Laparoscopy—A diagnostic aid in cases of suspected appendicitis

Brown, LaVigne, and Padilla

before further evaluation. This pregnancy, however, recently ended with an intrauterine fetal death of unknown cause at 30 weeks' gestation. In summary, this case demonstrates an unusual congenital anomaly consisting of a unicornuate uterus with a heterotopic left fallopian tube and a normal right tube and ovary. The left tube was not connected to the uterus and was attached to the left ovary by the fimbria ovarica. This tube contained an unruptured ectopic pregnancy, which provides supportive evidence for the phenom-

January 1987 Am J Obstet Gynecol

en on of trans peritoneal sperm migration. The left kidney and collecting system failed to develop, emphasizing the importance of evaluating the urinary tract when miillerian anomalies are encountered. REFERENCES I. Dabby V, Nardone R. Ruptured ectopic pregnancy in an

ectopic tube. J FlaMed Assoc 1977;64:809. 2. Szlachter N, Weiss G. Distal tubal pregnancy in a patient with a bicornuate uterus and segmental absence of the fallopian tube. Fertil Steril 1979;32:602.

Laparoscopy-A diagnostic aid in cases of suspected appendicitis Its use in women of reproductive age Nick M. Spirtos, M.D., Scott M. Eisenkop, M.D., Tanya W. Spirtos, M.D., Raymond I. Poliakin, M.D., and Lester T. Hibbard, M.D. Los Angeles, California In women of reproductive age the usefulness of laparoscopy in diagnosing acute appendicitis was evaluated. Eighty-six women underwent diagnostic laparoscopy. There was complete visualization of the appendix in 93% of the patients. Twenty-two patients were spared laparotomy. In the nonpregnant patients, salpingitis was the disease most often confused with appendicitis. Eighty-five percent of the patients with salpingitis had the onset of symptoms within 14 days of the last menstrual period, whereas acute appendicitis was found in 86% of the patients with the onset of symptoms > 14 days after the last menstrual period. The onset of symptoms relative to the first day of the last menstrual period differed in these two groups of patients (p < 0.01 ). Patients who were spared unnecessary laparotomy had significantly diminished hospital stays (p < 0.001 ). Laparoscopy was found to be a safe and effective way to diagnose acute appendicitis in women of reproductive age, and its liberal use is recommended. (AM J 0BSTET GYNECOL 1987;156:90-4.)

Key words: Pregnancy, ectopic, laparoscopy Acute appendicitis is one of the few surgical diseases encountered in which a correct preoperative diagnosis is not mandatory. Negative laparotomy rates (the percentage of laparotomies resulting in the removal of a normal appendix) average 15% to 20% and are considered acceptable. 1· 3 However, in women of reproductive age the negative laparotomy rate approaches From the Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Women's Hospital, Los Angeles County-University of Southern California Medical Center. Received for publication February 21, 1986; revised July 22, 1986; accepted August 14, 1986. Reprint requests: Nick M. Spirtos, M.D., Department of Gynecology and Obstetrics, Stanford University School of Medicine, Stanford, CA 94305-5317.

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40%. 3 -6 The differential diagnosis between inflammatory disorders of the female genital tract, appendicitis, torsion of adnexal structures, and other conditions remains a challenge. In addition, removal of a normal appendix is not without risk; complications include wound infection, pneumonia, peritonitis, pelvic abscess, paralytic ileus, bowel obstruction, deep vein thrombosis, infertility, and death. 7- 10 Recent reports suggest that laparoscopy can significantly reduce the negative laparotomy rate associated with the diagnosis and treatment of acute appendicitis. 11 · 12 This study reports the experience of the gynecology service at Los Angeles County-University of Southern California Medical Center in the use of laparoscopy for diagnosis in cases of suspected appendicitis.

