Resurrecting a dead topic: Incidental Surgery

[SLUser11]

We had a discussion a ways back where incidental surgery was brought up. It's a topic that I find very interesting, since most of the data on incidental surgery is very old and outdated.

I don't know about the rest of you, but in my program, we perform very little incidental surgery. We don't palpate the gallbladder and take it out if there's stones. We don't take the healthy appendix (if we're there for another reason), or remove an asymptomatic Meckel's. Are we doing the right thing for our patients? Would they benefit from these simultaneous procedures?

One of the chiefs from my program did a Grand Rounds presentation on this topic, and he presented some very interesting information. He asked the three questions:
1. Is it safe?
2. Will it prevent future problems?
3. Is it cost-effective?

His answers were surprising. I won't plagiarize him here, but a brief summary of his conclusions (these were his recommendations, not existing guidelines):

Incidental Appy: You should remove the appendix in open procedures if the patient is less than 50 yo. (Laparoscopic removal with stapler removed cost-effectiveness, and older patients significantly increased the number needed to treat)

Incidental Cholecystectomy: You should remove the gallbag if stones are discovered while doing an open colon resection, open AAA, and open or lap gastric bypass.

Incidental Meckel's Diverticulectomy: You should remove if the patient has three of four of these are present: Male, diverticulum length >2cm, age <50yo, or presence of a fibrous band.


Anyway, I found this topic interesting and wondered what some of you think. Should we be palpating the gallbladder during colon operations and removing it if there are stones? The literature would support such a decision. Should we be removing appendices while in there for another reason? I don't know the answer......

I have references and a very abridged version of the presentation that I can email people if they PM me.

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[Samoa]

If there's new data to support it, we should re-evaluate the idea. That's the whole point of evidence-based medicine.

 

[SLUser11]

If there's new data to support it, we should re-evaluate the idea. That's the whole point of evidence-based medicine.

Well, I think that there is relatively little data on the subject that isn't somewhat outdated. Measuring safety and cost-effectiveness changes too much with changing techniques and level of comfort.

I think we need more data. But, I think it's possible we're not doing enough incidental surgery....

 

[HurricaneKatt]

I think it makes sense. I mean, if they are already having surgery you could potentially save them the trouble, and risk, of needinganother surgery later. The only thing I would question would be the appendix. I might be kind of mad if someone took my appendix out without my prior knowledge; but then maybe not. I would be happy though if they removed any stones and stuff like that.
Also, what about talking to the patents about it beforehand too? Like letting them know that sometimes other health risks appear, or ways to prevent future health risks, during surgery and if so, does the doctor have permission to do the extra procedure? Of course letting the patient know that it could save them the need to undergo further surgeries later. What about billing too? Would that increase the patient's expenses because, technically, more things are being done?

 

[Winged Scapula]

I think it makes sense. I mean, if they are already having surgery you could potentially save them the trouble, and risk, of needinganother surgery later.

You are thinking like a patient and not a physician.

Patients always think its wonderful to get everything done at once, to "save themselves" anesthesia, etc. What they, and you, neglect, is that every surgical procedure, even incidental surgery carries risk. This is risk on top of the risk of the primary surgery. For example, what if you had a common duct injury during your cholecystectomy or a colonic injury with the incidental appy? Would you still be glad you had your incidental procedure?

Frankly, being superstitious, it is almost always the surgery you do incidentally, for benign disease or on family/friends which has the highest rate of complications.

The risks are small to be sure, but the risk of actually having appendicitis or cholecystitis, for the individual, are very small despite these being common afflictions. If you had a 1% chance of ever getting cholecystitis in your life, but the risk of surgical injury was greater than that, would you take the chance?

I'm not against incidental surgery by any means, but these issues are rarely addressed by the lay public. For some reason, they seem to think that the anesthesia is their greatest risk.

The only thing I would question would be the appendix. I might be kind of mad if someone took my appendix out without my prior knowledge; but then maybe not. I would be happy though if they removed any stones and stuff like that.

NO ONE is advocating removing these organs without informed consent.

Also, what about talking to the patents about it beforehand too? Like letting them know that sometimes other health risks appear, or ways to prevent future health risks, during surgery and if so, does the doctor have permission to do the extra procedure?

Since most cholelithiasis is in adults, parental consent would only be necessary in the situation of an incapacitated adult. Appendicitis does occur often in children but there is little way to prevent it. Again, informed consent is not the issue here. We already get permission to do procedures which may need to be completed during the primary surgery.

Of course letting the patient know that it could save them the need to undergo further surgeries later. What about billing too? Would that increase the patient's expenses because, technically, more things are being done?

Surgeons are not paid fully for every procedure. You *should* get 100% reimbursement of the contracted rate for the FIRST procedure. Anything subsequent is reimbursed at 50% or less. So for any incidental surgery, you are paid 50% or less of the contracted rate (depending on how many procedures you do). This is why I am less than interested in taking off benign skin lesions when doing other procedures (I often get asked to do so). If a patient is self-pay, then they will pay more, but under insurance coverage, they will be charged their co-pay and deductible and then the rest is billed to the insurance. I suppose you could say that if they did eventually need an appendectomy, they would be charged for another co-pay and deductible but remember, these diseases while common across the country, are not common for the individual (ie, you will likely never need your appendix or GB [even with stones] out).

