Incidental Appendectomy

Mohamed El-Sayed AbosdiraResident Doctor at general surgery department

Sohag university hospital

What is Incidental Appendectomy ??

Incidental appendectomy is the removal of the vermiform appendix accompanying another operation, without evidence of acute appendicitis.

Examples

Incidental appendectomy during the management

of Malrotation

Intestinal malrotation represents the classic clinical scenario when IA is performed. Ladd’s procedure, classically including laparotomy, lysis of Ladd’s bands, positioning of the large bowel on the left and small bowel on the right, and removal of

the left-sided appendix to prevent future misdiagnosis.

Incidental appendectomy during

Repair of congenital diaphragmatic hernia (CDH)

As malrotation is the most common associated anomaly, Ladd’s procedure will done, including appendectomy.

Incidental appendectomy during

Gynecologic surgery

Appendectomy at the time of laparoscopic surgery for endometriosis does not increase operative morbidity, and has diagnostic and preventive value.

Incidental appendectomy during

Intussusception

Incidental appendectomy during

Amyand’s and De Garengeot herniaThis is a rare form of inguinal hernia (less than 1 %,) that is defined by inclusion of the appendix within the hernia sac.

De Garengeot hernia, describes the uncommon

finding of the appendix positioned within a femoral.

Generally, IA is not recommended in cases where the appendix is contained with a hernia sac, unless the appearance of the appendix is abnormal ,as transection of the appendix converts the case from clean to clean-contaminated.

Incidental appendectomy during

Exploratory laparotomy/trauma laparotomyIA prevents future diagnostic confusion, and preventing the need for

an additional operation should acute appendicitis develop .

However, addition of an appendectomy to a procedure increases operative time and provides a potential source of contamination to an otherwise clean field.

Classic recommendations leave IA to the surgeon’s discretion, recognizing the conflict between the risks and benefits.

.A point of debate ??

why??

This depends on the use of the appendix as a tubular conduit

for reconstruction

Utility of the appendix

urological reconstruction, colonic irrigation, and biliary reconstruction.

Urologic indications for use of the appendix

Reconstruction of the ureter

when an interposed segment is required to bridge two segments of the ureter or bridge the ureter to the bladder

Urologic indications for use of the appendix

The Mitrofanoff procedure Appendicovesicostomy

mobilizes the appendix on its vascular pedicle to create a conduit from the anterior abdominal skin to the bladder. As the bladder fills, outward pressure is exerted on the tunneled appendix, compressing the lumen and maintaining continence. When a catheter is inserted, it drains readily.

neurogenic bladder or Bladder outlet obstruction Traumatic neurological injuries, posterior urethral valves, and congenital neurological deficits.

Advantages

Less painful Avoid traumatic disruption of the urethra, urethral

stricture, or development of a false passage. easy ,applicable “self-catheterization”

Utility of the appendix

Fecal Stoma

The introduction of the Malone antegrade continence enema (MACE) procedure in 1990 has improved the quality of life for patients suffering from conditions such as;

Chronic constipation,

imperforate anus,

Hirschsprung’s disease,

spinal disorders

MACE procedure

The MACE procedure connects the cecum to the abdominal wall using the appendix as a continent stoma to allow antegrade flushing of the entire length of the colon to evacuate the stool.

Allow self-administration by the Pt. through anterior abdominal stoma .

Advantages

Utility of the appendix

Biliary reconstruction

The appendix can also be useful in biliary reconstruction, after treatment for choledochal cysts. In 1971, Grosfeld et al. first tested the concept of relieving biliary obstruction by fashioning an appendiceal conduit between gall bladder and duodenum.

Advantages

The appendix provides an anti-peristaltic, small-caliber, epithelialized, and vascularized conduit that greatly reduces the occurrence of cholangitis, compared to small bowel conduits .

Appendiceal conduits are usually reserved for patients who fail conventional hepaticojejunostomy, rather than routine biliary repair .

conclusion

The decision to perform IA needs to be carefully weighed in regards to the procedure to be performed, the patients’ medical history, and the likelihood of requiring the appendix for future use as a tubular conduit for reconstruction.

Referances

Mitrofanoff P (1980) Trans-appendicular continent cystostomy in the management of the neurogenic bladder. Chir Pediatr 21(4):297–305

Leslie JA, Dussinger AM, Meldrum KK (2007) Creation of continence mechanisms (Mitrofanoff) without appendix: the Monti and spiral Monti procedures. Urol Oncol 25(2):148–153 17.

Melnikoff AE (1912) Sur le replacement de l’ureter pa anse isolee de l’intestine grele. Rev Clin Urol 1:601–610

. Stein R, Schro¨der A, Thu¨roff JW (2012) Bladder augmentation and urinary diversion in patients with neurogenic bladder: surgical considerations. J Pediatr Urol 8(2):153–161

Malone PS, Ransley PG, Kiely EM (1990) Preliminary report: theantegrade continence enema. Lancet 336(8725):1217–1218

Thank you