Management of Suspected Acute Appendicitis with Normal-Appearing Appendix

Rationale for Appendectomy and Biopsy

The European Association of Endoscopic Surgery recommends performing appendectomy when the appendix appears normal during surgery for suspected acute appendicitis, as intra-operative macroscopic assessment is unreliable, with 19-40% of visually normal appendices being pathologically abnormal on histopathology, and studies demonstrate that 90% of normal-looking appendices removed during laparoscopy harbor inflammatory changes on pathological examination, with a weak recommendation (2C) from the World Society of Emergency Surgery supporting appendix removal in symptomatic patients 1
Routine histopathology after appendectomy is strongly recommended (1B) to identify unexpected findings, such as inflammatory bowel disease, which can be suggested by a normal appendix with inflamed cecum and terminal ileum, making tissue diagnosis essential for appropriate long-term management 3, 1

Perform standard appendectomy using endoloops/suture ligation or polymeric clips for stump closure, and obtain multiple biopsies from the inflamed cecum and terminal ileum for histopathological examination, avoiding peritoneal irrigation and placement of drains, which are associated with longer hospitalization and potentially increased morbidity 3
Send all specimens (appendix and biopsies) for histopathological examination, and arrange prompt gastroenterology referral for evaluation of inflammatory bowel disease, with the gastroenterologist determining the need for additional diagnostic studies and initiating appropriate medical therapy if Crohn's disease is confirmed 3, 1