SLUser, you might consider asking some OB-Gyns about their practice and what data they use. Because I have rarely seen a patient with a hyster who doesn't claim that their OB took out their appendix as well. My own receptionist tells me that her OB does it as well routinely. I also thought that bariatric surgeons were not taking out GBs, even with stones now, because of the increased risk, and low likelihood of needing it out later.

 

[smq123]

Anyway, I found this topic interesting and wondered what some of you think. Should we be palpating the gallbladder during colon operations and removing it if there are stones? The literature would support such a decision. Should we be removing appendices while in there for another reason? I don't know the answer......

I have references and a very abridged version of the presentation that I can email people if they PM me.

That IS an interesting topic, and must have made for a good Grand Rounds.

I wonder if that data applies to other specialties. If a urologist is doing an open procedure, should THEY be removing the appendix as well? (Or at least having a general surgeon come in intraop to do it.) OB/gyns will sometimes to diagnostic laparoscopies for patients with chronic pelvic pain, and often look up near the liver (to look for evidence of PID/Fitz-Hugh--Curtis). Should they be examining the gallbladder as well, and calling in a surgeon intraop if a lap chole is warranted?

What about incidental LOAs? I don't know anything about how a general surgeon would approach this - under what circumstances do general surgeons do incidental LOAs? Is there any reason for doing this? (I'm asking because adhesions can cause, besides bowel obstructions, intractable pelvic pain, and I think that some people are starting to wonder if they somehow relate to IBS/IBD, etc.)

You are thinking like a patient and not a physician.

I'm not against incidental surgery by any means, but these issues are rarely addressed by the lay public. For some reason, they seem to think that the anesthesia is their greatest risk.

That's all they hear about on the news.

You'll never get on Dateline or 20/20 with a story about how a surgeon accidentally injured your CBD during a lap chole. (Well, unless your surgeon is Dr. Rey or Dr. Jan Adams, I suppose.) But you WILL get on one of those programs if you have a story about how you were "under general anesthesia, but could still hear every single word that the nurse was saying!"

Or everyone seems to have a story about how a neighbor's aunt's roommate's ex-boyfriend's grandmother went under general anesthesia and never woke up, etc., etc.

SLUser, you might consider asking some OB-Gyns about their practice and what data they use. Because I have rarely seen a patient with a hyster who doesn't claim that their OB took out their appendix as well. My own receptionist tells me that her OB does it as well routinely.

That's interesting, and something that I'd like to look into. If I find anything, I'll be sure to post it.

I don't hear of many programs that teach their OB/gyn residents how to do appendectomies anymore. (Johns Hopkins is one of the few that has "appendectomy" listed as one of its resident education curriculum goals.) I know that some of the gyn-oncs will do it (then again, these are guys that do their own splenectomies), but I don't know if it's routinely taught anymore.

How old is your receptionist's OB/gyn? He might be one of the last ones who were trained under the "old model" - i.e. a year or two of gen surg, and then branched off into OB.

At my institution, the OB/gyns don't do appendectomies. If they think the patient needs one, they call trauma/ACS for an intraop consult - although this is probably also due (in part) to politics.

 

[Winged Scapula]

smq - it may certainly be a generational thing.

The median age of my patients would be in their 60s, with hysters done > 25 years ago. The practice may have certainly changed.

I'm not sure how old my receptionist's OB-Gyn is; I only know she kept calling him a surgeon, and I kept correcting her.

 

[smq123]

Interestingly, a very brief skim of the literature shows that there have been a few people in OB/gyn looking at incidental appendectomies.

The safety of incidental appendectomy at the time of abdominal hysterectomy.
E. Salom, D. Schey, M. Peñalver, O. Gómez-Mar&#305;&#769;n, N. Lambrou, Z. Almeida, L. Mendez
American Journal of Obstetrics and Gynecology, Volume 189 , Issue 6 , Pages 1563 - 1567

In 2003, a group of gyn oncs at Jackson Memorial thought that incidental appendectomies was warranted, especially for patients >65 (because of the risk of morbidity/mortality if the appendix were to perf). They recommended incidental appendectomies for all laparotomies, but not everyone adopted that recommendation. Some places did, but I think most hospitals didn't feel it was cost effective, and previous studies had shown that it wasn't necessary. I have to say, after a quick read of this article, their rationale for doing this didn't seem all that clearly outlined.

257 Incidental Appendectomies During Total Laparoscopic Hysterectomy
O'Hanlan, Katherine; Fisher, Deidre; O'Holleran, Michael
Journal of the Society of Laparoendoscopic Surgeons, Volume 11, Number 4, October - December 2007 , pp. 428-431(4)

This later study came along in 2007 from a 2 OB/gyns and a general surgeon (all of whom seemed to be in private practice) that said that laparoscopic incidental appendectomy was also warranted. Their rationale (which was more clearly outlined than the previous study) was that there is a high percentage of pathologic appendices - but many of those diseased appendices looked completely normal on gross examination. (The appendix can be a site of endometriosis, and in that study 3 of the removed appendices contained carcinoid.) The feeling was also that a lot of women who complain of pelvic pain are actually suffering from chronic appendicitis - there was a lot of anecdotal evidence that a lap appy improved their pelvic pain. Since pelvic pain is the bane of every GYN's existence, this might be useful.

