Acute appendicitis--a clear-cut case in men, a guessing game in young women. A prospective study on the role of laparoscopy.
BACKGROUND
The aggressive surgical approach to patients suspected of having acute appendicitis for fear of perforation, and the inaccuracy of available diagnostic methods lead to an unacceptably high negative appendicectomy rate, especially in young women, in whom gynecological disorders frequently mimic appendicitis. Our objectives were to determine the value of diagnostic laparoscopy in women of child-bearing age to reduce the number of negative laparotomies and establish the correct diagnosis to allow prompt and appropriate treatment.


METHODS
161 consecutive adult female patients under 50 years of age with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy prior to the planned appendicectomy. If an inflamed appendix was found, appendicectomy was usually done through a muscle-splitting McBurney incision. Other diagnoses were treated accordingly. A normal appendix was not removed. Results were compared to a group of 42 similar patients in whom the laparoscopy was omitted for various reasons, to 23 postmenopausal women, and to all 137 male adults, directly operated by the McBurney approach.


RESULTS
After laparoscopy, 55% of the patients required appendicectomy for appendicitis while in 23% a gynecological diagnosis was made in spite of previous examination by a gynecologist. Fourteen percent had a negative laparoscopy. There were no false-negative results. The negative appendicectomy rate after laparoscopy was 5% due to two false positives and eight laparoscopy failures. In the group of fertile females who escaped laparoscopy the negative appendicectomy rate was 38%. The respective rates for postmenopausal women and men were 4% and 8%.


CONCLUSIONS
All women of child-bearing age suspected of having acute appendicitis should undergo diagnostic laparoscopy prior to the planned appendicectomy, regardless of the certainty of the preoperative diagnosis. This is currently the only way to reduce the negative appendicectomy rate and establish a correct diagnosis allowing prompt and appropriate treatment. In male patients and postmenopausal women one may proceed directly to emergency appendicectomy.
Borgstein
P J
PJ
Department of Surgery, Academic Hospital, Vrije Universiteit, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
Gordijn
R V
RV
Eijsbouts
Q A
QA
Cuesta
M A
MA
D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D001062:Appendectomy / Q000379:methods / Q000706:statistics & numerical data; D001064:Appendicitis / Q000175:diagnosis* / Q000453:epidemiology* / Q000601:surgery; D002983:Clinical Competence; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D005260:Female; D006801:Humans; D015994:Incidence; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D017678:Sex Distribution