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Prophylactic Surgery forBenign
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Gynecologic Pathologies
SabahattinAnilAri andAliAkdemir
28
28.1 Introduction
The rst goal of the prophylactic surgery is to
lower the risk of cancer. The procedures to prevent any disease or undesirable consequences are
very essential, especially in prophylactic surgery
for benign gynecologic pathologies. Prophylactic
salpingectomy, anti-prolapses surgery, and prophylactic cerclage can count in procedures related
to prophylactic surgery for general gynecology.
Prophylactic salpingectomy is the removal of
bilateral salpinx during pelvic surgery which is
performed for another indication. Its primary aim
is to reduce the risk of ovarian cancer which has
very poor prognosis. Prophylactic salpingectomy
can be performed to female sterilization, infertility surgery, and after hysterectomies. These procedures do not increase the risk of surgery, and
cost-effective approach considering possible
adnexal surgery costs in the future when tubes
left in place.
Pelvic organ prolapses have signicantly negative effects on quality of life. Treatment of pelvic organ prolapse is not hysterectomy.
Conversely, hysterectomy may cause the prob-
S. A. Ari
Department of Gynecology and Obstetrics,
Menemen State Hospital, Izmir, Turkey
e-mail: SabahattinAnil.Ari@saglik.gov.tr
A. Akdemir (*)
Department of Gynecology and Obstetrics,
Ege University, Izmir, Turkey
e-mail: ali.akdemir@ege.edu.tr
lems getting worse. McCall culdoplasty and
uterosacral ligament suspension as apical suspension procedures are safe and effective procedures
for women who candidates to prophylactic prolapses surgery after hysterectomy.
Prevention of preterm delivery is one of the
major issues in modern obstetrics, and cervical
insufciency is one of the many reasons of preterm delivery. Prophylactic cerclage is a procedure performed based on history of cervical
insufciency with high take home baby ratio.
Prophylactic appendectomy is removing
appendix at unrelated surgical procedure.
Prophylactic appendectomy reduces pain signicantly in patient with chronic pelvic pain.
Furthermore, women who will have pelvic or
abdominal radiation or chemotherapy, patients
who will have major operations in which dense
adhesions are anticipated after procedure, and
disabled patients who will have difculty for
describing possible appendicitis symptoms also
benet from prophylactic appendectomy.
If there is a chance for prophylactic procedure
before planned pelvic surgery, patient should be
fully informed and written consent should be
obtained with any decision before surgery.
28.2 Prophylactic Salpingectomy
Prophylactic salpingectomy is the excision of the
bilateral salpinx in order to prevent potential fallopian tube, ovary and peritoneum carcinoma
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_28
313
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S. A. Ari and A. Akdemir
when any other pelvic surgery performed for
another indication in women [1].
28.2.1 Background andBenets
Ovarian cancer is typically diagnosed in advanced
stage and accordingly has poor prognosis.
Limited screening and treatment tools can be
responsible for this insufcient condition.
Ovarian cancer is the most lethal gynecological
cancer type and has the fth place for the deaths
related to cancer within women [2]. In addition to
dreary situation, overall survival rates of ovarian
cancer have not improved noteworthy since
1980s [3–5]. But, the theory about serous, clear
cell and endometrioid carcinomas of ovary originated from fallopian tubes could be the light at
the end of the tunnel.
The lesions similar to ovarian serous carcinomas found in the fallopian tubes in women who
have genetic tendency to ovarian cancer. These
lesions could be the origin of the ovarian cancer
and they could be cause of peritoneal cancer
without ovarian cancer by spreading. In addition,
TP53 mutation was found in tubal lesions, like
high grade serous ovarian cancer [6, 7].
Supportive ndings continued to come with a
very large prospective cohort study known as the
Nurses’ Health Studies. According to this trial,
women who had underwent tubal ligation had
24% lower risk of ovarian cancer compared to
women who did not have this surgery [8]. The
Swedish population-based cohort study showed
that while salpingectomy causes 65% to fall of
ovarian cancer risk, tubal ligation effects reduces
28% the same risk [9]. Subsequently, The Million
Women Study (n=1,278,783) proved the protective effect of tubal ligation from ovarian, tubal
and peritoneal cancer [10]. A meta-analysis compared women who had hysterectomy for benign
indications with salpingectomy and who had
only hysterectomy. This powerful study with
30years follow-up period showed that the salpingectomy signicantly reduces the ovarian cancer
risk after the surgery [11]. These ndings especially tubal ligation effects on ovarian cancer risk
reduction bring out the idea that ovarian cancer
can be associated with retrograde menses [12]
which will be a new investigation area.
In the light of the abovementioned literature,
gynecologist should discuss with their patients
about prophylactic salpingectomy who will have
pelvic surgery. These procedures involve female
sterilization, infertility surgery, and surely hysterectomies for benign indications. It is important
to emphasize that salpingectomy reduces the risk
of ovarian cancer but does not completely eliminate it.
Many women admit to clinicians for permanent contraceptive methods. They should inform
about the success rates of other non-invasive contraceptive methods and the risk of regret related
to permanent techniques. After all, bilateral salpingectomy should suggest to women who ask
for permanent contraceptive methods.
