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A normal appendix

01 May 2012

Mr A, a 35-year-old accountant, was admitted to hospital overnight as an emergency under the care of consultant general surgeon Ms Q. He described an acute onset of severe right iliac fossa pain. Clinical examination revealed lower abdominal tenderness with localised peritonism in the right iliac fossa. Routine blood tests revealed an elevated white cell count whilst urinalysis was negative. A provisional diagnosis of appendicitis was made and the patient was commenced on intravenous antibiotics, and kept nil by mouth pending review by Ms Q in the morning.

When Ms Q saw Mr A she was unconvinced by his physical signs and organised an ultrasound scan, which did not demonstrate any abnormality. The appendix was not visualised. Twenty-four hours later the patient’s condition had not improved and Ms Q made a decision to perform an appendicectomy.

Open surgery was carried out by an experienced surgical trainee on behalf of Ms Q, who found no sign of any intra-abdominal pathology to account for Mr A’s symptoms. Ms Q attended the operation and confirmed that there was no peritoneal contamination and that the appendix, terminal ileum, gall bladder, duodenum and remaining accessible small bowel and colon all appeared normal. An appendicectomy was performed and the wound was closed.

Postoperatively Mr A made an unremarkable recovery and was discharged home one day later. Neither Ms Q nor the surgical trainee who performed the operation saw Mr A prior to discharge. The junior staff caring for Mr A simply informed him that an appendicectomy had been carried out and he left hospital under the impression that he had had an inflamed appendix removed. Subsequent histopathological examination of the appendix showed no evidence of inflammation.

Over the next few weeks and months Mr A continued to suffer from intermittent abdominal pain. He consulted his GP on numerous occasions and also attended the Emergency Department (ED) at times when the pain was severe. He received antibiotic treatment for a proven urinary tract infection on two occasions but his symptoms persisted. Further blood tests and a urological assessment (including a cystocopy) all proved to be negative.

Mr A was eventually referred to another surgeon, Mr B, who arranged a CT scan, which suggested there was a Meckel’s diverticulum in the terminal ileum. A subsequent radio-nucleotide scan confirmed evidence of active disease at this site. Mr B recommended a further operation and Mr A underwent a laparotomy, division of adhesions and Meckel’s diverticulectomy. Mr A made a claim against Ms Q for performing an unnecessary appendicectomy and for failing to identify the Meckel’s diverticulum.

The opinion of the experts consulted on behalf of MPS was supportive of Ms Q’s decision to remove the appendix at the time of surgery.

They were, however, critical of the failure by Ms Q and her team to adequately communicate to the patient the operative findings and the subsequent negative histology and were critical of the consent process. The failure to identify the diverticulum at the first operation was also criticised but it was pointed out that in the absence of a perforation it was not certain that the diverticulum was the cause of Mr A’s initial presentation. The case was subsequently discontinued.

Learning points

  • In the consent process for appendicectomy it is important to warn patients that the appendix may be normal and other causes for the pain may (or may not) be identified.
  • When open surgery is performed it is common surgical practice to remove the appendix even if it is not inflamed. This prevents the lifetime risk of future appendicitis and occasionally other pathology may be found in the appendix at the time of histopathological examination.
  • A Meckel’s diverticulum is a common congenital abnormality and may be found in up to 2% of the population. It can contain ectopic gastric mucosa, which can occasionally bleed or ulcerate causing pain or perforation. In the absence of obvious appendicitis at the time of an operation the terminal ileum should be thoroughly inspected and if a Meckel’s diverticulum is found (typically two feet from the ileo-caecal valve) a diverticulectomy can easily be performed.
  • Good communication between clinicians and a patient is essential. Ideally, the operating surgeon should discuss a procedure directly with the patient. This should be supported by clear written instructions to all staff involved in the patient’s care. In this case, had the patient understood that he did not have appendicitis and the rationale behind his appendicectomy, he may have been less likely to pursue a claim.
  • Although in this case the experts found the communication to be sub-optimal, it did not amount to negligence.