Routine histopathologic examination of the appendix after appendectomy for presumed appendicitis: Is it really necessary? A systematic review and meta-analysis

Surgery. 2020 Aug;168(2):305-312. doi: 10.1016/j.surg.2020.03.032. Epub 2020 May 27.


Background: Owing to substantial costs and increasing interest in the nonoperative management of appendicitis, the necessity of routine histopathologic examination of appendectomy specimens is being questioned. The aim of this study was to determine whether routine histopathologic examination after appendectomy for suspected appendicitis should still be performed.

Methods: PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies listing the histopathologic diagnoses after appendectomy for suspected appendicitis. Main outcomes were the incidence of histopathologically proven aberrant findings, the ability of surgeons to recognize unexpected appendiceal pathology intraoperatively, and the percentage of aberrant findings resulting in a change of postoperative management. A meta-analysis was performed using a random-effects model.

Results: Twenty-five studies with 57,357 patients were included. The pooled percentage of aberrant findings was 2.52% (95% confidence interval 1.81-3.51). Neoplasms were found in 0.71% (95% confidence interval 0.54-0.94). Findings of the intraoperative assessment by the surgeon were reported for 82 of the 2,718 (3.0%) unexpected diagnoses, with great variation between studies. The impact on postoperative management was described for 237 of 2,718 (8.7%) aberrant findings. Of these, 166 (70.0%) resulted in a change of postoperative management.

Conclusion: Based on current evidence, it remains unclear how many of the unexpected appendiceal pathologies with clinical consequences can be identified intraoperatively by the surgeon. Until reliable data on the safety and potential cost savings of a selective policy becomes available, we advise sending appendectomy specimens routinely for histopathologic examination.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Appendectomy*
  • Appendiceal Neoplasms / diagnosis
  • Appendicitis / diagnosis
  • Appendicitis / surgery*
  • Appendix / pathology*
  • Diagnostic Errors*
  • Endometriosis / diagnosis
  • Female
  • Granuloma / diagnosis
  • Humans
  • Intraoperative Period
  • Missed Diagnosis*
  • Parasitic Diseases / diagnosis
  • Postoperative Care