Thought provoking case to break the silence.

[SLUser11]

Things have been slow here, so I thought I'd bring up a dilemma from a case earlier today.

57 yo female, post-menopausal, otherwise healthy, surgical h/o tubal ligation: Came in with RLQ pain, N/V, WBC 13, CT shows right sided "hydrosalpinx vs. pyosalpinx," and a normal appendix.

I am with an attending experienced with gynecologic surgery, and we decide to do a Dx Laparoscopy with plans for a right salpingectomy. When we get in, the fallopian tube is torsed clockwise x 3-4, hemorrhagic and partially necrotic. We take it out with a stapler.

Question: Should we take the appendix while we're in there? I will say right off that we left it alone.

Conventional teaching is that if we go in for a Dx Lap, and we find something other than appendicitis, e.g. ovarian cyst or fallopian tube issue, that we should take the appendix anyway to "prevent future confusion." This is the board answer as far as I've always been told.

However, we didn't go in there thinking it might be appendicitis. We knew the appendix was normal. I was intrigued because if we'd done the same exact surgery with suspicion of appendicitis, and had the same findings, we would have done an appendectomy.

Of course, if we think an incidental appy is indicated, then we should encourage our gyn colleagues to take the appendix every time they do pelvic laparoscopy.

What do you guys think?

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[nonbilious]

As a lowly new tern I will venture my underpowered opinion.

I would argue to leave the appy alone, my reasons:
1. How many patients have you seen unable to tell you if they had their appendix out or not?
(point is, I don't think its as much of an issue today)
3. The last appy i scrubbed on turned into a rt hemi from complications. I would hate to tell a patient "well we thought it would be good to take your appendix out even though it was ok, but then there were complications and it turned into a rt hemicolectomy..... oops"

I guess if it were me and I woke up after a diagnositic lap with a hemicol I would be unhappy. Also, in the era of lap, you don't know whats going on in there unless you ask.... Now if you were leaving a mcburney with the app still inside, that I would say would be no good.

just some weak thoughts to keep the board moving.

 

[tussy]

Nope, i would have left the appendix alone. If i'm doing a laparoscopy for RLQ pain and i don't find a source then i remove the appendix in case there is early appendicitis/endoappendicitis (i've seen what looks like a normal appendix in this case and the final path shows neutrophil infiltration in keeping with an acute appendicitis). If I find an alternative diagnosis that explains the pain then i leave the appendix alone. Definite risk to removing it (small risk of stump leak, SBO, etc, but there is a risk).

Another question - if you thought it was PID with a tubo-ovarian abscess why didn't you manage it with IV antibiotics. This is the usual treatment, not salpingectomy.

 

[Winged Scapula]

Yep, I always thought that "board answer" was dumb.

Not that I do general surgery anymore but I would have left the appendix alone. Unlike our medical student's belief above, patient's do forget whether or not they've had their appendix out and since the rate of potential complications is not zero, I can see no reason for taking out a healthy organ except for cancer prophylaxis.

 

[SLUser11]

3. The last appy i scrubbed on turned into a rt hemi from complications. I would hate to tell a patient "well we thought it would be good to take your appendix out even though it was ok, but then there were complications and it turned into a rt hemicolectomy..... oops"

That being said, the morbidity of appendectomy is usually very low, and complications exist for all incidental surgery, yet it is sometimes indicated.

Another question - if you thought it was PID with a tubo-ovarian abscess why didn't you manage it with IV antibiotics. This is the usual treatment, not salpingectomy.

I did not think the patient had TOA. I thought the patient had a painful hydrosalpinx from her previous tubal ligation. It was a therapeutic laparoscopy. It turned out to be torsed and necrotic, which made the next decision easier.

Yep, I always thought that "board answer" was dumb.

Not that I do general surgery anymore but I would have left the appendix alone. Unlike our medical student's belief above, patient's do forget whether or not they've had their appendix out and since the rate of potential complications is not zero, I can see no reason for taking out a healthy organ except for cancer prophylaxis.

This is the tough part. When we take out the appendix during a dx lap, it's usually because we think the patient will re-present in the future with RLQ pain, e.g. recurrent cysts, mittelschmerz, whatever....and we can avoid the future confusion.

Honestly, I think it would be easy to make an argument for either decision, but I find it amusing since it can be sort of a slippery slope.

