ORIGINAL ARTICLE


https://doi.org/jp-journals-10033-1432
World Journal of Laparoscopic Surgery
Volume 14 | Issue 1 | (January–April 2021)

Do We Still Encounter Non-appendicitis Pathologies during Laparoscopic Appendectomy?

Yasser A Orban1, Mohammed Algazar2, Ahmed Farag3, Tamer R Elalfy4

1 Department of Surgery, Zagazig University, Zagazig, Sharkia, Egypt

2 Department of Surgery, Zagazig University, Zagazig, Sharkia, Egypt

3 Department of Surgery, Zagazig University, Zagazig, Sharkia, Egypt

4 Department of Surgery, Zagazig University, Zagazig, Sharkia, Egypt

Corresponding Author: Mohammed Algazar, Department of Surgery, Zagazig University, Zagazig, Sharkia, Egypt, Phone: +20 01028913029, e-mail: drmohammedezzat4@gmail.com

How to cite this article: Orban YA, Algazar M, Farag A, et al. Do We Still Encounter Non-appendicitis Pathologies during Laparoscopic Appendectomy? World J Lap Surg 2021;14(1):10–14.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Aims and objectives: Acute appendicitis is the most common surgical disease with a lifetime risk of 7–8%. Numerous studies have shown many benefits of laparoscopic appendectomy over open appendectomies, such as better visualization and identification of other abdominal pathologies that can mimic acute appendicitis. Herein, we illustrated the current incidence of non-appendicitis pathologies during laparoscopic appendectomies in our hospital.

Materials and methods: A retrospective study was carried out involving patients operated for acute appendicitis laparoscopically at the Surgical Emergency Unit, Zagazig University Hospitals, Egypt, during the period from March 2017 to December 2019. The diagnosis of acute appendicitis was based on clinical examination, laboratory findings, and ultrasonography. We drew out the patients’ demographic data, duration of surgery, and surgical procedure reports.

Results: One hundred forty-five patients presented clinically, and confirmed by laboratory and ultrasonography with the diagnosis of acute appendicitis. Eighty-nine were males, 56 were females. The median operative time was 56.5 minutes. Eight cases (5.5%) showed a pathology other than acute appendicitis, including gynecological pathologies, Mickel’s diverticulitis, inflamed sigmoid appendices epiploica, low-grade appendiceal mucinous neoplasm, and inflamed cecal diverticulum.

Conclusion: Diagnosis of acute appendicitis is challenging up to date. We faced many conditions mimicking acute appendicitis during surgical intervention.

Keywords: Appendectomy, Appendicitis, Diverticulitis.

World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1432

INTRODUCTION

Acute appendicitis is the most common surgical disease with a lifetime risk of 7–8%.1 In 1977, Hans de Kok performed the first laparoscopic-assisted appendectomy, which was not popularized until Semm published the first laparoscopic appendectomy in 1983.2 Numerous studies have shown many benefits of laparoscopic appendectomy over open appendectomies, such as better visualization and identification of other abdominal pathologies that can mimic acute appendicitis.3

The current incidence of incidental non-appendicitis histopathological findings during appendectomy is 3.9%, whether open or minimally invasive appendectomies.4 Herein, we illustrated the incidence of non-appendicitis pathologies during a laparoscopic appendectomy in the Surgical Emergency Unit, Zagazig University Hospitals, Egypt.

MATERIALS AND METHODS

A retrospective analysis of patients who underwent laparoscopic appendectomies from March 2017 to December 2019 at the Surgical Emergency Unit, Zagazig University Hospitals, Egypt. Pathologies other than acute inflammation of the appendix were recorded. We extracted the patients’ demographic data, duration of surgery, and surgical procedure reports.

All patients had a preoperative diagnosis of acute appendicitis depending on the clinical picture, laboratory investigations (complete blood count for leukocytosis and neutrophilia), and ultrasonography.

At the laparoscopic appendectomy, the abdominal cavity was laparoscopically explored for other surgical pathologies. If any other pathology had been encountered, it was dealt with laparoscopically. Appendectomy was done on all patients, even if there was another intra-abdominal pathology.

A case of intraoperative suspected cecal diverticulitis was treated conservatively postoperatively without any further surgical intervention.

Histopathology of the resected biopsies (appendix and other pathologies) was done for all cases. A histopathological report of a removed appendix revealed low-grade mucinous neoplasm with free margins and no infiltration to the basement membrane (carcinoma in situ); the patient was referred to the medical oncology department that recommended only follow-up of the patient.

RESULTS

One hundred and forty-five patients presented clinically. They were diagnosed with acute appendicitis after laboratory tests and ultrasonography. Eighty-nine patients (61.38%) were males, and 56 (38.6%) patients were females (Table 1). The mean age was 27.81 ± 8.34 years (Table 2). The minimum age was 16 years and younger patients were operated by pediatric surgery staff.