 

[SLUser11]

Patients always think its wonderful to get everything done at once, to "save themselves" anesthesia, etc. What they, and you, neglect, is that every surgical procedure, even incidental surgery carries risk. This is risk on top of the risk of the primary surgery. For example, what if you had a common duct injury during your cholecystectomy or a colonic injury with the incidental appy? Would you still be glad you had your incidental procedure?

Exactly. However, what we need are studies that weigh the risks and benefits......determine the frequency of complications from incidental surgery (is it safe?), determine the lifetime frequency of disease related to the organ/likelihood of the patient developing significant pathology (will it prevent future problems?), and then determine if the cost and number needed to treat justify the indidental surgery (is it cost effective?).

Frankly, being superstitious, it is almost always the surgery you do incidentally, for benign disease or on family/friends which has the highest rate of complications..

That's fine, but there are plenty of old-school surgeons that are superstitious about Lovenox causing bleeding, or afraid to discontinue antibiotics post-op, etc, because of their anecdotal experience, but we want to practice evidence-based medicine and eliminate superstition from our field.

There are several studies, most very old (early 80s), that show that incidental appendectomies do not significantly affect complication rates (wound infection, length of stay, etc). What we need is some newer data.

The risks are small to be sure, but the risk of actually having appendicitis or cholecystitis, for the individual, are very small despite these being common afflictions. If you had a 1% chance of ever getting cholecystitis in your life, but the risk of surgical injury was greater than that, would you take the chance?

Lifetime risk of appendicitis is 7%. Of course, severe morbidity and mortality from that is very low.

Some studies show that anywhere between 25-30% of patients with asymptomatic cholelithiasis will go on to have biliary complications (symptoms, cholecystitis, cholangitis).

As for bariatric patients, I don't think that the book is closed on whether or not the GB should be taken if they have stones. There are good arguments and data from both camps. What I can say, which is anecdotal, is that when they get choledocholithiasis or cholangitis, it changes the treatment plan when ERCP is not an option, and Lap CBD exploration is unsuccessful.

Surgeons are not paid fully for every procedure. You *should* get 100% reimbursement of the contracted rate for the FIRST procedure. Anything subsequent is reimbursed at 50% or less......but remember, these diseases while common across the country, are not common for the individual (ie, you will likely never need your appendix or GB [even with stones] out).

You keep mentioning the small risk to the individual, but this can be extrapolated to other subjects as well. The risk of CBD injury is very small to the individual...should we never do cholangiography? The risk of a life threatening PE is very small to the individual...should we stop giving DVT prophylaxis? There are a thousand other examples.

We're not trying to tailor our treatment to the individual, but to our entire patient community to decrease incidence of disease complications.

SLUser, you might consider asking some OB-Gyns about their practice and what data they use. Because I have rarely seen a patient with a hyster who doesn't claim that their OB took out their appendix as well. My own receptionist tells me that her OB does it as well routinely. I also thought that bariatric surgeons were not taking out GBs, even with stones now, because of the increased risk, and low likelihood of needing it out later.

I do believe that a lot of the incidental appy data comes from the OBGYN literature, but I'll have to double check.




I want to mention that I'm not necessarily a proponent of routine incidental surgery. I think it is opening up a big can of worms. But, it is very interesting, and maybe we need to have a second look at it.

One thing is for sure: The enthusiasm has diminished. Most of the literature is outdated. What is the reason for this? Is it because it doesn't benefit us financially? It's more work and very little (if any) extra money.....

 

[SLUser11]

In 2003, a group of gyn oncs at Jackson Memorial thought that incidental appendectomies was warranted, especially for patients >65 (because of the risk of morbidity/mortality if the appendix were to perf).

Interesting theory, because my argument would be that the older the patient, the less likely they are to suffer from appendicitis in their remaining life.

If someone really wanted to justify appendectomy, they should aim for the young population, who still has many years to develop problems.

 

[Winged Scapula]

Exactly. However, what we need are studies that weigh the risks and benefits......determine the frequency of complications from incidental surgery (is it safe?), determine the lifetime frequency of disease related to the organ/likelihood of the patient developing significant pathology (will it prevent future problems?), and then determine if the cost and number needed to treat justify the indidental surgery (is it cost effective?).

Absolutely. You're preaching to the choir..I agree it would be nice to have this data, in an updated form.

That's fine, but there are plenty of old-school surgeons that are superstitious about Lovenox causing bleeding, or afraid to discontinue antibiotics post-op, etc, because of their anecdotal experience, but we want to practice evidence-based medicine and eliminate superstition from our field.

What I didn't say is that despite my superstitions, I still follow good evidence based medicine rules. OTOH, I would like to see a study investigating whether or not my (common) superstition that operating on family or friends is bad news, is valid.

There are several studies, most very old (early 80s), that show that incidental appendectomies do not significantly affect complication rates (wound infection, length of stay, etc). What we need is some newer data.