 

[SammyDavisJrJr]

The complications of an appendectomy do need to be factored into the decision; however, the benefits of an appendectomy also need to be considered. In an elderly patient, especially one with multiple medical comorbidities, the risks may outweigh the benefits. In a young and healthy patient I would probably take the appendix out (assuming it can be done safely). In this patient, the source of RLQ pain appears obvious upon laparoscopy (as stated in the original post), but I would seriously consider removing the appendix as well in order to completely rule out and/or treat appendicitis. The decision would also be based upon the patients status in the OR (hemodynamics, respiratory status, etc)

 

[butterfly0660]

One of my friends recently had a young female patient with classic presentation of appendicitis, elevated wbc and ct showing a dilated, thickened structure in the RLQ- not definitely the appendix, but most likely. Took her to the OR for lap appy and couldn't find the appendix, but a lot of adhesions. He was with a new attending, and they decided to open. Still couldn't find the appendix. Turns out pt didn't have one. And still doesn't know when or who took it out. Talk about embarrassing.

 

[opr8n]

a couple of points

1. If on the absite, i would answer leave it alone, in the last couple of years i have answered to take it out and domehow have missed every one of those questions.

2. In real life, if i was in there, already had a stapler open ($500), then the 2 extra loads for the stapler ($150-200) is so minimal in the overall scheme of things, i would take it out to "avoid confusion in the future." I think the important thing to realize is how much money it costs to do a surgery, the pt is alreayd being charged $6-8K for this surgery you are doing, assuming they are actually paying for it, and the $150 extra and the extra 5 min of OR time is just a drop in the bucket. Now what happens if the patient comes back in the future with RLQ pain? and they get an extensive workup in the ER, eventually get taken to the OR for a " dx lap" and get their incidental appy then, you have just increased their lifetime medical costs over $6-8K more, and they had to undergo another anesthesia. So, ill be taking it out

 

[Guile]

Of course, if we think an incidental appy is indicated, then we should encourage our gyn colleagues to take the appendix every time they do pelvic laparoscopy.

Interesting you mention this because on my gynecology rotation, I had probably 10+ patients that had appendectomies during gyn operations (I went through the op notes). Most of them had big cancer operations so it was probably pretty easy to pop the appendix out while you're down there.

 

[SLUser11]

The complications of an appendectomy do need to be factored into the decision; however, the benefits of an appendectomy also need to be considered. In an elderly patient, especially one with multiple medical comorbidities, the risks may outweigh the benefits. In a young and healthy patient I would probably take the appendix out (assuming it can be done safely). In this patient, the source of RLQ pain appears obvious upon laparoscopy (as stated in the original post), but I would seriously consider removing the appendix as well in order to completely rule out and/or treat appendicitis. The decision would also be based upon the patients status in the OR (hemodynamics, respiratory status, etc)

We did talk about the incidental appendectomy on this forum a while back. Most of the literature was old, but it supported taking the appendix out if it was in a young patient (defined as <50yo) and it was an open case. Here is a link to that discussion.

As far as the patient's status, that seems sort of a moot point because these patients are all undergoing laparoscopic surgery for RLQ pain, so they're very rarely in true hemodynamic or respiratory distress. But sure, if you go in there for RLQ pain and the patient is crashing, you should leave the appendix.

a couple of points

1. If on the absite, i would answer leave it alone, in the last couple of years i have answered to take it out and domehow have missed every one of those questions.

2. In real life, if i was in there, already had a stapler open ($500), then the 2 extra loads for the stapler ($150-200) is so minimal in the overall scheme of things, i would take it out to "avoid confusion in the future." I think the important thing to realize is how much money it costs to do a surgery, the pt is alreayd being charged $6-8K for this surgery you are doing, assuming they are actually paying for it, and the $150 extra and the extra 5 min of OR time is just a drop in the bucket. Now what happens if the patient comes back in the future with RLQ pain? and they get an extensive workup in the ER, eventually get taken to the OR for a " dx lap" and get their incidental appy then, you have just increased their lifetime medical costs over $6-8K more, and they had to undergo another anesthesia. So, ill be taking it out

I've taken the same ABSITE and had the same question, always answered by taking the appendix, and I don't remember ever getting it wrong/seeing the topic on my score sheet.

Also, I agree with the practical side. It may not significantly contribute to this patient's cost, but her charges will go up, and over the years if used in wide practice, the incidental lap appy may not be cost-effective.