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Material and methods

Ninety-four women underwent laparoscopy to rule out appendicitis at Los Angeles County-University of ·southern California Medical Center from 1974 to 1983. A two-puncture technique performed by resident and/or staff physicians was used. (Thirteen of the 94 patients were pregnant in the first trimester.) Eightysix charts were reviewed for menstrual and contraceptive history as well as chief complaints, physical findings, and laboratory analysis. Eight charts were unavailable for review. All microscopic specimens were reviewed by one of us. (Statistical comparison was done with use of X2 , Student's t test and Rankit analysis.) Results

Eighty-six women between 16 and 42 years of age, with a median age of 21 years, presented with a chief complaint of abdominal pain. The differential diagnoses included appendicitis, salpingitis, pyelonephritis, torsion of the adnexa, ectopic pregnancy, and early intrauterine pregnancy complicated by acute appendicitis. Previously, because the diagnosis of appendicitis was considered, laparotomy would have been performed in all of these patients. Instead, laparoscopy was performed initially followed by laparotomy if indicated. Of the 86 patients, 80 had satisfactory laparoscopy (93%) in that visualization of the pelvic viscera and the entire appendix was possible. Six laparoscopies were unsatisfactory; in these six patients the appendix could not be entirely visualized. In four instances the appendix could not be visualized because of the presence of pus and dense adhesions from ruptured appendices. In one instance the appendix could not be visualized because of the presence of a 200 ml spillage from a ruptured endometrioma. In the final instance the surgeon could not induce a pneumoperitoneum. Of the 80 patients with satisfactory laparoscopy, 56 were thought to have acute appendicitis, 17 salpingitis, one a ruptured corpus luteum cyst, one a fecalith, and five were thought to have no pathologic condition present (Table 1). Appendicitis was confirmed histologically in 51 patients; 4 7 correctly diagnosed at the time of laparoscopy and four diagnosed at the time of laparotomy following unsatisfactory laparoscopy. The nine patients whose diagnosis of appendicitis was incorrect at the time of laparoscopy were retrospectively diagnosed as having salpingitis, based on concurrent findings of both an inflammatory exudate on the fallopian tubes as well as the appendix and a histologic diagnosis of periappendicitis. Seventeen patients had a correct diagnosis of salpingitis at the time of laparoscopy as well as another 10 patients following laparotomy. These patients included the nine patients with salpingitis and

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Table I. Laparoscopic and final diagnoses Final diagnosis (n)

Acute appendicitis Salpingitis Ruptured corpus luteum cyst Mesenteric addenitis Ruptured endometrium Fecalith No pathologic findings Unsatisfactory Total

56 17 I

0 I I

5

5* 86

51 27 I I I I 4 0 86

*Four patients had unsatisfactory laparoscopy with appendicitis; one patient had failed laparoscopy.

Table II. Presenting clinical data (nonpregnant patients)

Median age (yr) Range Nausea and vomiting(%) Anorexia(%) Obstipation(%) Temperature Median range White blood count Range Total no. of patients

Patients with appendicitis

Patients with salpingitis

21 16-42 80 89 18 100.6° 98.0-103.2 14,300 (8,200-25,000) 51

22 (15-36) 72 85 20 101° 98-102 12,600 (6,800-23,500) 27

concurrent periappendicitis and one patient who underwent laparotomy when the surgeon could not induce a pneumoperitoneum (Table I). Of the five patients who were thought to be disease-free at the time oflaparoscopy, only one underwent laparotomy. Based on this patient's history, findings at exploratory laparotomy, and histologic review, a diagnosis of mesenteric adenitis was made. One patient had a ruptured corpus luteum cyst. Another patient was found to have a dilated appendix with multiple large fecaliths, and a final patient had a ruptured endometrioma. Twenty-two patients underwent successful laparoscopy with visualization of the entire appendix and pelvic viscera, and laparotomy was avoided by confirmation of a nonsurgical diagnosis. Seventeen of these patients were found to have acute salpingitis. One patient was noted to have a ruptured corpus luteum cyst, and in four instances, no findings requiring laparotomy could be found at laparoscopy (Table I). All left the hospital with resolution of their physical findings and symptoms, and none later required surgical intervention. The clinical presentations of the nonpregnant patients were remarkably similar. As in other series, salpingitis was the condition most often confused with

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Table III. Historic characteristics (nonpregnant patients)