That wasn't my point. My POV was in response to the above pre-med poster who wasn't considering any downside to incidental surgery. We all know that these risks are small but if you are the patient who gets the complication, who gives a damn if the risk was a known 1%? Not the patient (or their attorney).

Lifetime risk of appendicitis is 7%. Of course, severe morbidity and mortality from that is very low.

Some studies show that anywhere between 25-30% of patients with asymptomatic cholelithiasis will go on to have biliary complications (symptoms, cholecystitis, cholangitis).

And there are some studies that show its only 10%.

As for bariatric patients, I don't think that the book is closed on whether or not the GB should be taken if they have stones. There are good arguments and data from both camps. What I can say, which is anecdotal, is that when they get choledocholithiasis or cholangitis, it changes the treatment plan when ERCP is not an option, and Lap CBD exploration is unsuccessful.

Obviously. You've taken what is an easy fix (ie you're RIGHT there during the Roux) and turned it into a treatment problem if they do ever develop a problem.

You keep mentioning the small risk to the individual, but this can be extrapolated to other subjects as well. The risk of CBD injury is very small to the individual...should we never do cholangiography? The risk of a life threatening PE is very small to the individual...should we stop giving DVT prophylaxis? There are a thousand other examples.

We take thousands of small risks daily. The question is at what level of risk is the PATIENT willing to take? What level of risk is society willing to accept? I have lots of patients who are mad that insurance won't cover screening exams for patients under a certain age without risk factors. They cannot understand the concept that society has to decide, with the aide of medical and public health research, at what point does risk increase to make screening feasible for the cost involved.

I'm not saying we shouldn't do things which have risk. If I wasn't comfortable with risk taking, I'd never have become a surgeon. But I think there also has to be some thought which goes beyond mere knowledge of the risks. Overall risk means little to the patient in front of you. What is their risk? Does every lap chole need an IOC? No, but there are some which would benefit from it, despite the risk. There are some practitioners who do it all the time and some who do not. I definitely would have fallen into the latter category.

We're not trying to tailor our treatment to the individual, but to our entire patient community to decrease incidence of disease complications.

I would disagree with that. While the practice patterns are based on populatio data, each patient may require a different approach based on his or her anatomy, medical history, etc.

One thing is for sure: The enthusiasm has diminished. Most of the literature is outdated. What is the reason for this? Is it because it doesn't benefit us financially? It's more work and very little (if any) extra money.....

It very well could be the diminished reimbursement. Why do more work when you may not even get paid for it or will be paid much less? I know surgeons who admit they will not do bilateral or multiple procedures at the same time because they won't get paid much for the additional work.

 

[SLUser11]

It very well could be the diminished reimbursement. Why do more work when you may not even get paid for it or will be paid much less? I know surgeons who admit they will not do bilateral or multiple procedures at the same time because they won't get paid much for the additional work.

I agree with the majority of what you said.

I do have another question: What if the evidence was new and solid, and supported incidental surgery, but the adjunct was that the surgeon would not be reimbursed, or receive a very small reimbursement, in order to retain its cost effectiveness? How would the community react?

Doing an open appy takes 2 minutes, but doing it laparoscopically (esp. when its retrocecal, etc) may take longer. Doing an open chole is fast, but still takes some time, and by doing it, you are exposing yourself to the complications of bile leak, CBD injury, etc. Doing a lap chole, even if super fast, would still add on to your operative time significantly.

What would the surgeon do? Knowing it was indicated, but also knowing it would not give them any more money, and it would take extra time, it would be a tough decision.

 

[Winged Scapula]

I agree with the majority of what you said.

Only the majority? Remind me to revoke your SDN membership!

Those are tough questions SLUser.

Now that I am more familiar with community practices than I was during my academic training, it is clear that some practitioners will refuse to perform certain procedures when it doesn't benefit them.

And I can't say that I blame them when the situation is doing extra work for no more reimbursement (I have a different opinion when physicians don't tell patients about alternate procedures available but that the practitioner doesn't do...surgeons aren't the only ones guilty of this).

It may be that these will further the divide between the community and the academic world, with patients who may benefit from additional or incidental surgery being referred to a tertiary hospital or hospital employed surgeons. Or perhaps one of these days surgeons will actually get an increase in reimbursement rather than a yearly reduction.

I'd love to say that everyone would do what is best for the patient without regard to being paid, but that's just not realistic is it?

 

[SocialistMD]

Maybe it is just my simple mind, but this isn't a hard question to answer. Is the procedure indicated? If yes, take out the organ. If not, don't.

Let's look at a cholecystectomy for asymptomatic gallstones. If you had a patient referred to you who had asymptomatic gallstones, would you take out his/her gallbladder? No, because it isn't indicated. Why, then, would you decide to change your treatment algorithm simply because you were already in their abdomen?

We aren't, generally, in the business of the prophylactic procedure. The complications associated with a cholecystectomy (which, by the way, are among the most litigated surgical complications in the United States) are incredibly morbid. Simply because we are in the abdomen doesn't mean we need to fix every problem there. You may think an appy or a chole are chipshot procedures, but where do you draw the line? Colorectal surgeons could argue that they can do a sigmoid resection as easily as most general surgeons could do an appy, so are you going to let them add it to a Nissen because the patient has diverticuli (or, because you do a bunch of colectomies, will you add it)? What about doing a ventral hernia repair (with mesh) while doing a gastric resection? It is a very slippery slope.