Anyway, the patient did well and went home with her appendix intact. I think it's a judgment call, and I'll probably have to individualize in the future

 

[ESU_MD]

I would take the appendix out.
Normal organs are extremely easy to remove. In this scenario, I would imagine the leak/complication rate to be close to zero.
It simplifies life for the patient, and those taking care of her in the future.
More to the point, thats what I would want if I were the patient.
I never want to have appendicitis!

That being said, maybe a mention of the appearance of "mild erythema" or something in your operative note wouldn't hurt either. no one is gonna say anything if you SAY you took it for that reason. if you look at the appy long enough, and manipulate it abit trying to figure out to take it or not, by then it WILL have some erythema!

interesting case

 

[JackADeli]

...Of course, if we think an incidental appy is indicated, then we should encourage our gyn colleagues to take the appendix every time they do pelvic laparoscopy...

...That being said, maybe a mention of the appearance of "mild erythema" or something in your operative note wouldn't hurt either. no one is gonna say anything if you SAY you took it for that reason. if you look at the appy long enough, and manipulate it abit trying to figure out to take it or not, by then it WILL have some erythema!...

I think folks can read these two together and consider the implications.

I do not believe the incidental appy is a correct oral board answer any longer. If you are there for what is believed to be an appy (thus family may be confused years later and believe it was removed), some unusual "appendiceal colic syndrome" or anatomic abnormalities (malrotation), you would be a go to take it out.

However, you have a laparascope in the belly for a gynecologic or other issue. You presumably have told patient and family what you are going in for.... then you stop by the cecum to pick up a little more? While complications may be rare, you are hard pressed to demonstrate benefit. You are thus engaging in a risk greater then benefit scenario when just taking the appy cause you are there. It is more telling that in order to engage in this activity and CYA you may need to "manipulate" the appy and inflame it a little. Do not just give a patient an unecessary ~stapled anastamosis, uneccesary site for additional healing and/or adhesions, and unecessary risk of complications. Take your tube or whatever and call it a day. Keep in mind that Ob/Gyns are doing laparoscopy all the time and there doesn't seem to be an urgency to remove the appendix.

 

[toxic-megacolon]

Its nice to see General Surgeons in Academic Centers still tackling GYN pathology. I agree its in the scope of general surgery, but I think many/most of these cases would be passed off to a gynecologist, when the preoperative diagnosis is GYN. I plan to tackle as much GYN pathology as possible, but how is that going to work from a liability and hospital privilidges standpoint?

 

[Smurfette]

Its nice to see General Surgeons in Academic Centers still tackling GYN pathology. I agree its in the scope of general surgery, but I think many/most of these cases would be passed off to a gynecologist, when the preoperative diagnosis is GYN. I plan to tackle as much GYN pathology as possible, but how is that going to work from a liability and hospital privilidges standpoint?

From what I've seen from my hospital, the standard gen surg privileges usually includes some general gyne procedures (TAH/BSO, ectopic, tubals, c-sections mainly). You can choose to apply for them.... While it is RARE that one of the gen surg attendings does one of these procedures, they are privileged to do them in case a scenario occurs (bleeding, locally invasive rectal cancer, rectovaginal fistula, pregnant trauma pt needing laparotomy, etc.) where they need to do it to adequately treat the patient.

 

[vhawk]

a couple of points

1. If on the absite, i would answer leave it alone, in the last couple of years i have answered to take it out and domehow have missed every one of those questions.

2. In real life, if i was in there, already had a stapler open ($500), then the 2 extra loads for the stapler ($150-200) is so minimal in the overall scheme of things, i would take it out to "avoid confusion in the future." I think the important thing to realize is how much money it costs to do a surgery, the pt is alreayd being charged $6-8K for this surgery you are doing, assuming they are actually paying for it, and the $150 extra and the extra 5 min of OR time is just a drop in the bucket. Now what happens if the patient comes back in the future with RLQ pain? and they get an extensive workup in the ER, eventually get taken to the OR for a " dx lap" and get their incidental appy then, you have just increased their lifetime medical costs over $6-8K more, and they had to undergo another anesthesia. So, ill be taking it out

Now what happens if they get hit by a bus? Yes, its possible that what you describe could happen. Its not even that unlikely. But since you've seemingly laid out an argument based primarily around financial factors (which I dont think is inappropriate) then it seems a little bit silly to conclude it on some handwaving hypothetical that justifies your choice. You claim that the cost of this incidental appy is something like an additional $200. This is probably low but for our purposes it doesnt matter. Then, you estimate that the cost of her next procedure will be $6-8k. Ok. It does not just automatically follow that since $6-8k>>>$200, that somehow this is a financially justified decision. If her lifetime risk of operation for RLQ pain (that would have 100% certainly been prevented by this incidental, mind you) is less than 1 in 30-40, then you are actually COSTING more money than you are saving. What is her actual risk? I dont know, but it should be reasonable to make a guess.

