Is incidental appendectomy necessary in women with ovarian endometrioma?
: Dr Joong Sub Choi, Division of Gynecological Oncology and Gynecological Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108, Pyung-dong, Jongno-gu, Seoul, South Korea. Email: firstname.lastname@example.org
Background: Several studies reported that pathology of the appendix is frequently detected alongside endometriosis, especially with chronic pelvic pain. Furthermore, ovarian endometriosis is a marker of more extensive pelvic and intestinal disease.
Aims: To evaluate the feasibility and efficacy of incidental appendectomy in laparoscopic surgical treatment for ovarian endometrioma.
Methods: One hundred and six women with ovarian endometrioma underwent laparoscopic surgery including laparoscopic appendectomy. Clinicopathological data were collected and analysed.
Results: The main symptoms consisted of lower abdominal pain in 51 (48.1%) women, dysmenorrhoea in 23 (21.7%), left lower quadrant pain in 6 (5.7%), right lower quadrant pain in nine (8.5%), chronic pelvic pain in five (4.7%), and others in 12 (11.3%). Only three (3.3%) of the 106 women had abnormal findings on gross inspection during laparoscopic surgery: two women with endometriotic spots on the surface of their appendixes, and one with peri-appendiceal inflammation with severe adhesions. Of the 106 resected appendixes, 37 (34.9%) had histopathologically confirmed pathology including lymphoid hyperplasia in 12 (11.3%), endometriosis in 14 (13.2%), peri-appendicitis and serositis in five (4.7%), carcinoid tumour in three (2.8%), and others in three (2.8%).
Conclusions: In all surgical treatments for ovarian endometrioma, surgeons need to preoperatively inform the patients of the fact that appendiceal pathology including endometriosis is found frequently regardless of concurrent symptoms or gross finding of the appendix. Furthermore, surgeons should take into account the possibility of appendiceal pathology during operation.
Endometriosis commonly involves the pelvic organs such as the ovaries, the uterosacral ligament, and the rectovaginal septum,1 although endometriosis can also occur in the gastrointestinal tract, the ureter, the pleura, and the lungs.2,3 Endometriosis of the gastrointestinal tract occurs in about 5% of women with endometriosis, and appendiceal involvement is seen in approximately 1% of women.4–7
Women with appendiceal endometriosis may present with acute or chronic symptoms such as lower abdominal pain, chronic pelvic pain (CPP), acute appendicitis, haemorrhage and intestinal perforation.3,8–10 Consequently, based on results from the elimination of further appendicitis, the removal of undiagnosed incidental pathology of the appendix, and the excision of potential appendicitis for future diagnostic consideration, several studies have argued that incidental appendectomy is needed for the surgical treatment of endometriosis.11–14
The aim of this study was to examine the feasibility and efficacy of incidental appendectomy in women with ovarian endometrioma.
We retrospectively reviewed the medical records of women who underwent laparoscopic surgical treatment for ovarian endometrioma between January 2004 and October 2007. For women without a history of appendectomy, our department suggests laparoscopic appendectomy (LA) as a laparoscopic surgical treatment of endometriosis. After fully explaining the advantages, risks, and possible complications of LA, we performed LA in women who provided an informed consent. One hundred and six women who underwent laparoscopic surgical treatment for ovarian endometrioma including LA were enrolled in this study. The women's medical records, clinical data, operative data, and histopathological results were reviewed and analysed.
LA was performed according to the following procedure. A 5-mm trocar was inserted directly into the midline just below the umbilicus through a vertical skin incision without the use of a Veress needle. Under the guidance of a central 5-mm telescope, two 5-mm ancillary trocars were placed in the left and right upper quadrants, lateral to the superior and inferior epigastric vessels. The fourth trocar was placed two-finger widths above the symphysis pubis.15 To allow for the use of an endocutter and the safe removal of the resected appendix, a 5-mm umbilical trocar was replaced by a 12-mm trocar. On completion of excision and fulguration of all suspected endometriotic lesions, we completely removed the peri-appendiceal adhesions before performing LA. After the lysis of peri-appendiceal or pericaecal adhesions, the appendix was grasped tightly and elevated with the left-hand forceps. A bipolar coagulator and monopolar scissors were used to skeletonise, coagulate, and cut the mesoappendix. An endocutter with vascular staples (Endoscopic Linear Cutter with white cartridge, Ethicon Endo-Surgery, Cincinnati, OH, USA) or pre-tied loops (Round LapLoop, Sejong Medical, Seoul, South Korea) were used to ligate and amputate the appendix. When using an endocutter with vascular staples, the endocutter was placed on the umbilical 12-mm trocar, and a 5-mm telescope was located on one of the ancillary 5-mm trocars. When using pre-tied loops, the base of the appendix was triple ligated with the pre-tied loops. The stump was amputated between the distal second and third ligatures, and handled meticulously to prevent dropping the dissected appendix within the abdominal cavity. The dissected appendix was removed through the umbilical 12-mm trocar. An endobag (Lap bag, Sejong Medical, Seoul, South Korea) was used to remove appendixes that were too large to be removed through the 12-mm trocar.