Table V. Length of hospitalization Patients with salpingitis

Patients with appendicitis

Menstrual pattern Normal Abnormal Total Contraception Oral contraceptives Intrauterine device Bilateral tubal ligation None

26 II 37

20 5 25*

6 6 I 24 37

6 5 1 I2 24

Laparoscopy only Laparoscopy-laparotomy with removal of normal appendix Laparoscopy-laparotomy with removal of inflamed appendix

Appendectomy Wound infections

Table IV. Onset of symptoms from last menstrual period (nonpregnant patients; n = 71)*

No. of patients

29

>14 days

days J

3.8 ± 2.5 5.7 ± 2.6

51

6.2 ± 3.3

p < 0.001

NS

Complications Type

Appendicitis

2I 14

Table VI. Complications

*Data not available on all patients.

~14

Significance

Procedure

Salpingitis

Appendicitis

23

25

l

Salpingitis

Pelvic abscess Pulmonary embolism Ileus Laparoscopy None

n

Final diagnosis

4

Appendicitis (3); normal appendix (I) Appendicitis Appendicitis Appendicitis

2 1 1

4

*Dates of last menstrual period not available for two patients.

appendicitis!· 5 There was no remarkable physical finding, symptom, or laboratory test that proved to be of value in differentiating acute appendicitis from salpingitis. The percentage of patients in each group found to have a history of significant nausea and vomiting, anorexia, or obstipation for >24 hours was calculated (Table II). There was no significant difference between the salpingitis and appendicitis groups. The median age of the patients with appendicitis and salpingitis was 21 and 22 years old, respectively. The groups were remarkably similar in terms of menstrual patterns and contraception (Table III). Only when the onset of symptoms was compared to the first day of the last menstrual period did the two groups significantly differ; the patients with acute appendicitis were distributed equally throughout the menstrual cycle whereas most patients with salpingitis (85%) had their symptoms begin within 2 weeks of the last menstrual period (p < 0.01 ). Patients with the onset of symptoms at > 14 days after the last menstrual period had acute appendicitis 86% of the time (Table IV). Thirteen patients had positive pregnancy tests and were in their first trimester. In addition to menstrual histories significant for amenorrhea, the histories and physical findings of the pregnant patients in this series were similar to the nonpregnant patients. All 13 ap-

pendices were visualized; 12 were found to be acutely inflamed and one was normal. There were no maternal complications in this group and no fetal losses occurred. The patients with histologic confirmation of appendicitis had an average hospital stay of 6.2 ± 3.3 days (Table V). This is identical to the group of patients who underwent diagnostic laparoscopy and appendectomy with the removal of a normal appendix (5.7 ± 2.6 days). However, in those patients where laparoscopy prevented laparotomy, the average hospital stay was 3.8 ± 2.5 days, a significant decrease in hospitalization (p < 0.001). There were no complications among the patients spared laparotomy, but eight complications occurred in patients who required laparotomy (Table VI). It should be noted that seven of these eight patients did have acute appendicitis and needed laparotomy. There were no deaths in either group. Comment

Recently three studies reported the use of laparoscopy in the diagnosis of acute appendicitis. 9 • 11 • 12 In 1979 the retrospective study of Leape and Ramenofsky 12 included 32 pediatric patients, the negative laparotomy rate was 12%, and six patients were spared laparotomy. There was one false negative laparoscopy. This patient developed increasingly severe peritoneal signs; appendectomy was performed and appendicitis was confirmed histologically. In 1982 Deutsch et al. 11 prospectively performed laparoscopy on 36 patients between 18 and 50 years of age. The negative laparotomy rate