Then you must factor in all the times that we do this incidental appy, and then this patient STILL ends up needing a diagnostic lap, and so now ends up paying the max.

And thats if you just consider the financial aspects. It may very well be the case that it is a cost-saver in the long run to habitually perform this incidental appendectomy, but I dont think you laid out the argument for it very well, or very thoroughly. It might also just as easily be the case that it is a slow bleed of healthcare dollars.

 

[opr8n]

Now what happens if they get hit by a bus? Yes, its possible that what you describe could happen. Its not even that unlikely. But since you've seemingly laid out an argument based primarily around financial factors (which I dont think is inappropriate) then it seems a little bit silly to conclude it on some handwaving hypothetical that justifies your choice. You claim that the cost of this incidental appy is something like an additional $200. This is probably low but for our purposes it doesnt matter. Then, you estimate that the cost of her next procedure will be $6-8k. Ok. It does not just automatically follow that since $6-8k>>>$200, that somehow this is a financially justified decision. If her lifetime risk of operation for RLQ pain (that would have 100% certainly been prevented by this incidental, mind you) is less than 1 in 30-40, then you are actually COSTING more money than you are saving. What is her actual risk? I dont know, but it should be reasonable to make a guess.
.

valid point

Then you must factor in all the times that we do this incidental appy, and then this patient STILL ends up needing a diagnostic lap, and so now ends up paying the max.
.

i dont know many surgeons that would do that dx lap

 

[opr8n]

And thats if you just consider the financial aspects. It may very well be the case that it is a cost-saver in the long run to habitually perform this incidental appendectomy, but I dont think you laid out the argument for it very well, or very thoroughly. It might also just as easily be the case that it is a slow bleed of healthcare dollars.

this wasent a disscertation, it was a simple point with very little evidence on my part to back it up

but in all seriousness
if you have a problem patient with CRAP (chronic recurrent abd pain) and you are in there to look around, you are telling me that you wont remove the appendix to take it out of the equation FOREVER!?

 

[JackADeli]

...but in all seriousness
if you have a problem patient with ...chronic recurrent abd pain... and you are in there to look around, you are telling me that you wont remove the appendix to take it out of the equation FOREVER!?

This was not, to my understanding a chronic abdominal pain syndrome or even a "appendiceal colick" scenario in which you look in the belly, find no obvious source and proceed to appendectomy just in case. What you ask/describe is a different animal all together as opposed to what the OP described and what is generally being discussed. Namely, does the surgeon in the abd for a specific diagnosis decide to just take the normal appendix on the way out.

...57 yo female...Came in with RLQ pain...CT shows right sided "hydrosalpinx vs. pyosalpinx," and a normal appendix.

...we decide to do a Dx Laparoscopy with plans for a right salpingectomy...

Question: Should we take the [normal] appendix while we're in there?...

In the OP's scenario, the family and physician in theory have discussed this as being an issue with a fallopian tube. The operation confirms this is a problem with the fallopian tube.

If I was doing an exploratory laparoscopy for chronic or recurrent unexplained RLQ pain, I would perform an appendectomy. The family and I would have discussed this prior to the procedure and understand that it is not without risk and may very well not resolve the chronic underlying pain problem. As noted, that is not the same as doing an appendectomy when in the abd for a gynecologic or other surgical reason.

 

[vhawk]

this wasent a disscertation, it was a simple point with very little evidence on my part to back it up

but in all seriousness
if you have a problem patient with CRAP (chronic recurrent abd pain) and you are in there to look around, you are telling me that you wont remove the appendix to take it out of the equation FOREVER!?