Data are expressed as the median and range. All statistical analyses were performed using sas version 9.1 (SAS Institute Inc., Cary, NC, USA).
The median age of the patients was 31 years (21–49 years). The median parity was 0 (0–3), and the median body mass index was 21.5 kg/m2 (16.0–33.5 kg/m2). The main preoperative symptoms are presented in Table 1.
Table 1. Main symptom-specific incidence of histopathologically determined endometriosis and other diseases of the appendix
|Lower abdominal discomfort||51 (48.1)||12 (11.3)||13 (12.3)|
|Dysmenorrhoea||23 (21.7)|| 1 (0.9)||2 (1.9)|
|Left lower quadrant pain||6 (5.7)|| 0||1 (0.9)|
|Right lower quadrant pain||9 (8.5)|| 0||5 (4.7)|
|Chronic pelvic pain||5 (4.7)|| 0||0|
|Others||12 (11.3)|| 1 (0.9)||2 (1.9)|
|Total||106 (100)||14 (13.2)||23 (21.7)|
In terms of the operative results, the operating time for LA was defined as the time elapsed from the time the appendix was elevated with the use of a grasping forceps for LA to the time of its removal from the abdominal cavity. The median operating time of LA was 2.5 min (two to 11 minutes). The return of bowel activity was defined as the period from the end of anaesthesia to the first occurrence of bowel gas passage. The median return of bowel activity was 29.7 h (16.7–69.9 h). The median change in haemoglobin concentration from before surgery to postoperative day one was 1.7 g/dL (0.1–3.8 g/dL). Classified according to the Revised American Society for Reproductive Medicine Classification of Endometriosis,16 39 woman (36.8%) were at stage III and 67 (63.2%) at stage IV. The median length of hospital stay was three days (two to nine days). The date of discharge was not determined based on the objective criteria, but varied according to the type of major operation for endometriosis. There were no intraoperative complications. Postoperative fever was defined as a body temperature of ≥ 38°C in two consecutive evaluations of at least six hours apart, except during the first 24 h. Postoperative complications occurred in seven women: postoperative fever in one, transient paralytic ileus in three, diarrhoea in two, and wound disruption in one. These symptoms were resolved with conservative treatment. Thirty-seven (34.9%) women had histopathologically abnormal findings in their resected appendixes, including 14 (13.2%) with appendiceal endometriosis. Detailed histopathological results are shown in Table 2.
Table 2. Histopathological results of the resected appendixes
|Abnormal findings||37 (34.9)|
| Lymphoid hyperplasia||12 (11.3)|
| Endometriosis||14 (13.2)|
| Peri-appendicitis and serositis||5 (4.7)|
| Carcinoid tumour||3 (2.8)|
| Acute appendicitis||1 (0.9)|
| Chronic appendicitis||1 (0.9)|
| Obliterating fibrosis||1 (0.9)|
|No abnormal findings||69 (65.1)|
Endometriosis is a common disorder seen in 4–50% of reproductive-age women, and can cause a variety of mild to severe symptoms, the most common of which are pelvic pain and subfertility.17 Treatment for endometriosis is determined by the severity of symptoms and the future pregnancy plans.