Table 1: Gender distribution of the patients
Frequency Percent
Valid Male 89 61.4
Female 56 38.6
Total 145 100.0
Table 2: Age
N Minimum Maximum Mean Std. deviation
Age 145 16.00 57.00 27.8069 8.34024

Fig. 1: Right ovarian torsion with gangrene

Fig. 2: Gangrenous Mickel’s diverticulum

During laparoscopic exploration, the cause of acute abdomen was discovered not to be acute appendicitis in 7 (4.83%) patients; 3 cases had ruptured ovarian cyst, 1 case had torsion ovary (Fig. 1), 1 patient had acute Meckel’s diverticulitis (Fig. 2), 1 patient had caecal diverticulitis (Fig. 3), and 1 patient had inflamed sigmoid appendices epiploica (Fig. 4) (Table 3).

Fig. 3: Inflamed cecal diverticulum

Fig. 4: Resected inflamed sigmoid appendicitis epiploica

Table 3: Distribution of non-appendiceal pathology by gender and age
Male Female Age Total
Ruptured ovarian cyst 1 20 1
Ruptured ovarian cyst 1 24 1
Ruptured ovarian cyst 1 28 1
Torsion ovary 1 30 1
Meckel’s diverticulitis 1 31 1
Inflamed sigmoid appendices epiploica 1 33 1
Inflamed cecal diverticulum 1 44 1
Total Ruptured ovarian cyst 0 3 3
Torsion ovary 0 1 1
Meckel’s diverticulitis 1 0 1
Inflamed cecal diverticulum 0 1 1
Inflamed sigmoid appendices epiploica 1 0 1
Total 2 5 7
Table 4: 0perative time
Procedure N Mean Std. deviation t p-value
Operative time Appendectomy and other pathology 7 72.4286 10.37396 10.310 0.000
Appendectomy only 138 43.6667 7.02896
Table 5: Distribution of histopathological features of the removed appendix
S ex
Age group Male Female Total
16–25 Histopathology of the removed appendix Acute catarrhal inflammation 25 14 39
Suppurative appendicitis 9 6 15
Gangrenous appendicitis 7 2 9
Normal appendix 5 4 9
Total 46 26 72
26–35 Histopathology of the removed appendix Acute catarrhal inflammation 10 7 17
Suppurative appendicitis 11 9 20
Gangrenous appendicitis 4 3 7
Normal appendix 2 3 5
Low-grade mucinous neoplasm 0 1 1
Total 27 23 50
36–45 Histopathology of the removed appendix Acute catarrhal inflammation 7 3 10
Suppurative appendicitis 4 0 4
Gangrenous appendicitis 0 3 3
Normal appendix 1 0 1
Total 12 6 18
46–55 Histopathology of the removed appendix Acute catarrhal inflammation 0 1 1
Suppurative appendicitis 2 0 2
Total 2 1 3
56 or older Histopathology of the removed appendix Acute catarrhal inflammation 1 1
Suppurative appendicitis 1 1
Total 2 2
Total Histopathology of the removed appendix Acute catarrhal inflammation 43 25 68
Suppurative appendicitis 27 15 42
Gangrenous appendicitis 11 8 19
Normal appendix 8 7 15
Low-grade mucinous neoplasm 0 1 1
Total 89 56 145

The mean operative time when appendectomy was the only procedure done was 43.6667 ± 7.02896 minutes while in the case of associated pathology, this time was longer (72.4286 ± 10.37 minutes) (p = 0.000) (Table 4).

Appendicular histopathology showed acute inflammation with different subtypes in 130 (89.66%) cases, low-grade appendiceal mucinous neoplasm in one case (0.69%), and 15 (10.34%) cases had normal appendix in histopathological examination (Table 5). Six patients with normal appendix had another surgical cause of acute abdominal pain, that was managed laparoscopically. Nine (6%) patients showed no apparent cause of their abdominal pain. The appendix of the patients with cecal diverticulitis showed acute catarrhal inflammation.

Eight cases (5.5%, 8/145) showed histopathologies other than acute appendicitis, seven non-appendiceal, and one appendiceal pathology.

DISCUSSION

One of the most common causes of surgical emergencies is acute appendicitis.5 Diagnosis of acute appendicitis is a challenge even to experienced surgeons and is usually a clinical one. Accurate medical history taking and clinical examination are essential to prevent unnecessary surgery, thereby avoiding operative complications.6

Approximately 80% of the clinically diagnosed acute appendicitis is accurate, with a false-negative appendicitis rate of 20%. The patient gender plays a vital role in the diagnostic accuracy of acute appendicitis, with a range of 78–92 and 58–85% in male and female patients, respectively presenting with right lower abdominal pain.7

The hazards of ionizing radiation make the routine use of computed tomography (CT) scans in diagnosing acute appendicitis highly controversial, especially in trenchant clinical presentations.