To get an accurate feel for if incidental surgery is justified, you need to look at several factors:

• incidence of disease as age increases
  incidence of complications with disease as age increases
  incidence of operative complications with disease as age increases
  incidence of operative complications with previous abdominal surgery

While I'm too lazy today to look all of this up, I don't recall ever having read anyone doing these analyses. Maybe it is worth investigating, but I wouldn't do it outside of the confines of an IRB approved study right now.

 

[SLUser11]

Let's look at a cholecystectomy for asymptomatic gallstones. If you had a patient referred to you who had asymptomatic gallstones, would you take out his/her gallbladder? No, because it isn't indicated. Why, then, would you decide to change your treatment algorithm simply because you were already in their abdomen?

If you are already in the abdomen, the risk/benefit ratio has changed. You have to think about why a cholecystectomy isn't indicated in the first place. As the situation changes, so do the indications.

We aren't, generally, in the business of the prophylactic procedure. The complications associated with a cholecystectomy (which, by the way, are among the most litigated surgical complications in the United States) are incredibly morbid. Simply because we are in the abdomen doesn't mean we need to fix every problem there. You may think an appy or a chole are chipshot procedures, but where do you draw the line? Colorectal surgeons could argue that they can do a sigmoid resection as easily as most general surgeons could do an appy, so are you going to let them add it to a Nissen because the patient has diverticuli (or, because you do a bunch of colectomies, will you add it)? What about doing a ventral hernia repair (with mesh) while doing a gastric resection? It is a very slippery slope.

Nobody is saying that all incidental surgeries would be chip shots. There would absolutely be complications. The question is whether or not the disease prevented by "prophylactic" procedures would outweigh the complications.

To get an accurate feel for if incidental surgery is justified, you need to look at several factors:

• incidence of disease as age increases
  incidence of complications with disease as age increases
  incidence of operative complications with disease as age increases
  incidence of operative complications with previous abdominal surgery

While I'm too lazy today to look all of this up, I don't recall ever having read anyone doing these analyses. Maybe it is worth investigating, but I wouldn't do it outside of the confines of an IRB approved study right now.

Of course you have to look at those factors...that's the entire point of my thread. As far as being too lazy to look it up, I share your level of motivation on the subject. However, as I said previously, one of my co-residents was not lazy, and he did an extensive and thorough review of the existing literature, and came to the aforementioned conclusions.


In my opinion, the subject is not simple, and it is a hard question to answer. It is very surgeon-esque of us to dismiss the concept/brush it aside as nonsense, but our opinions may not be supported by the data.

Here's a place for both of us to start (I admittedly have not looked at any of these yet, but will do so next time I'm in the library):


Albright JB, et al. Incidental Appendectomy:18-Year Pathologic Survey and Cost Effectiveness in the Nonmanaged-Care Setting. J Am Coll Surg 2007; 205:298-306

Ikard RW. Prospective analysis of the effect of incidental appendectomy on infection rate after Cholecystectomy. Southern Med J 1987; 80 (3): 292-95

Wang HT, Sax HC. Incidental Appendectomy in the Era of Managed Care and Laparoscopy. J Am Coll Surg 2001; 192:182-88

Salom EM, et al. The safety of incidental appendectomy at the time of abdominal hysterectomy. Am J Obstet Gynecol 2003; 189:1563-68

Snyder TE, Selanders JR. Incidental Appendectomy-Yes or No? A Retrospective Case Study and Review of the Literature. Inf Dis in Ob Gyn 1998; 6:30-37

Juhasz ES, et al. Incidental Cholecystectomy During Colorectal Surgery. Ann Surg 1994; 219(5)467-74

Klaus A, et al. Incidental Cholecystectomy during Laparoscopic Antireflux Surgery. Am Surg 2002; 68:619-23

Nougou A, Suter M. Almost Routine Prophylactic Cholecystectomy During Laparoscopic Gastric Bypass is Safe. Obes Surg 2008; 18:535-39

Villegas L, et al. Is routine Cholecystectomy required during laparoscopic gastric bypass? Obes Surg 2004; 14(1):60-66

Wolff, BG Current Status of Incidental Sugery . Dis of Colon Rectum. 1995; 38:435-41

O’Malley VP, et al. Wound sepsis after Cholecystectomy. Influence of incidental appendectomy. J of Clin Gastroenterology 1986; 8(4):435-37

 

[Playmakur42]

Increased Morbidity in Surgical Patients Undergoing Secondary (Incidental) Cholecystectomy, J. Green MD, Ann. Surg - Jan 1990 (article attached)

Of ~4200 patients who had a primary surgery & secondary surgery may have been considered, 69 had a secondary (not necessarily incidental, it may have been coprimary) cholecsytectomy.

Wound infection rate was 8.7% vs 2.4% for secondary surgery group & primary surgery group respectively.

Post-op complication rate was 10.1% vs 4.1% for secondary surgery group & primary surgery group respectively.

