Management of Macroscopically Normal Appendix During Appendectomy in Children

Evidence-Based Rationale for Appendix Removal

The World Society of Emergency Surgery (WSES) provides a weak recommendation (2C) supporting appendix removal when the appendix appears normal during surgery for suspected appendicitis in symptomatic patients 1, 2
Intra-operative macroscopic distinction between a normal appendix and acute appendicitis can be challenging, with studies showing 19-40% of visually normal appendices are actually pathologically abnormal 2, 4
Risks of leaving an apparently normal appendix in situ include subclinical or endo-appendicitis with persisting symptoms 5 and missed appendiceal malignancy 1, 5

A study found that 90% of normal-looking appendices removed during laparoscopy for abdominal pain harbored inflammatory changes on histopathological examination 1, 3
Routine removal of normal-looking appendices was effective for preventing recurrent symptoms 1, 5

A study found that among 271 patients who underwent diagnostic laparoscopy where the appendix was not removed, only 20.7% were readmitted with right iliac fossa pain after 10 months, and only one of the subsequently removed appendices showed histological signs of inflammation 1, 6
No significant difference in complication rates or length of stay was found between negative appendectomy and uncomplicated appendicitis groups 1, 6

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines state that if no other pathology is identified, the decision to remove the appendix should be considered based on the individual clinical scenario 2, 4
The European Association of Endoscopic Surgery (EAES) guidelines recommend performing an appendectomy when the appendix appears normal during surgery for suspected acute appendicitis 2, 4

Routine histopathology after appendectomy is strongly recommended (1B) to identify unexpected findings 7, 8
Operative findings and intra-operative grading correlate better than histopathology with morbidity, overall outcomes, and costs in children 7, 8
The negative appendectomy rate can be as high as 36% in some series, highlighting the diagnostic challenges 6

Surgeon's macroscopic judgment of early grades of acute appendicitis is inaccurate and highly variable 1, 2
The decision to remove a normal-appearing appendix should weigh the risk of leaving a potentially abnormal appendix against the risk of appendectomy in each individual scenario 1, 2