Appendiceal involvement is seen in about 1% of patients with endometriosis, although no study has established the mechanism by which appendiceal involvement occurs. It may be speculated that the appendiceal pathology originates from appendicitis or luminal obstruction caused by the adhesion formed around the appendix in patients with endometriosis, as occurs with other diseases.12 Several studies have reported a high incidence of histopathologically proven appendiceal endometriosis in women with endometriosis and CPP.12,18,19 During the surgical treatment for endometriosis, laparoscopic surgeons must resect suspected lesions as completely as possible, meticulously examine the appendix, and perform appendectomy in patients when an abnormal finding is identified.1 Redwine pointed out that ovarian endometriosis is a marker for the presence of extensive pelvic and intestinal disease, although the rate of appendiceal endometriosis was 2.7% in his series; furthermore, surgical treatment of the ovarian endometrioma alone may lead to the underdiagnosing and undertreating of endometriosis.20
There is still controversy over the necessity for incidental appendectomy in the surgical treatment of endometriosis. Some authors recognise the need for incidental appendectomy for a limited range of patients, such as those with endometriosis in which the adhesion and inflammation are grossly present in the appendix or when the symptoms suggest appendiceal disease.19,21 In contrast, other authors claim that appendectomy should be done even in patients whose appendixes seem grossly normal because the intraluminal findings cannot be examined accurately, and there is a risk that in situ appendiceal disease may progress without appendectomy.18 In addition, at present, there are no typical symptoms or specific tests to preoperatively predict appendiceal endometriosis in women with endometriosis. On gross examination in our series, just three of 106 women had abnormal findings: two women with endometriotic spots on the surface of the appendix, and one woman with peri-appendiceal inflammation plus severe adhesions. Although the other patients had no grossly abnormal findings, 37 (34.9%) women presented with abnormal histopathological findings, and 14 (13.2%) of these women had appendiceal endometriosis. These findings indicate that 34 of 37 women with abnormal histopathological findings in their resected appendixes showed normal findings on gross inspection. Three of these 34 women had carcinoid tumours of the appendix with sizes of 1.2, 0.5, and 0.3 cm. One of these women had history of an emergency operation for the rupture of an ovarian endometrioma. The others underwent laparoscopic surgery for ovarian endometrioma, which was found unexpectedly during routine gynaecological ultrasonography. No diagnostic clues were present on gross inspection during surgery to cause suspicion of appendiceal disease in these women. In other words, if we did not conduct incidental appendectomy based on the normal findings on gross inspection of the appendix, we might have failed to make a correct diagnosis in 34 of 37 women (32.1%). These 34 women presented with abnormal histopathological findings including 12 women with appendiceal endometriosis and three women with carcinoid tumours of the appendix.
The study of endometriosis patients with right lower quadrant (RLQ) pain by Harper and Soules18 and the study of endometriosis patients with CPP by Berker et al.12 both reported higher incidence in both appendiceal endometriosis (33% vs 22.1%) and appendiceal disease (75% vs 49.8%) compared to our study. Table 3 shows that appendiceal endometriosis (13.2%) and appendiceal disease (34.9%) occurred less frequently in our study than in the studies by Harper and Soules18 and Berker et al.12 However, a study of endometriosis patients with and without CPP or RLQ pain showed a lower incidence of appendiceal endometriosis (4–13%) and appendiceal disease (5.7%) compared to our study. These results suggest that the existence of CPP or RLQ pain in an endometriosis patient may help predict appendiceal disease. Considering that only five of our patients had CPP (4.7%) and nine had RLQ pain (8.5%), performing incidental appendectomy on all women with ovarian endometrioma without CPP or RLQ pain may be reasonable.
Table 3. Summary of previous studies on laparoscopic surgery for endometriosis
|Pittaway14 (1983)||104||ES||13 (13%)||–|
|Harris et al.22 (2001)||52||ES with RLQ pain||12 (31%)||39 (75%)|
|Berker et al.12 (2005)||231||ES with CPP|| 51 (22.1%)||115 (49.8%)|
|Gustofson et al.8 (2006)||87||ES|| 4 (4.6%)||5 (5.7%)|
|Current study||92||Ovarian endometrioma|| 14 (13.2%)|| 37 (34.9%)|
An argument certainly can exist against our statement claiming that incidental appendectomy should be performed on all ovarian endometrioma patients as a result of a lack of correlation between abnormal histopathological findings in the resected appendixes and clinical symptoms. However, the pathophysiology and pathogenesis of patients with abnormal appendiceal histopathological findings, but no clinical symptoms, are not clearly defined thus far, thereby leaving no solutions to predict the patients’ possibility of clinical symptoms. Moreover, the incidence of acute appendicitis peaks between the age of 15 and 30 years, with a cumulative lifetime risk of 7%;22 furthermore, the incidence of endometriosis peaks at a younger age of 25–29 years compared to other gynaecological disorders.23 Therefore, to eliminate further appendicitis, we believe that performing incidental appendectomy needs to be considered in the surgical treatment for all women with ovarian endometrioma, regardless of CPP or RLQ pain.
In all surgical treatments for ovarian endometrioma, surgeons need to preoperatively inform the patients of the fact that appendiceal pathology including endometriosis is found frequently regardless of concurrent symptoms or gross finding of the appendix. Furthermore, surgeons should take into account the possibility of appendiceal pathology during operation.