Post-op length of hospital stay was 13.8 vs 8.9 days for secondary surgery group & primary surgery group respectively.

Noteably, the patients who were in the secondary cholecystectomy group were an avg of 10 yrs older and had a higher proportion of patients w/ a coexisting malignancy, so it wasn't exactly an apples to apples comparison. According to the article, after controlling for age and coexisting medical diagnoses, there was still an elevated risk.

A few factors hypothesized to increase the complication rate was longer surgery duration, longer incisions, additional manipulation of abdominal contents, and contamination w/ bile which may harbor microorganisms.

And the conclusion............. undecided.
more & larger studies need to be done.
..................................................................

Schwartz's Surgery Text has a short section on incidental appendectomy that seemed to recommend against incidental appy. It mentioned that 36 IA's (incid. appy's) had to be performed to prevent 1 future appendicitis. Financially, it said that 20 million had to be spent to save 6 million in costs. It was cost-effective to laparascopically remove the appy only if the patient was under age 25 and the surgeon was reimbursed at 10% the usual rate.

The unusual situations where IA was recommended was for children about to undergo chemotherapy, disabled who cannot describe or react appropriately to abdominal pain, individuals about to travel abroad where medical care is limited, and Crohn's disease patients w/ cecum free of macroscopic disease.

....................................................................

The abstracts of the articles listed by SLU basically said that incidental appendectomy is a safe addition, but not cost-effective. One article (Incidental appendectomy--yes or no? A retrospective case study and review of the literature. Snyder TE, Selanders JR.)
recommended that IA be performed in patients <35, 35-50 is up for debate, and 50+ should not have IA.

....................................................................

Would the rate of adhesions & post-op pain from adhesions in patients who had an incidental appendectomy be expected to increase in those who had an IA if the primary surgery didn't involve the large intestine?

 

[Dimoak]

With the increasing instance of "client"-centered medicine, incsurg will likely be greenlit as long as the pt makes an informed decision and signs off on the paperwork. Unless or until EBM can conclusively demonstrate incsurg directly causes morbidity, I doubt that will change.

 

[SLUser11]

Increased Morbidity in Surgical Patients Undergoing Secondary (Incidental) Cholecystectomy, J. Green MD, Ann. Surg - Jan 1990 (article attached)

This article was included in the resident's review, and is a good example of my belief that a well-read surgeon can find some article to back up his/her bias, no matter what the opinion is. One of my previous staff was notorious for doing so, and could find mounds of literature to support all of his biases. Great teacher, though.....

This is a single retrospective case-control study, that is far from perfect (if you read their methods section, you'll see what I mean), that is 18 years old. There are several other papers that show no difference in morbidity between chole and no chole.

Schwartz's Surgery Text has a short section on incidental appendectomy that seemed to recommend against incidental appy. It mentioned that 36 IA's (incid. appy's) had to be performed to prevent 1 future appendicitis. Financially, it said that 20 million had to be spent to save 6 million in costs. It was cost-effective to laparascopically remove the appy only if the patient was under age 25 and the surgeon was reimbursed at 10% the usual rate.

The unusual situations where IA was recommended was for children about to undergo chemotherapy, disabled who cannot describe or react appropriately to abdominal pain, individuals about to travel abroad where medical care is limited, and Crohn's disease patients w/ cecum free of macroscopic disease.

Cost-effectiveness never been shown in lap appendectomies, but there are several that show it for open IAs:

Albright JB, et al. Incidental Appendectomy:18-Year Pathologic Survey and Cost Effectiveness in the Nonmanaged-Care Setting. J Am Coll Surg 2007; 205:298-306

Wang HT, Sax HC. Incidental Appendectomy in the Era of Managed Care and Laparoscopy. J Am Coll Surg 2001; 192:182-88

It's still not enough to really accept or denounce the practice, which is why I think more studies are needed.

The abstracts of the articles listed by SLU basically said that incidental appendectomy is a safe addition, but not cost-effective. One article (Incidental appendectomy--yes or no? A retrospective case study and review of the literature. Snyder TE, Selanders JR.)
recommended that IA be performed in patients <35, 35-50 is up for debate, and 50+ should not have IA.

Once again, that amounts to expert opinion, which has been wrong before. Honestly, after reading some of these articles, I still have no idea what to do.

Would the rate of adhesions & post-op pain from adhesions in patients who had an incidental appendectomy be expected to increase in those who had an IA if the primary surgery didn't involve the large intestine?

That sounds like a good paper to me......Of course, do people get much adhesions from an appy? That ## must already exist somewhere.

 

[SocialistMD]

If you are already in the abdomen, the risk/benefit ratio has changed. You have to think about why a cholecystectomy isn't indicated in the first place. As the situation changes, so do the indications.

The indications don't change. You don't remove a gallbladder full of stones if there are no symptoms because 60-90% of them will never have a problem with it, not solely because of the risk of anesthesia. Just because you are in the abdomen doesn't mean the patient now has a higher risk of developing cholecystitis down the road and needs their gallbladder out. The indications are still the same. By your rationale, we should take out every gallbladder during and abdominal procedure, regardless of whether or not stones are present, as ~20% of people will develop gallstones at some point in their life and once they have these asymptomatic stones, you'd be taking out their gallbladder anyway (and the indications would be the same for both).