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was 4%, and 12 patients (33%) were spared laparotomy. There were no false-negative laparoscopies in this study. Leape and Deutsch were able to significantly reduce their negative laparotomy rates by using laparoscopy as a diagnostic aid. In 1980 Jersky eta!." prospectively performed laparoscopy on 27 patients. After classification of patients into three groups (likely to have appendicitis, unlikely to have appendicitis, and uncertain), appendectomy was performed. Nineteen of the 27 patients were classified as unlikely to have appendicitis or had uncertain diagnoses. Twelve of these 19 patients had acute appendicitis, and thus Jersky et al. concluded l<~paroscopy would not improve their negative laparotomy rate. These results are so different from the <;~hove-men­ tioned studies, as well as our own, that further discussion is warranted. Although Jersky et al. classified patients as having an uncertain diagnosis if (I) the appendix was incompletely visualized (eight patients), (2) the appendix was normal and no other pathologic condition was identified (three patients), or (3) the appendix and other pelvic organs were concurrently inflamed (two patients), they did not state why the appendices were incompletely visualized or why patients with no evident pathologic condition were categorized into the uncertain group, and they did not describe what they considered coexistent salpingitis and appendicitis. Since this information is not provided, we feel it is not possible to evaluate Jersky et al.'s ~tudy and compare it to the results of others. Unlike Jersky et al., who were unable to entirely visualize eight of 27 appendices (33%), we had little difficulty visualizing the appendix. Eighty of 86 patients (93%), including 13 pregnant patients, had appendices that were entirely visualized. Other than our one technical failure, all patients whose appendices could not be visualized ultimately proved to have surgical conditions; four had acute appendicitis, and one had a ruptured endometrioma. The diagnositc problems we encountered when the entire appendix was completely visualized were decisions regarding which organ was primarily affected when there was concurrent salpingitis and periappendicitis. In nine such patients, a review of the operative reports revealed that, in spite of the presence of gross pus exuding from inflamed fallopian tubes, a concerned surgeon decided to perform an appendectomy. The nine patients had only periappendicitis. Jersky et al. had two somewhat similar patients, and both of their patients had acute appendicitis. Thus it is somewhat difficult to wholeheartedly advocate abandoning appendectomy in such cases. In spite of the misdiagnosis in nine such cases, we were still able to halve our negative laparotomy rate by adding laparoscopy to our diagnostic armamentarium. In all, 22

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patients were spared laparotomy. Perhaps as more data are gathered and more experience gained with use of laparoscopy as a diagnostic aid, laparotomy in similar cases will be avoided. Another group of patients who presented special diagnostic problems were those presenting with lower abdominal pain, questionable uterine enlargement and a positive pregnancy test. Differential diagnoses included ectopic pregnancy, early intrauterine pregnancy with appendicitis or torsion of an adnexal structure, pyelonephritis, or a rupture of a corpus luteum cyst. Physical examinations in these patients were usually unproductive, since abdominal guarding often prevented an accurate assessment of uterine size and the adnexal structures. A correct diagnosis in this group of patients is critical because complications following a misdiagnosis include maternal and fetal death. 13 · 11 Since we had only 13 pregnant patients in our study and all were in the first trimester, it is difficult to advocate laparoscopy in all pregnant patients. However, with the use of open laparoscopy, even patients with advanced gestations could undergo laparoscopy. Other benefits of laparoscopy include decreased postoperative complications, shortened hospital stays, and a better selection of abdominal incisions. In the literature, 15% of patients whose normal appendix is removed by laparotomy develop significant postoperative complications such as pneumonia, intestinal obstruction, stress ulceration, ileus, peritonitis, pelvic abscess, deep vein thrombosis, wound infection, and death?· 7· 9 · 15 In addition, pregnant patients have an increased risk of spontaneous abortion. On the other hand, laparoscopy is associated with 1% to 2% postoperative complications.'· 16 Laparoscopy reduces the length of hospital stay and provides the surgeon with information that can be used in selecting the location of the abdominal incision when laparotomy proves necessary. If acute appendicitis is diagnosed, a muscle-splitting incision can be made in the best location. A properly placed incision is particularly important in the pregnant patient in whom exposure can be especially troublesome. Not only is laparoscopy in experienced hands usually safe and simple, but as a diagnostic procedure, it has proved to be quite valuable. In our series of 86 patients, the negative laparotomy rate was 19%; if laparoscopy had not been performed, the negative laparotomy rate would have been 41%. Therefore we recommend laparoscopy to rule out appendicitis in women of reproductive age. When the onset of symptoms is ""14 days after the last menstrual period, laparotomy can often be avoided. With patients whose symptoms begin after 14 days from the last menstrual period, use of laparotomy, without laparoscopy, cannot be criticized. Since

