Aim: To determine whether elective laparoscopic appendicectomy is justified for chronic right iliac
fossa (RIF) pain of undetermined origin.
Methods: A retrospective audit of all laparoscopic appendicectomies between January 1997 and
August 2003 was performed. The expanded medical audit system (EMAS) and a Microsoft Access
database of operative records were used to identify patients with chronic RIF pain subjected to elective
appendicectomy. Case notes were retrieved and analysed for patient profile, duration of symptoms
including clinic visits and admissions, operative findings, histological analysis, and postoperative
performance. A correlation between histological findings and final outcome was investigated.
Results: Ninety-eight patients underwent laparoscopic appendicectomy during the period of the
study. A total of 11 cases with chronic RIF pain were identified. Nine were female and 2 male. Age
ranged from 9 to 14 years with a mean of 11.9 years. The number of clinic visits and admissions
for chronic RIF pain ranged from 2 to 8, with a mean of 4. Duration of symptoms ranged from 1
to 36 months, with a mean of 12.1 months. Detailed history, clinical examination, and serological
and radiological investigations failed to reveal the cause of the pain in all cases. Patients were followed
up in postoperative clinics for between 1 and 72 months, with a mean of 16.1 months. Histology
of resected appendices showed acute inflammation (3 cases), fecoliths (2 cases), lymphoid hyperplasia
(LH) (1 case), LH and a foreign body reaction (1 case), LH and mucosal hyperplasia (1
case), and Enterobius vermicularis parasites in 1 case. The appendix was normal in 2 cases. Eight
patients had complete resolution of RIP pain. Seven of these had pathology within the appendix and
1 was histologically normal. Two patients with resolved RIF pain, but with pain elsewhere, had lymphoid
hyperplasia noted within the appendix. One patient with persistent pain 6 years postoperatively
had a normal appendix.
Conclusion: This study demonstrates that a significant number of patients with chronic RIF pain
have pathology within the appendix. The majority of these cases will benefit from elective appendicectomy.
It is critical however that all other possible causes of pain in the RIF are excluded. Laparoscopy
is an integral part of the diagnosis and management of this particularly difficult group of patients.