The dose of radiation delivered to the patients during CT scan of the abdomen is high, which may be comparable to 400 chest X-rays, and this certainly will increase the risk of occurrence of malignancies like leukemia.810

In our institution, a CT scan is not routinely used to diagnose acute appendicitis.

Acute appendicitis can mimic many gynecologic conditions, making the diagnosis uncertain. Although the imaging techniques have improved over the last three decades, it may still be challenging to differentiate between non-gynecologic and gynecologic causes of the acute abdomen before surgery.11

This retrospective study was done on 145 patients who were admitted to the Emergency Unit, Zagazig University Hospitals, Egypt with a diagnosis of acute appendicitis from March 2017 to December 2019.

In this study, the incidence of non-appendicitis acute abdomen among our patients was 7/145 (4.83%). The gynecological causes were 4/145 (2.76%): three ruptured ovarian cysts, and one ovarian torsion. The extra-appendiceal non-gynecological causes were 3/145 (2.07%): one Meckel’s diverticulitis, one cecal diverticulitis, and one inflamed sigmoid appendices epiploica.

Seetahal et al. conducted a retrospective study that revealed that the gynecologic conditions involving the ovary are the commonest to be misdiagnosed as an appendiceal disease in females.12 Literature depicted the risk of a wrong preoperative diagnosis (ovarian causes versus acute appendicitis) to be 5–8%, which was not high but still worthy of attention.13

The clinical presentation of Meckel’s diverticulitis is typically nonspecific.14 Radiologically, the diagnosis of Meckel’s diverticulitis can be challenging, especially if it is initially not suspected.15

In this study, one case (0.69%) of complicated gangrenous Meckel’s diverticulitis was detected in a 31-year-old male who presented with right iliac fossa pain and leukocytosis, and ultrasonography showed only free fluid in the right iliac fossa.

Epiploic appendagitis of the sigmoid colon is a rare cause of acute abdominal pain. The cause of this pathology may be torsion or thrombosis of the appendage’s veins.16 It is often misdiagnosed as either appendicitis or diverticulitis, according to its location17 Two studies found that the most common presentation of epiploic appendagitis was left lower quadrant pain (69–89%), right lower quadrant pain (8–16%), and pain at other locations, including in right and left upper quadrants (1.5–3%)18,19

In our study, one case (0.69%) was detected in a 33-year-old male who presented with right iliac fossa pain mimicking acute appendicitis that started a week before the presentation.

Inflammation of a colonic diverticulum in the caecum or ascending colon is called right-sided diverticulitis.20 The presentation of cecal diverticulitis is usually acute abdominal pain, which may be misdiagnosed by most surgeons as acute appendicitis. The treatment of the cecal diverticulum in most studies ranges from conservative medical treatment to right hemicolectomy.21

In this study, we encountered a case of cecal diverticulitis in a 44-year-old female during laparoscopic appendectomy that was managed conservatively, and the patient improved and was discharged after three days postoperatively.

Oudenhoven et al. reported the success of the conservative medical treatment in most of the cases with cecal diverticulitis (41/44) and surgery in three patients. The symptoms recurred in five patients who received the medical treatment, two of them needed surgical treatment.22

In this study, histopathology of the removed appendix was done for all cases. 131 (90.34%) patients had appendiceal pathology, 130 (89.66%) patients had different types of acute inflammations, and one patient had a low-grade mucinous neoplasm non-infiltrative with free margins. Fifteen patients had negative appendectomies. The appendix of the patient with cecal diverticulitis showed acute catarrhal inflammation. Six patients with negative appendectomy had another pathology of their acute abdominal pain, which managed laparoscopically. Nine (6%) patients had no apparent cause of their abdominal pain.

Appendiceal mucinous neoplasms are rare tumors with an incidence of 0.4–1.0% among gastrointestinal cancers. In the early stage and due to distension of the appendix with mucin, it presents with acute appendicitis-like symptoms. About one-third of the patients with appendiceal mucinous neoplasms are diagnosed preoperatively as acute appendicitis.23,23

The incidence of non-appendicitis pathology in our study was 7/145 (4.83%), which was slightly higher than that reported by Yabanoglu et al. (3.9%).4

CONCLUSION

Diagnosis of acute appendicitis is challenging up to date; we faced many conditions mimicking acute appendicitis during surgical intervention.

ORCID

Mohammed Algazar © https://orcid.org/0000-0001-7307-8579

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© Jaypee Brothers Medical Publishers. 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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© The Author(s). 0000 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.