The question is whether or not the disease prevented by "prophylactic" procedures would outweigh the complications.

In my opinion, the subject is not simple, and it is a hard question to answer. It is very surgeon-esque of us to dismiss the concept/brush it aside as nonsense, but our opinions may not be supported by the data.

I'm not dismissing it as nonsense, I'm simply saying that the justifications that have been offered don't make logical sense to me because you are doing an unindicated procedure simply because you have potentially lessened one risk factor of surgery. All other risk factors are still present and you are adding a longer time under general anesthesia. I think it is a bad idea to go mucking around adding complexity to an operation when you wouldn't be doing the added operation otherwise.

What is the enemy of good again?

 

[Celiac Plexus]

The concept of "incidental surgery" goes against one of my favorite surgical mantras: "the enemy of good is better".

I am inclined to agree with everything that Socialist, and WS has written. I just don't see any compelling reason to start embracing doing operations that are not indicated. That just adds more risk, more morbidity, and more cost.

 

[SLUser11]

The indications don't change. You don't remove a gallbladder full of stones if there are no symptoms because 60-90% of them will never have a problem with it, not solely because of the risk of anesthesia.......All other risk factors are still present and you are adding a longer time under general anesthesia. I think it is a bad idea to go mucking around adding complexity to an operation when you wouldn't be doing the added operation otherwise.

What is the enemy of good again?

While I mostly agree with your train of thought, I do believe the indications change. The determination of whether or not a procedure is indicated involves weighing the risks and benefits, as well as the cost-effectiveness. When the risk:benefit ratio changes, or the cost changes, so do the indications.


If Lovenox was $500/dose, and it was equal to Heparin in effectiveness and side effect profile, it wouldn't be indicated. However, if you could show me that it had lower side effects, equal effectiveness, and was cost-effective, it would (and has) become indicated. We're giving LMWH to prevent problems with incidences way below 10-40%, which you quoted for conversion from asymptomatic cholelithiasis to a biliary complication.

Why is it indicated to do appendectomy when it's grossly negative during a diagnostic lap for RLQ pain? Isn't that incidental?

There are a million examples of things that we consider indicated despite it taking us longer to do, and carrying a complication rate, all because studies have shown that they improve overall outcomes.


While "the enemy of good is better" is a cute phrase to throw around when you're in the OR, and has been utilized by me frequently, the last 50 years of significant surgical advancement has come from people trying to find a "better" way to do things.



"The great tragedy of Science- the slaying of a beautiful hypothesis by an ugly fact."-- Thomas Henry Huxley

 

[SocialistMD]

If Lovenox was $500/dose, and it was equal to Heparin in effectiveness and side effect profile, it wouldn't be indicated. However, if you could show me that it had lower side effects, equal effectiveness, and was cost-effective, it would (and has) become indicated. We're giving LMWH to prevent problems with incidences way below 10-40%, which you quoted for conversion from asymptomatic cholelithiasis to a biliary complication.

I have to clarify a couple of things.

First, the 2008 CHEST guidelines (Chest 2008;133;381-453) make grade 1a recommendations that either LMWH or LDUH be used. They do not say one is better than the other. All of the studies I've seen (and, I'll admit, I haven't really searched for many) that favor LMWH over LDUH are funded by industry.

Second, you are comparing apples to oranges. If appendicitis is made a "never event" by the governing bodies, then maybe we can see it in the same light as using LMWH for DVT prophylaxis, but it isn't. Therefore, you can't say that the cost is justified simply because there are external factors (i.e. "never events") affecting the cost analysis. The risks of surgery are different than the risks of LMWH (except bleeding) and the benefits of having a normal appendix or gallbladder prophylactically removed are different than PE prophylaxis (because, let's be serious, if the clots would stay in the legs we really wouldn't care) because appendicitis and cholecystitis (or the more rare yet serious necrotizing gallstone pancreatitis) are vastly different in terms of cost and morbidity/mortality than a pulmonary embolus.

Why is it indicated to do appendectomy when it's grossly negative during a diagnostic lap for RLQ pain? Isn't that incidental?

I shouldn't address this, but I will. First, at many institutions, many surgeons no longer operate on a patient with a negative CT scan, so you've now eliminated the negative diagnostic lap. However, the reason you take the appendix out is two-fold. First, it eliminates it from the differential should the patient have recurrent RLQ pain. This is especially true in females. Second, you are covering yourself in the event that it actually is appendicitis and it just looks normal when you are in the OR. You aren't removing it to prevent a future case of appendicitis. Furthermore, many patients don't know what procedures they have had, so a surgeon may see the characteristic incision and think the patient had an appendectomy, so you are preventing that confusion.

 

[SLUser11]

I have to clarify a couple of things.

First, the 2008 CHEST guidelines (Chest 2008;133;381-453) make grade 1a recommendations that either LMWH or LDUH be used. They do not say one is better than the other. All of the studies I've seen (and, I'll admit, I haven't really searched for many) that favor LMWH over LDUH are funded by industry.

