Surgical Endoscopy

, Volume 27, Issue 5, pp 1594–1600 | Cite as

Evaluation of the appendix during diagnostic laparoscopy, the laparoscopic appendicitis score: a pilot study

  • Jenneke T. H. Hamminga
  • H. Sijbrand Hofker
  • Paul M. A. Broens
  • Philip M. Kluin
  • Erik Heineman
  • Jan Willem Haveman



Diagnostic laparoscopy is the ultimate diagnostic tool to evaluate the appendix. Still, according to the literature, this strategy results in a negative appendectomy rate of approximately 12–18 % and associated morbidity. Laparoscopic criteria for determining appendicitis are lacking. The goal of this study is to define clear and reliable criteria for appendicitis during diagnostic laparoscopy that eventually may safely reduce the negative appendectomy rate.


From December 2009 through April 2011, 134 patients were included and analysed in a single-centre prospective pilot study. Intraoperatively, the appendix was evaluated by the surgeon according to nine criteria for appendicitis. The operating surgeon decided whether it should be removed or not. Immediately after the operation the surgeon had to complete a questionnaire on nine criteria for appendicitis. All removed appendices were examined by a pathologist. In case the appendix was not removed, the clinical postoperative course was decisive for the (missed) presence of appendicitis.


In 109 cases an inflamed appendix was removed; in 25 patients the appendix was normal, 3 of which had been removed. After univariate analysis and clinical judgement six variables were included in the Laparoscopic APPendicitis score (LAPP score). In this study, use of the LAPP score would have led to a positive predictive value of 99 % and a negative predictive value of 100 %.


This study presents the LAPP score. The LAPP score is an easily applicable score that can be used by surgeons to evaluate the appendix during diagnostic laparoscopy. The score has high positive and negative predictive value. The LAPP score needs to be validated in a multicentre validation study.


Appendicitis Appendectomy Laparoscopy Evaluation 



Authors Jenneke T. H. Hamminga, H. Sijbrand Hofker, Paul M. A. Broens, Philip M. Kluin, Erik Heineman and Jan Willem Haveman have no conflicts of interest or financial ties to disclose.


  1. 1.
    Bijnen CL, van den Broek WT, Bijnen AB et al (2003) Implications of removing a normal appendix. Dig Surg 20:215–219PubMedCrossRefGoogle Scholar
  2. 2.
    Bakker OJ, Go PM, Puylaert JB, Kazemier G, Heij HA (2010) Guideline on diagnosis and treatment of acute appendicitis: imaging prior to appendectomy is recommended. Werkgroep richtlijn Diagnostiek en behandeling van acute appendicitis. Ned Tijdschr Geneeskd 154:A303Google Scholar
  3. 3.
    Andersson RE, Hugander A, Thulin AJ (1992) Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg 158:37–41PubMedGoogle Scholar
  4. 4.
    Marudanayagam R, Williams GT, Rees BI (2006) Review of the pathological results of 2,660 appendicectomy specimens. J Gastroenterol 41:745–749PubMedCrossRefGoogle Scholar
  5. 5.
    Rosai J (2004) Rosai and Ackerman’s surgical pathology. 9th edn. Mosby, EdinburghGoogle Scholar
  6. 6.
    Sauerland S, Agresta F, Bergamschi R et al (2006) Laparoscopy for abdominal emergencies. Surg Endosc 20:14–29PubMedCrossRefGoogle Scholar
  7. 7.
    Korndorffer JR Jr, Fellinger E, Reed W (2010) SAGES guideline for laparoscopic appendectomy. Surg Endosc 24:757–761PubMedCrossRefGoogle Scholar
  8. 8.
    van den Broek WT, Bijnen AB, de Ruiter P et al (2001) A normal appendix found during diagnostic laparoscopy should not be removed. Br J Surg 88:251–254PubMedCrossRefGoogle Scholar
  9. 9.
    Flum DR, Koepsell T (2002) The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 137:799–804; discussion 804Google Scholar
  10. 10.
    van Dalen R, Bagshaw PF, Dobbs BR et al (2003) The utility of laparoscopy in the diagnosis of acute appendicitis in women of reproductive age. Surg Endosc 17:1311–1313PubMedCrossRefGoogle Scholar
  11. 11.
    Moberg AC, Ahlberg G, Leijonmarck CE (1998) Diagnostic laparoscopy in 1,043 patients with suspected acute appendicitis. Eur J Surg 164:833–840PubMedCrossRefGoogle Scholar
  12. 12.
    Teh SH, O’Ceallaigh S, McKeon JG et al (2000) Should an appendix that looks “normal” be removed at diagnostic laparoscopy for acute right iliac fossa pain? Eur J Surg 166:388–389PubMedCrossRefGoogle Scholar
  13. 13.
    Kraemer M, Ohmann C, Leppert R et al (2000) Macroscopic assessment of the appendix at diagnostic laparoscopy is reliable. Surg Endosc 14:625–633PubMedCrossRefGoogle Scholar
  14. 14.
    Kaselas C, Molinaro F, Lacreuse I et al (2009) Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience. J Pediatr Surg 44:1581–1585PubMedCrossRefGoogle Scholar
  15. 15.
    Leun TT, Dixon E, Gill M (2009) Bowel obstruction following appendectomy: what is the true incidence? Ann Surg 250:51–53CrossRefGoogle Scholar
  16. 16.
    Andersson RE (2001) Small bowel obstruction after appendectomy. Br J Surg 88:1387–1391PubMedCrossRefGoogle Scholar
  17. 17.
    Alvarado A (1986) A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 15:557–564PubMedCrossRefGoogle Scholar
  18. 18.
    Coursey CA, Nelson RC, Patel MB et al (2010) Making the diagnosis of acute appendicitis: do more preoperative CT scans mean fewer negative appendectomies? A 10-year study. Radiology 254:460–468PubMedCrossRefGoogle Scholar
  19. 19.
    Pickhardt PJ, Lawrence EM, Pooler BD et al (2011) Diagnostic performance of multidetector computed tomography for suspected acute appendicitis. Ann Intern Med 154:789–796PubMedGoogle Scholar
  20. 20.
    Collaborative SCOAP, Cuschieri J, Florence M, Flum DR et al (2008) Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg 248:557–563Google Scholar
  21. 21.
    Wagner PL, Eachempati SR, Soe K et al (2008) Defining the current negative appendectomy rate: For whom is preoperative computed tomography making an impact? Surgery 144:276–282PubMedCrossRefGoogle Scholar
  22. 22.
    Kim K, Kim YH, Kim SY et al (2012) Low dose abdominal CT for evaluating suspected appendicitis. N Engl J Med 366:1596–1605PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Jenneke T. H. Hamminga
    • 1
  • H. Sijbrand Hofker
    • 1
  • Paul M. A. Broens
    • 1
  • Philip M. Kluin
    • 2
  • Erik Heineman
    • 1
  • Jan Willem Haveman
    • 1
  1. 1.Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
  2. 2.Department of Pathology and Medical BiologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands

Personalised recommendations