Sir
I read with interest the article by Dr Olsen and colleagues on the value of laparoscopy before appendicectomy in women (Br J Surg 1993; 80: 922-3). The use of laparoscopy in the diagnosis and treatment of acute appendicitis is becoming widespread in this country and elsewhere in the world. Although this technique is very useful in confirming acute appendicitis and also in diagnosing other pathologies (especially gynaecological ones), practising surgeons must be wary of the 'laparoscopically normal' appendix.
Dr Olsen and colleagues used the criterion that appendicitis could be excluded 'if a normal appendix could be seen throughout its length'. However, a recent study by Grunewald and Keating' showed that, at open operation, surgeons diagnosed a normal appendix incorrectly in 26 per cent of patients when it was subsequently checked histologically. Furthermore, when the appendix appeared normal and no other pathology could be found, the false-reassurance rate rose to 29 per cent.
The laparoscope affords excellent views of much of the peritoneal cavity and allows visualization of the pelvic organs while causing minimal morbidity to the patient. It also magnifies the appendix, allowing very close inspection of this structure. Unfortunately, there are no data to show conclusively that laparoscopic assessment of the 'normal' appendix is any more accurate than inspection at open operation. My own attempts at assessing the turgidity of the 'normal' looking appendix via the laparoscope (the 'wobbly' sign) and comparing this with subsequent histological findings in an attempt to identify the hidden inflammation has shown no correlation.
TherefoJe, in the face of such a high false-reassurance rate it is inadvisable at present to leave a laparoscopically normal appendix, especially if the clinical picture is suspicious of appendicitis and no other cause of pain can be identified.