Copenhagen, Denmark 19 - 22 June 2005

Laparoscopic appendectomy in endometriosis E Rikani [1], S Ferrero [1], E De Masi [1], P Anserini [1], V Remorgida [1], E Fulcheri [2], N Ragni [1] [1] San Martino Hospital and University of Genoa Department of Obstetrics and Gynaecology Genoa, Italy [2] University of Genoa Department of Anatomy and Histopathology Genoa, Italy

Introduction
The aim of the current study is to evaluate the pathologic findings in appendixes of women with endometriosis undergoing laparoscopic surgery for pelvic pain.

Materials and methods
We examined the clinical records of 37 women who underwent appendectomy in conjunction with the laparoscopic removal of pelvic endometriotic lesions. In all cases chronic pelvic pain was the main
indication for surgery. Appendectomy was performed only when intraoperative appearance of the appendix was abnormal (appendix curved like a shrimp, rigid, swollen, hyperaemic, and wrapped with adhesions).

The macroscopic appearance of the appendix at surgery was recorded. The extent of endometriosis
was scored using the revised American Fertility Society (rAFS) classification. All the appendixes were histopathologically evaluated in a standardized fashion. Pathologic features of the appendix included in the definition of an abnormal appendix were: inflammation of any type (acute or chronic), primary or secondary neoplasm, foreign body, cystic lesions, and abscess. Pathology reports that described the appendix as having only adhesions, fibrosis, vascular congestion, fecolith, lymphoid hyperplasia or periappendicitis, if without associated inflammation of the appendix, were not considered abnormal.

In all patients, the diagnosis of endometriosis was confirmed on the removed specimens at histology.

Results
The mean (±SD) age of the study population was 31.4 (±7.5) years; 10 (27.0%) women had previously been surgically treated for endometriosis. Seventeen women had mild endometriosis (rAFS stage I–II) and 20 had severe endometriosis (rAFS stage III-IV). On pathologic evaluation, 31 (83.8%; 95%
CI, 68.0–93.8%) appendixes were diagnosed as abnormal.

The majority of patients (64.9%, 24/37) had chronic appendicitis. Six patients (16.2%) had appendiceal endometriosis involving serosa and muscolaris; in two of those patients this was the only abnormal finding. Two women (5.4%) had acute appendicitis, one had a carcinoid tumor of the appendix, one had a large mucocele, and 1 had an appendix abscess. Obliteration of the appendiceal lumen was observed in 13 (35.1%) cases, lymphoid hyperplasia in 24 cases (64.9%, 24/37).

In four patients, the presence of endometriosis on the appendix was suspected at surgery but was not histologically confirmed. Conversely, the presence of endometriosis on the appendix was suspected in four out of six cases of histologically confirmed appendiceal endometriosis.

Conclusions
Laparoscopic inspection of the appendix should be undertaken in all cases of chronic pelvic pain, even in patients with pelvic endometriosis. Although, the intraoperative appearance of the appendix at the time of laparoscopy may not predict the presence of endometriosis at histology, it is useful in identifying appendiceal pathology.

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