I'm not saying that, I was really just trying to show that it actually takes a moderately complete, rigorous economic analysis, and not just a "simple point." I think you actually made a good point, I just think you got a little lazy on it at the end...and it matters. Because as you expand the indications for these types of additional costs, then these economic issues begin to play a bigger and bigger role. This is merely one part of the "slippery slope" argument but its the one that is the most realistic and unavoidable.

 

[Cruzinman]

My dad, who is a general surgeon (and a chief) always told me that any surgeon with the proper index of suspicion will always have a small percentage of cases of suspected appendicitis that look normal on laparotomy. He said that it is always better to go in immediately on suspicion rather than take a wait-and-see approach, which he considers dangerous, but which to my amazement happens not infrequently today. If you do that enough he almost guaranteed me that you will wind up with a ruptured appendix, periappendiceal abscess, peritonitis, septicemia and a dead patient.

Hopefully GYN surgeons are better trained, but in my dad's day the GYN surgeons operated like they were driving a Zamboni through the belly. In fact, much of dad's training in urology consisted in repairing ureters that had been sliced and diced by the GYN's.

 

[JackADeli]

My dad...always told me ...He said ...he considers ...he almost guaranteed me...

...in my dad's day ...much of dad's training...

We have a great deal more data and there is a good deal more published then simple family anecdote on treatment of suspected appendicitis. I'm not sure if the post is serious, a joke, or a troll. I'm not sure if you are pursuing a career in medicine, are in medical school, or what.... but, I encourage you to do a search for more support then this. I have seen numerous M&M presentations in which a trainee referred to something a supposed expert told them... it was not pretty. Go beyond the anecdote, family or otherwise.

 

[JackADeli]

...In real life, if i was in there, already had a stapler open ($500), then the 2 extra loads for the stapler ($150-200) is so minimal in the overall scheme of things, i would take it out to "avoid confusion in the future." ...the $150 extra and the extra 5 min of OR time is just a drop in the bucket....

...as you expand the indications for these types of additional costs, then these economic issues begin to play a bigger and bigger role. This is merely one part of the "slippery slope" argument but its the one that is the most realistic and unavoidable.

VH, I think your point is valid. If you are in the belly for a suspected gyn (or other non-appy) diagnosis, you can not just disregard adding an extra few hundred or more dollars to remove a normal appendix. Again, our colleagues in gyn do not routinely resect normal appendices when dealing with tubes and ovaries. The amount of dollars such a practice would globally add to health care costs would be significant. The justification is somewhere along the lines of ~avoiding confusion as to if the appendix is present or not in the future? Let me muddy the waters....

More and more lap appies and lap choles are being performed with the same incision as a tubal ligation (and even Nissens). That is, single umbilical port incisions (LESS). Should the appendix be removed at the time of tubal? lap chole? Nissen? Should the gall bladder be removed at the time of a single incision appendectomy? I think the answers are "no". Why? Because, there should be no vast amounts of future population confusion based on the scar. But, more importantly, because these incidental resections represent risk and cost with little if any demonstratable benefit.

The confusion arises if you tell the patient/family you are performing the operation for possible appendicitis and then do not remove the appendix. If however, you tell the patient and/or family you are exploring for a fallopian tube pathology, ovarian pathology, gall bladder pathology, etc.... there should be no confusion.

Further, imaging/diagnostic studies are increasingly improving and will be conceivably better then our patients' memories in the hypothetical 10-15 years in the future RLQ pain scenario. There just is not much of a valid financial, medical, or ethical argument to expend a few hundred dollars and resect a normal appendix in the scenario posed by the OP. Then multiply that expenditure by many thousands of similar scenarios accross the country!

 

[45408]

Interesting case I heard at my school's M&M about a year ago. ~20 y/o man presented with RLQ pain typical of appendicitis. PMH of hemophilia. CT scan wasn't done, and he was taken to the OR. Instead of appendicitis, they found a retroperitoneal hematoma they pretty much just backed out without touching anything and closed him up. He recovered just fine. The surgeon opted to leave his appendix alone because of the additional concern of bleeding in a hemophiliac.

 

[JackADeli]

Interesting case I heard at my school's M&M about a year ago. ~20 y/o man presented with RLQ pain typical of appendicitis. PMH of hemophilia. CT scan wasn't done, and he was taken to the OR. Instead of appendicitis, they found a retroperitoneal hematoma they pretty much just backed out without touching anything and closed him up. He recovered just fine. The surgeon opted to leave his appendix alone because of the additional concern of bleeding in a hemophiliac.

