Preservation Versus Routine Removal: Morbidity and Long-Term Outcomes Following Diagnostic Laparoscopy Versus Negative Appendectomy-A Regional Multicentre Observational Cohort Study.

BACKGROUND

Guidelines recommend laparoscopic appendectomy (LA) for a macroscopically normal appendix when no pathology is identified during diagnostic laparoscopy (DL) for suspected acute appendicitis (AA). This approach may lead to increased hospitalization, higher costs, and greater morbidity. Whether these guidelines are justified remains debatable.

METHODS

This retrospective cohort study included all patients aged > 2 years undergoing DL for suspected AA at four Danish University hospitals from March 2017 to April 2021. Patients undergoing LA despite normal intraoperative findings were compared with patients with normal intraoperative findings undergoing DL only. Sensitivity analyses included patients with incidental intraoperative gynecological or histopathological findings not corresponding with the symptoms. The primary outcome was subsequent DL for suspected AA during follow-up, and the main secondary outcomes were complications within 30 days.

RESULTS

627 patients underwent DL and 518 underwent LA. Median follow-up was 5.2 years (IQR 4.1-6.1) and 5.7 years (IQR 4.5-6.6), respectively. At a median of 1.7 years (IQR 0.7-3.4), 3.5% (95% CI 2.0-4.9) of the DL group underwent a second DL for suspected AA, with a subsequent 0.96% risk of AA. In the main analyses, no significant differences between the groups were observed for subsequent intra-abdominal surgery, gastrointestinal endoscopy or surgical complications. In sensitivity analyses, surgical complications occurred significantly more frequently after LA (3.7% vs. 1.6% after DL, p = 0.02), mainly driven by a trend toward a higher risk of intra-abdominal bleeding (0.6% vs. 0%, p = 0.056) and intra-abdominal abscess.

CONCLUSIONS

The risks of both subsequent DL and AA following initial DL are minimal. The risk of increased surgical complications after LA is low, and the clinical relevance is questionable.