. We report our experience of the indications for appendectomy performed at the time of gynaecologic surgery using a standardized approach, together with the associated pathology and outcomes, in a tertiary level academic health sciences centre. Table 1. Demographics of population Characteristics Mean age, years (range) 38 (23 to 78) Mean BMI, kg/m 2 (range) 26 (18 to 43) Previous abdominal surgery (one or more procedures), Appendectomy route, 48 (68) Laparoscopy 68 (96) Laparotomy 3 (4) Length of stay (one day or less), 66 (93) Primary diagnosis, Endometriosis 44 (62) Minimal 7 (9.8) Moderate 6 (8.4) Severe 31 (44) Chronic pelvic pain 8 (11) Pelvic mass 12 (17) Other (hemoperitoneum, perforated IUD, ectopic pregnancy) 7 (9.9) Positive appendiceal pathology, * 42 (59) *Listed in Table 3 METHODS We conducted a review of all appendectomy cases performed from September 2007 to December 2011 in a tertiary level gynaecologic surgical practice. Cases were identified through billing records. Cases were audited with review of surgical reports, history on file, and pathology reports. The surgical practice involved two Canadian gynaecologists who have a standardized approach to appendectomy in their gynaecologic surgical cases and who have been trained at the fellowship level to perform appendectomy at both laparotomy and laparoscopy. Their standardized approach is as follows: The appendix is identified at every case to rule out abnormalities. All abnormal-appearing appendixes are removed at the time of surgery, even if appendectomy is not related to the primary surgery being performed. The appendix is removed if indicated by primary pathology (e.g., ovarian mucinous tumours). All patients with severe endometriosis provide written consent for possible appendectomy, and the appendix is removed if abnormal in appearance or adherent to adjacent diseased organs. All patients with chronic pelvic pain provide written consent for possible appendectomy, and the appendix is removed if it is abnormal in appearance or if it is normal and the patient has right lower quadrant pain and/or there is no other clear cause. Appendectomy is not performed incidentally to prevent future appendicitis. In the majority of cases reported procedures were performed laparoscopically (96%). All patients received perioperative antibiotic prophylaxis with a first-generation cephalosporin and an aminoglycoside or metronidazole. At laparoscopy the mesoappendix was isolated and separated close to the base of the appendix using bipolar electrosurgery forceps and monopolar scissors or laparoscopic ultrasonic shears. The base of the appendix was secured with two 0-PDS Endoloops (Ethicon Endo- Surgery Inc., Cincinnati, OH) on the proximal stump and one on the side of the surgical specimen. The appendix was transected with laparoscopic scissors. The appendix was always removed through an endoscopic retrieval bag. All specimens were sent for pathologic examination. Cases performed by laparotomy did not use energy sources to isolate and seal the mesoappendix; instead a simple clamp and suture ligation technique was used to secure the vessel and appendix stump. Approval for this project was obtained from The Ottawa Hospital Research Ethics Board. JANUARY JOGC JANVIER

3 Gynaecology Table 2. Operative characteristics Operative characteristic (primary procedure) Laparoscopic management of endometriosis* Excision of endometriosis (including ovarian cystectomy for endometrioma) 53 (75) Laparoscopic hysterectomy 9 (13) Laparoscopic management of pelvic mass Unilateral salpingo-oophorectomy 24 (34) Bilateral salpingo-oophorectomy 11 (16) Tumour staging (omentectomy, pelvic lymphadenectomy) 3 (4.2) Laparoscopic hysterectomy for fibroids 2 (2.8) Caesarean section 2 (2.8) Caesarean hysterectomy 1 (1.4) *May have included several concomitant procedures including laparoscopic myomectomy, presacral neurectomy, and cystoscopy. Table 3. Appendiceal pathology Histopathology Total with abnormal pathology 42 (59) 44 pathologies found* Endometriosis 26 (37) Appendicitis 4 (5.6) Mild acute Periappendicitis Perivascular lymphovascular infiltration Appendiceal pathology benign 9 (13) Fecolith Serosal fibrosis Fibrous obliteration of lumen Carcinoid tumour 3 (4.2) Mucinous cystadenoma 2 (2.8) No abnormal findings 29 (41) *Two patients had two separate pathologies within the appendix. Table 4. Presence of appendiceal pathology based on primary diagnosis Primary diagnosis Positive pathology n = 42 (59%) Negative pathology n = 29 (41%) Endometriosis 44 (62) 28 (64) 16 (36) Chronic pelvic pain 8 (11) 3 (38) 5 (62) Pelvic mass 12 (17) 6 (50) 6 (50) Other 7 (9.9) 5 (71) 2 (29) Table 5. Correlation of appearance of the appendix and pathology General appearance Positive pathology n = 42 (59%) Negative pathology n = 29 (41%) Normal 27 (38) 12 (44) 15 (56) Abnormal 44 (62) 30 (68) 14 (32) RESULTS Using a standardized approach to the indications for appendectomy during gynaecologic surgery, a total of 71 appendectomies were performed during the study period (Tables 1 and 2). All cases were primary gynaecologic surgical cases, with the most common diagnoses being endometriosis, pelvic pain, and pelvic mass (Table 1). Overall, 42 study cases (59%) were found to have abnormal histopathology, and two cases had two separate pathology findings within the appendix (Table 3). Of the 44 patients with a primary diagnosis of endometriosis, 28 (64%) had positive appendiceal pathology (not necessarily endometriosis only). In patients with chronic pelvic pain, three of eight patients within our sample (38%) had pathology within their appendix (Table 4). Of all appendixes removed that appeared normal on gross inspection, irrespective of diagnosis, 44% had positive pathology (Table 5). Appendiceal pathology varied and included benign, inflammatory, and malignant conditions. Two patients required bowel resections at a later time because of the 46 JANUARY JOGC JANVIER 2013