That is very interesting. I would have liked to have been at that M&M and heard the arguments. If the appy was readily accessable without significant dissection, I would have taken it. "you" went in for a stated/suspected diagnosis of appendicitis with a known comorbidity (that presumably was being addressed too). I would be curious as to what this hemophiliac's future intra-abdominal adhesion level will be (not from retro bld). The abd was entered and presumably could have more then usual intra-abd ooze during recovery.... Yes the incidents acute appy markedly drops after 3rd decade or so. But, he is still a bleeder and if an acute appy occurred and he now has additional oozing adhesions....also...

This is one that I could see the patient/family having some confusion of what occurred years into the future. Ideally our imaging and medical records could overcome that...but.

 

[Guile]

Interesting case I heard at my school's M&M about a year ago. ~20 y/o man presented with RLQ pain typical of appendicitis. PMH of hemophilia. CT scan wasn't done, and he was taken to the OR. Instead of appendicitis, they found a retroperitoneal hematoma they pretty much just backed out without touching anything and closed him up. He recovered just fine. The surgeon opted to leave his appendix alone because of the additional concern of bleeding in a hemophiliac.

If the surgeon wasn't comfortable taking the appendix why was he okay with taking him to the OR in the first place? The risk of bleeding after a vascular staple fire is pretty low, even for a hemophiliac, and I'm sure anesthesia gave him some FFP to replete his factor IX.

 

[45408]

If the surgeon wasn't comfortable taking the appendix why was he okay with taking him to the OR in the first place? The risk of bleeding after a vascular staple fire is pretty low, even for a hemophiliac, and I'm sure anesthesia gave him some FFP to replete his factor IX.

Appendicitis needs an appendectomy. Normal appendix doesn't need treatment. That was his justification, and they pretty much moved onto the next case in M&M after that.

 

[Guile]

Appendicitis needs an appendectomy. Normal appendix doesn't need treatment. That was his justification, and they pretty much moved onto the next case in M&M after that.

But isn't the majority of the morbidity from opening and the dissection to locate the appendix? If you're put through all of that, I at least would want my appendix out so it can't cause trouble in the future. The additional morbidity from the staple line is marginal compared to what you've already been through by that point in the operation. On the other hand, it would be pretty tough to have a complication from an appendectomy of a normal appendix... That's a hard conversation to have with the family.

 

[JackADeli]

Appendicitis needs an appendectomy. Normal appendix doesn't need treatment. That was his justification, and they pretty much moved onto the next case in M&M after that.

Well, it sounds like a grey hair attending. Clearly wasn't particulary educational discussion with that sort of an absolute explanation/approach.... IMHO, we have had a better educational discussion in ~27 posts on this forum then what you describe.

 

[SocialistMD]

On the other hand, it would be pretty tough to have a complication from an appendectomy of a normal appendix...

No, it isn't; that is why the conventional teaching is to leave a normal appendix alone and why you don't take it out every time you enter the abdomen. You are violating the bowel when you take out the appendix. If your stapleline fails or your knot slips, bowel contents leak into the peritoneum and you have a bigger problem than you did without taking the appendix.

 

[SLUser11]

If the surgeon wasn't comfortable taking the appendix why was he okay with taking him to the OR in the first place? The risk of bleeding after a vascular staple fire is pretty low, even for a hemophiliac, and I'm sure anesthesia gave him some FFP to replete his factor IX.

The problem is that we are all critical of the decision to leave the appendix, but if the patient had a significant post-op bleed from the appendectomy, those grey-haired attendings at M and M would say "why did you take the appendix in this coagulopathic patient when you knew it wasn't necessary?"

I feel like incidental surgery can be individualized, and it's harder to make those decisions when you're actually in the case compared to answering a multiple choice question.

If there's anything I've learned in my short stint as an unsupervised senior resident, it's that tough operative decisions are a lot harder to make when you don't have a trusted attending standing next to you and nodding in agreement.

 

[Guile]

No, it isn't; that is why the conventional teaching is to leave a normal appendix alone and why you don't take it out every time you enter the abdomen. You are violating the bowel when you take out the appendix. If your stapleline fails or your knot slips, bowel contents leak into the peritoneum and you have a bigger problem than you did without taking the appendix.

I meant "tough" as in it would really suck to have a complication from taking a normal appendix.