The Importance of Fully Removing the Appendix During an Appendectomy.

A Case Example

In this case, the Patient underwent a CT after attending their GP with abdominal pain. A diagnosis of a mild acute appendicitis was made, and a prescription of Ciprofloxacin and Metronidazole was given. The pain continued and ten days later the patient attended A&E where they consented to a laparoscopic appendectomy.

A month later the patient was diagnosed with Parkinson’s disease and was prescribed Sinemet. Later, the patient suffered intense abdominal pain and an ambulance was called. A suspected diagnosis of infectious gastroenteritis was made and they were discharged without referral or follow-up scheduled.

The patient attended their GP 2 days later, still in considerable pain and the GP requested the patient be admitted to hospital to the gastrointestinal surgical service. A diagnosis of collection post-appendectomy or adhesions was made. A CT scan revealed the stump of the appendix was dilated measuring 11mm in dimeter. The patient underwent a second procedure to remove the remaining part of the appendix.

Main Learning Points

  • The removal of 3cm of appendix at the first operation should have alerted the surgeon to the possibility of incomplete appendicectomy. The average length of the normal appendix is 7cms. Any excision substantially smaller than this should heighten concern that there may be an excessive length of stump remaining.

  • An appendix should be removed completely, or if leaving a stump, the stump length should be less than 0.5cm in order to avoid the stump becoming ischaemic. This avoids stump blowout, abscess formation and stump appendicitis [1].

Reducing the Risk of Litigation

By not fully removing the appendix, general surgeons put themselves at an enhanced risk of litigation and the patient at risk of further complications or possible infection [2]. In order to mitigate the risk, TMLEP recommends the following:

  • Appropriately visualising the base of the appendix as it joins the caecum. Ideally with clear photographic evidence if possible.

  • Leaving no more than 0.5cm of stump in situ as there is a greatly increased risk of complications if more than this is left.

  • Following an appendicitis, severe abdominal pain should open the possibility of a stump appendicitis as a possible diagnosis and also warrant further investigation to find its source.

Conclusions

Stump appendicitis occur in 1 in 50,000 cases[1], to reduce the risk of litigation, surgeons should be confident in the location of the base of the appendix and leave no more than a 0.5cm stump appendix after an appendectomy to reduce the risk of a stump appendicitis.

When a patient re-presents with right iliac fossa pain following appendicectomy a low threshold for imaging with CT prevents delay in diagnosis of this and similar complications.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable.