Appendectomy: The Importance of Complete and Correct Removal

In recently published findings after investigating a case that needed repeat surgery, clinical risk and medical safety group TMLEP articulated the need for surgeons to complete appendectomies correctly. Their panel of experts analysed the circumstances involving a patient who had suffered complications arising from mild acute appendicitis.

Initially, the family GP requested a CT scan to confirm the diagnosis. Following the hospital scan, doctors prescribed ciprofloxacin and metronidazole to deal with mild appendicitis. However, within ten days, the patient was still in pain and returned to the hospital accident and emergency department. There, on examination, doctors recommended a laparoscopic appendectomy, also known as appendicectomy.

After the operation, the patient duly returned home to recover. Notably, within approximately one month, the same individual received an additional diagnosis of Parkinson’s disease and a prescription for Sinemet. According to published pharmaceutical findings, this medication controls Parkinson’s symptoms to good effect and does not usually cause gastric side effects.

Unfortunately, the patient subsequently experienced such intense abdominal pain that an ambulance call-out and emergency hospital admission were necessary. The duty staff suspected infectious gastroenteritis and discharged the individual without a further referral or scheduled follow-up.

Repeat Surgery

Two days later, the affected patient returned to the GP, complaining of continued and considerable pain. As a result, the family doctor requested readmission to hospital. There, gastrointestinal surgical specialists diagnosed collection post-appendectomy or adhesions.

Straight away, another CT scan showed a dilate appendix stump, measuring some eleven millimetres in diameter. Consequently, a further surgical intervention was necessary to remove the remaining portion of the diseased organ.

Learning points

By failing to complete the appendix removal correctly, the first general surgeon and staff exposed the patient to an increased danger of complications – and themselves to a heightened risk of litigation.

To minimise such hazards in the future, the investigators recommended:

  1. Tissue stumps left in situ are to be of five millimetres maximum diameter, to avoid an unnecessarily elevated risk of recurrent inflammation.
  2. Surgeons should visualise the appendix base where it joins the caecum, using clear video or photographic evidence and adjusting their planning for the procedure and excision accordingly.
  3. Triage and emergency medical staff ought to be aware of the possibility of stump appendicitis following appendectomies and continuing abdominal pain, along with the pressing need for further investigation.

Conclusions

Fortunately, this type of post-appendectomy complication occurs only rarely, in around one case per 50,000*. Nonetheless, to minimise such incidences and reduce the risk of legal action to claim compensation, surgeons ought to locate the base of the appendix with reasonable precision. Also, they should excise to leave a maximum stump diameter of 5 millimetres, to lessen the possibility of continued illness due to unresolved inflammatory response and possible infection.

Furthermore, to preclude missed or delayed diagnoses and aggravated symptoms in patients who present with right iliac fossa pain following an appendectomy, healthcare professionals ought to remain alert and avoid delay in requesting CT imaging.

*Footnote Hendahewa R, Shekhar A, Ratnayake S.: ‘The dilemma of stump appendicitis — A case report and literature review’.
https://www.sciencedirect.com/science/article/pii/S2210261215003235