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some groups using laparoscopy have been able to decrease their negative laparotomy rate to as low as 5%, we still recommend laparoscopy in these patients. In the pregnant patient, laparoscopy also proved a valuable diagnostic aid, and we recommend its liberal use to further reduce negative laparotomy rates. Only when the entire appendix is visualized should laparoscopy be called satisfactory. In summary, although these data were collected and analyzed retrospectively, valuable clinical information was acquired. First, it is apparent that, with experienced laparoscopists, adequate visualization of the appendix is possible in most patients (93%). In those patients where visualization was not adequate, significant pathologic conditions requiring laparotomy proved to be the reason visualization was not possible. Second, our institution's negative laparotomy rate was significantly reduced from 41% to 19% by use of laparoscopy. This study was not prospectively designed, but there are historic controls that have consistently documented negative laparotomy rates of 40% for women in the reproductive age group. This, as it happens, is almost identical to what ours would have been if laparoscopy had not been performed on our patients. Although there is some selection bias on our study population, it is difficult to conclude that we are overstating the benefit of laparoscopy in the differential diagnosis of appendicitis from salpingitis. Third, it is interesting to note that, as suspected, salpingitis develops much more commonly early in the menstrual cycle. In fact, only four of29 (13%) of the patients with the onset of symptoms more than 14 days after the last menstrual period had salpingitis. With the above guidelines and u~e of the laparoscope, surgeons and obstetricians-gynecolo-

January 1987 Am J Obstet Gynecol

gists should be able to significantly reduce negative laparotomy rates in diagnosing women with suspected appendicitis.

REFERENCES 1. Cantrell JR, Stafford ES. The diminishing mortality from appendicitis. Ann Surg 1955;141:749. 2. Hobson T, Rosenman ID. Acute appendicitis-when is it right to be wrong? Am] Surg 1964;108:306. 3. Jess P, Bjerregard B, Brynitz S, eta!. Acute appendicitis prospective trial concerning diagnostic accuracy and complications. Am .J Surg 1981;141:232. 4. Dunn EL, Moore EE, Elerding SC, eta!.: The unnecessary laparotomy for appendicitis-can it be decreased? Am Surg 1982;48:320. . 5. Gilmore OJA, BrowettJP, Griffin PH, eta!. Appendicitis and mimicking conditions. Lancet 1975;2:421. 6. Silberman VA. Appendectomy in large metropolitan hospital..Am.J Surg 1981;142:615. 7. Chamberlain G. Gynaecologicallaparoscopy. Ann R Coli Surg Engl1980;62:133. 8. Howie .JGR. Death from appendicitis and appendectomy-an epidemiological survey. Lancet 1966;4:72. 9 . .Jersky J, Hoffman.J, Kurgan A. Laparoscopy in patients with suspected acute appendicitis. South African .J Surg 1980:19:147. 10. O'Rourke M, Milton GW. The results of removing a "normal" appendix. Aust NZ J Surg 1963;33: 12. II. Deutsch AA, Zelikovsky A, Reiss R. Laparoscopy in the prevention of unnecessary appendectomies: A prospective study. Br .J Surg 1982;69:336. 12. Leape LL, Ramenofsky ML. Laparoscopy for questionable appendicitis. Ann Surg 1979; 191:410. 13. Babakni A, Hossein P, WoodruffJD. Appendicitis during pregnancy. Obstet Gynecol 1977;50:40. 14. Fisenda R, Roty AR, Kilway .JR, eta!. Acute appendicitis during pregnancy. Am Surg 1979;45:503. 15. Jerman RP. Removal of the normal appendix: the cause of serious complications. Br J Clin Pract 1969;23:466. 16. Chang FC, Hogle HH, Welling DR. The fate of the negative appendix. Am .J Surg 1973; 126:752.