Second, you are comparing apples to oranges. If appendicitis is made a "never event" by the governing bodies, then maybe we can see it in the same light as using LMWH for DVT prophylaxis, but it isn't. Therefore, you can't say that the cost is justified simply because there are external factors (i.e. "never events") affecting the cost analysis. The risks of surgery are different than the risks of LMWH (except bleeding) and the benefits of having a normal appendix or gallbladder prophylactically removed are different than PE prophylaxis (because, let's be serious, if the clots would stay in the legs we really wouldn't care) because appendicitis and cholecystitis (or the more rare yet serious necrotizing gallstone pancreatitis) are vastly different in terms of cost and morbidity/mortality than a pulmonary embolus.

You can dissect my example into a million pieces if you don't like it, but it doesn't change the general philosophy, and it sort of avoids the first and last parts of my post altogether.

Of course, since I'm argumentative in nature, I have to say that the vast majority of DVTs will not result in a life threatening PE. You're describing the worst case scenario for not giving DVT proph, but then commenting on the rare nature of worst case scenario biliary complications, which until I can see some numbers, I won't swallow blindly.

Now, I can add a lot more examples, but what's the point if you are going to take them all literally. There are plenty of examples of similar incidental surgeries, like choles in the gastric bypass, cardiac transplant, or kidney transplant (though that's been disproven) groups where it has been studied, and we can make an informed decision.

There are plenty of things we do without evidence that lengthen our OR time (sewing up mesenteric defects, adding a second layer to your bowel anastomosis). There are plenty of things we do without evidence that make our surgeries less cost-effective (insert name of all gadgets here). This is different because its role is still undefined. All I'm saying is that we should attempt to better define its role.

I shouldn't address this, but I will....the reason you take the appendix out is two-fold. First, it eliminates it from the differential should the patient have recurrent RLQ pain. This is especially true in females. Second, you are covering yourself in the event that it actually is appendicitis and it just looks normal when you are in the OR. You aren't removing it to prevent a future case of appendicitis. Furthermore, many patients don't know what procedures they have had, so a surgeon may see the characteristic incision and think the patient had an appendectomy, so you are preventing that confusion.

I understand why we take the appendix out, just like I'm familiar with the Chest guidelines. You can say it is to "prevent future confusion" or "eliminate appendicitis from future uncertain differentials," but it doesn't change the fact that the surgery is incidental. It just changes your indications, and as the indications change, like I said before....


I think you're misinterpreting my objective here. I always respect your posts, and welcome your input, and I'm not saying we should all have our appendices and gallbladders out.....I'm not sure if it will turn out to be beneficial. All I'm saying is that by completely dismissing the topic without an extensive evaluation, we are showing very common and surgeon-esque arrogance, tunnel vision, and resistance to change. We turn our noses up to most things we disagree with, be it the 80 hour work week, NOTES, and every other buzz topic. In the past, it was coronary and peripheral endovascular procedures.......we're a close-minded bunch, and sometimes that makes up miss the bus.

 

[SocialistMD]

I want to prefice this by saying that, while I give lots of facts to support what I'm going to say, I know you know them all as well and I'm not trying to talk down to you by doing so; I'm just trying to back up what I'm saying.

You can dissect my example into a million pieces if you don't like it, but it doesn't change the general philosophy, and it sort of avoids the first and last parts of my post altogether.

I don't argue the first and last parts of your post; I agree that we can't become stagnant in our approach to the treatment of surgical disease. I just don't agree with you on this particular issue.

Of course, since I'm argumentative in nature, I have to say that the vast majority of DVTs will not result in a life threatening PE. You're describing the worst case scenario for not giving DVT proph, but then commenting on the rare nature of worst case scenario biliary complications, which until I can see some numbers, I won't swallow blindly.

My main point was to say that (1) DVT prophylaxis is used to prevent something chemically that is almost iatrogenic which is very different from performing an operation (whether you are already in the abdomen or not) to prevent a disease and that (2) PEs are never events, which means the hospital eats the cost for a whole lot more of the admission. Let's say they make wound infections or bilary injuries never events. Would you still advocate incidental surgery then? You'd better. If not, you aren't being a good surgeon by advocating for them now because you are admitting there is an added risk to your patient and are not adhering to your Hippocratic oath of "do no harm." That is my main issue. I don't like adding risk to a procedure to prevent the possibility of a future infection.

There are plenty of examples of similar incidental surgeries, like choles in the gastric bypass...

1. Not always indicated and, therefore, not always performed.
2. Not incidental

...cardiac transplant, or kidney transplant (though that's been disproven)

You kind of answered this yourself, but transplant patients do not have the same physiology (immunity) as normal patients, making infections worse for them.

 

[SLUser11]

I don't argue the first and last parts of your post; I agree that we can't become stagnant in our approach to the treatment of surgical disease. I just don't agree with you on this particular issue.

We're allowed to disagree. If we didn't, the forum would become much less fun:

SLUser: "I think incidental surgery is awesome!"

WS: "Me too!"

Soc MD "I agree!"

/end thread





The whole point of me bringing this topic up was to discuss the pros/cons, and explore our gap in the evidence supporting or condemning the practice, which I think we accomplished, so I'm okay letting the topic go back to the grave.

 

[Winged Scapula]

Buts its so fun to argue!