4 The Role of Appendectomy in Gynaecologic Surgery: A Canadian Retrospective Case Series final pathology results (the first had a carcinoid tumour infiltrating the mesoappendix and the second had a mucinous cystadenoma with invasive characteristics). Complications occurred postoperatively in four of the cases; however, the appendectomy was not directly related to these complications. The complications were a small bowel obstruction on postoperative day 15, which was managed conservatively; an entry trocar injury detected on the first postoperative day; a tumour lysis syndrome in a patient with an embryonic ovarian tumour; and a visit to the emergency room by a patient with pain on the second postoperative day. DISCUSSION During gynaecologic surgery, the appendix may be removed for several reasons. In this series, the appendix was not removed incidentally to prevent future appendicitis; instead, it was removed on the basis of a systematic approach noted above. The main concomitant diagnoses in these cases were endometriosis, chronic pelvic pain, and adnexal mass. In similar published reports, the rate of appendiceal pathology in cases of endometriosis ranges from 0.8% to 22%. 5,9 14 The authors of these reports suggest that the potentially high incidence of pathology supports consideration of routine removal of the appendix during surgical management of endometriosis. 5,10 11,14,15 In our series we found a higher incidence of appendiceal pathology than in previous reports, but this may have been because appendectomy was performed selectively, rather than routinely in all cases of endometriosis (as was the case in some of the referenced studies). In women who had chronic pelvic pain as the sole indication for surgery, in the absence of endometriosis, 38% had pathology within their appendix. The reported range of positive appendiceal pathology in women with chronic pelvic pain ranges from 3.3% to 92%. 4,9,12,14,16 17 The potentially high rate of pathology in the appendix lends support to the argument that the appendix can harbour pathology other than endometriosis, and therefore that appendectomy can play a role in effective long-term management of chronic pelvic pain. There is a current trend to consider removing the appendix if it is grossly abnormal, with a 23% positive pathology rate reported by Alsalilli and Vilos. 12 However, our study found a pathology rate of 44% in appendixes that had a normal appearance. This is significant, especially considering the clinical implications of findings such as chronic appendicitis, endometriosis, and mucinous cystadenoma. It is important to note that fellowship-trained gynaecologic surgeons performed the appendectomies in this study with no complications directly related to the appendectomy itself. The ability to perform an appendectomy is not a requirement for graduation from an obstetrics and gynaecology residency program in Canada at present. 17 In addition, a national consensus project addressing core competencies for gynaecologic endoscopy in Canadian residency training found there are no expectations or consensus that graduating residents should have the skills required to perform an appendectomy. 18 CONCLUSION Appendiceal pathology was found with a relatively high incidence during gynaecologic surgery. With a systematic approach to indications, performing appendectomy may be considered in benign gynaecologic surgery. This study did not assess the role of incidental appendectomy. There were no complications directly related to appendectomy in our series, providing support to the idea that appropriately trained gynaecologists can safely perform appendectomy during laparoscopy. These findings support the need for routine inspection of the appendix and management of appendiceal pathology at the time of gynaecological surgery. REFERENCES 1. Jaffe BM, Berger DH. The appendix. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JE, et al., eds. Schwartz s principles of surgery. 9th ed. New York: McGraw-Hill Professional; Snyder TE, Selanders JR. Incidental appendectomy-yes or no? A retrospective case study and review of the literature. Infect Dis Obstet Gynecol 1998;6: American College of Obstetricians and Gynaecologists. ACOG Committee Opinion. Incidental appendectomy. Int J Gynaecol Obstet 1996;52: Agarwala N, Liu CY. Laparoscopic appendectomy. J Am Assoc Gynecol Laparosc 2003;10: Berker B, Lashay N, Davarpanah R, Marziali M, Nezhat CH, Nezhat C. Laparoscopic appendectomy in patients with endometriosis. J Minim Invasive Gynecol 2005;12: O Hanlan KA, Fisher DT, O Holleran MS. 257 incidental appendectomies during total laparoscopic hysterectomies. JSLS 2007;11: Song J, Yordon E, Rotman C. Incidental appendectomy during endoscopic surgery. JSLS 2009;13: Lee JH, Choi JS, Jeon SW. Laparoscopic incidental appendectomy during laparoscopic surgery for ovarian endometrioma. Am J Obstet Gynecol 2011;204:28.e1 e5. JANUARY JOGC JANVIER

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