Objective
We sought to investigate the safety and efficacy of laparoscopic incidental appendectomy during laparoscopic surgery for endometrioma.
Study Design
We conducted a retrospective study of 356 patients undergoing laparoscopic surgery for endometrioma with appendectomy (appendectomy group, n = 172) or not (nonappendectomy group, n = 184). Primary outcome measures were operating time, hemoglobin change, hospital stay, return of bowel activity, and any complications. The secondary outcome was appendiceal histopathology.
Results
There were no statistical differences between groups in operating time, postoperative changes in hemoglobin concentration, hospital stay, return of bowel activity, or complication rate. Of the 172 resected appendices, 52 had histopathologically confirmed abnormal findings including appendiceal endometriosis in 16.
Conclusion
Incidental appendectomy at the time of laparoscopic surgery for endometrioma does not increase operative morbidity, and it has considerable diagnostic and preventive value. However, a large prospective randomized study is needed in the future to confirm this conclusion.
Endometriosis usually involves pelvic structures, such as the ovaries, uterosacral ligament, and rectovaginal septum. Approximately 1–3% of patients with endometriosis reportedly have appendiceal endometriosis. In recent studies of incidental appendectomies performed in patients with endometriosis accompanying chronic pelvic pain, right lower quadrant pain, or ovarian endometrioma, abnormal pathologies, including appendiceal endometriosis (13.2–31%), were detected in 34.9-75% of the resected appendices. Based on these results, the studies recommended incidental appendectomy during the surgical management of endometriosis.
In the obstetric and gynecological fields, there have been several reports of the safety of incidental appendectomy at the time of hysterectomy or cesarean delivery. However, there is no study about the safety of incidental appendectomy at the time of surgery for endometriosis as yet. Furthermore, because laparoscopic surgery is becoming common in the surgical management of endometriosis with the striking advances in laparoscopic surgical techniques and instruments, the safety of concurrent laparoscopic appendectomy is another important issue.
In this study, we compared patients who had undergone laparoscopic appendectomy (appendectomy group) with patients who had not (nonappendectomy group) to investigate the safety and efficacy of laparoscopic incidental appendectomy at the time of laparoscopic surgery for ovarian endometrioma.
Materials and Methods
Between January 2004 and August 2009, 356 consecutive women who had undergone laparoscopic surgery for ovarian endometrioma ≥3 cm were enrolled in this retrospective study at Kangbuk Samsung Hospital, Seoul, Korea. Patients with pathologies other than endometriosis on the histopathological results of the ovaries were excluded.
In our institution, laparoscopic incidental appendectomy was preoperatively suggested to all patients who were suspected to have ovarian endometrioma and had no history of appendectomy. A laparoscopic appendectomy was conducted with the consent of the patient; the decision was not influenced by abdominal surgical history or body mass index (BMI).
The subjects were classified into 2 groups: the appendectomy group and the nonappendectomy group. In all, 172 patients who had incidental appendectomy during the laparoscopic surgery were assigned to the appendectomy group, and the nonappendectomy group enrolled 24 patients with a history of appendectomy and 160 patients who had refused to undergo incidental appendectomy.
The preoperative evaluations comprised a medical history, physical examination, pelvic examination, hematological tests, gynecological ultrasonography, Pap smear, serum tumor markers (CA 125 and CA 19-9), and, when necessary, radiological evaluations, such as computed tomography or magnetic resonance imaging. We reviewed the clinical charts and analyzed the data regarding the patient age, parity, BMI, history of abdominal surgery, American Fertility Society (AFS) classification stage, operating time, change in hemoglobin concentration from before surgery to the first postoperative day, hospital stay, return of bowel activity, histopathological reports, and any operative complications.
The operating time was defined as the period from the incision of the skin to the closure of the skin; the return of bowel activity was defined as the period from the end of anesthesia to the first occurrence of bowel gas passage; postoperative fever was defined as a body temperature ≥38°C on 2 consecutive occasions at least 6 hours apart, except during the first 24 hours; and the AFS classification stage was assessed intraoperatively and postoperatively by 2 gynecologists (J.S.C., J.H.L.) based on the surgical view, operative record, and laparoscopic images, according to the revised AFS classification system.
The surgical technique used for laparoscopic appendectomy has been described in our previous report. This study was approved by the Kangbuk Samsung Hospital Institutional Review Board.
Statistical analysis
Data are expressed as medians (ranges). Each variable was confirmed as not following a normal (gaussian) distribution with the Shapiro-Wilk test. The median test was used to compare each group’s continuous variables, and the Mantel-Haenszel χ 2 test or Fisher’s exact test was used to compare each group’s categorical variables. P < .05 was taken to indicate a significant difference. All statistical analyses were performed using software (SAS, version 9.1; SAS Institute Inc, Cary, NC).
Results
Analysis of the clinical characteristics of the 2 groups showed that they did not differ significantly in terms of age, parity, BMI, the number of previous abdominal operations other than appendectomy, size and bilaterality of ovarian endometrioma, serum levels of CA 19-9 and CA 125, or AFS classification stage ( Table 1 ).
| Characteristic | Median (range)/No. of subjects (%) | P value | |
|---|---|---|---|
| Appendectomy group (n = 172) | Nonappendectomy group (n = 184) | ||
| Age, y | 31 (18–49) | 33 (20–52) | .057 a |
| Parity | 0 (0–3) | 0 (0–3) | .167 a |
| Body mass index, kg/m 2 | 21.5 (14.2–33.5) | 21.1 (15.6–41.6) | .526 a |
| No. of previous abdominal surgeries | 0 (0–2) | 0 (0–2) | < .001 a |
| No. of previous abdominal surgeries, except appendectomy | 0 (0–2) | 0 (0–2) | .298 a |
| Size of ovarian endometrioma, cm | 6 (2–16) | 5 (2–18) | .142 a |
| Bilaterality of endometrioma | 64 (37.2) | 59 (32.1) | .536 b |
| Serum CA 125 level, U/mL | 45.6 (1.45–1705.0) | 35.0 (5.31–4853.0) | .378 a |
| Serum CA 19-9 level, U/mL | 20.4 (2.33–862.0) | 26.6 (1.07–1793.0) | .724 a |
| AFS classification | |||
| Stage III | 65 (38.9) | 80 (43.5) | .447 c |
| Stage IV | 102 (61.1) | 104 (56.5) | |
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