Furthermore, the worldwide popularity of bilateral salpingectomy increases compared to tubal
ligation. A retrospective analysis showed an
increase from 1 to 78% for prophylactic bilateral
salpingectomy (PBS) instead of tubal ligation for
last 5 years [13]. PBS increases the effectiveness
in comparison with tubal ligation theoretically, as
well as reduces the re-operation risks for ectopic
pregnancy and hydrosalpinx [14].
Nowadays, almost all reproductive surgeries
performed laparoscopically and hydrosalpinx is
one of the fertility-related surgery indication.
Detrimental consequences of hydrosalpinx for
pregnancy put forth clearly by several trials. A
meta-analysis investigated 6713 IVF cycles and
showed that pregnancy rate was 50% lower in
expectant mothers who had hydrosalpinx compared to women without hydrosalpinx. Moreover,
miscarriage rate was higher in hydrosalpinx
group [15]. Another meta-analysis focused on
tubal factor infertility and determined that hydrosalpinx was the worst one. Pregnancy rate was
20% for women with hydrosalpinx and 31% for
women with other tubal factors [16]. Fortunately,
salpingectomy for hydrosalpinx before IVF cycle
improved the implantation and pregnancy rates
per transfer from 5% and 19% to 10% and 34%,
respectively [16].
Hysterectomies with benign indications are
the one of the chances for performing bilateral
28 Prophylactic Surgery forBenign Gynecologic Pathologies
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315
salpingectomy and reduce the ovarian cancer
risk. According to Cadish’s decision analysis
model, 225 hysterectomies with PBS exclude 1
diagnosis of ovarian cancer and 450 PBS added
to hysterectomies save a life [17].
28.2.2 Salpingectomy or
Salpingo-Oophorectomy?
Patient who will have pelvic surgery should be
informed about PBS and prophylactic salpingooophorectomy (PBSO) and this counseling
should be documented. Although PBSO is a very
important risk reducing strategy for women with
a genetic predisposition for ovarian carcinoma;
PBSO does not eliminate ovarian carcinoma risk
totally. Because, peritoneal carcinoma can
develop after this prophylactic surgery.
On the other hand, serious concerns have
arisen about PBSO. We know that the ovaries
after menopause continue to produce androgens
besides estrone and estradiol with a lower
amount. In addition to that, androgens turn estrogen in the fatty tissue with aromatization.
Removing this effect with PBSO in the young
ages increased the all-cause mortality risk as in
the Mayo Cohort Oophorectomy and Aging
Study [18]. Nurses’ Health Study proved the
increased all-cause mortality and cancer-related
mortality risk (16.8% and 13.3%, respectively) in
women who had BSO. Especially, the risk was
higher for patients who had this surgery before
their 50s and never used additional hormone therapy [19]. Furthermore, surgery related to menopause raises the risk of cardiovascular disease,
cancers other than ovarian cancer, cognitive
impairment, and osteoporosis [20]. Protective
effects of ovarian conservation decreased with
age and it is just so minimal after 65years [21].
Lastly, the risk of ovarian carcinoma after hysterectomies without PBSO is 0.1–0.75% and patient
lost related to ovarian carcinoma is 0.03% [22].
Although we understand better the risks of
early menopause, there are often clear indications
for salpingo-oophorectomy for women with a
gynecologic malignancy. Obesity, oral contraceptive use less than 1 year, nulliparity, not
breastfeeding, dysmenorrhea, endometriosis, and
polycystic ovarian syndrome may increase the
risk of ovarian cancer by up to 4%. There are also
advantages of PBSO for patient with endometriosis and tubo-ovarian abscess. The surgery might
prevent re-operation risks and decrease
endometriosis- related symptoms [23, 24].
Patients with pelvic adhesions are candidates for
PBSO, as well [25]. The risk of residual ovary
syndrome which is characterized by posthysterectomy pelvic pain is high in these group.
The incidence of residual ovary syndrome can
reach from 0.9 to 3.4% [26].
28.2.3 Risks Against Benets
andFeasibility
Prophylactic bilateral salpingectomy as an additional procedure to hysterectomy or as an alternative to tubal ligation seems to be safe and does
not increase the complication rates like fever,
infection, blood transfusion, and re-operation
[27, 28].
Regret and seeking alternatives for fertility
after PBS ought to be discussed with patients
who desire permanent sterilization. This is shared
risk for all permanent contraceptive methods, as
well [29]. Ovarian function is another concern
about PBS especially procedures before IVF,
whereas PBS does not affect ovarian function if it
is performed properly [30]. Sahin etal. performed
a prospective study with 131 patients who have
ectopic pregnancy. Participants divided into three
groups for treatment as methotrexate (MTX)
only, salpingectomy only, and salpingectomy following MTX groups. There was no signicant
difference pre-treatment and three months after
treatment on anti-Mullerian hormone (AMH)
levels between groups, although the decreasing
of AMH levels was detected on rst month after
treatment in salpingectomy groups. Researchers
explained these results with compensatory
increase of blood ow [31]. In a prospective randomized cohort study, ovarian reserve was compared after hysterectomy with benign indication
between only hysterectomy group and hysterectomy with opportunistic salpingectomy group.
316
S. A. Ari and A. Akdemir
Patients who had only open abdominal hysterectomy was enrolled the study due to risk of
ischemia- perfusion injury in laparoscopic surgery. After 6 months follow-up, there was no signicant difference between groups for ovarian
reserve parameters like AMH and ovarian volume [32]. Seventy-one women who had laparoscopic hysterectomy with PBS compared to
ovarian function parameters like AMH, follicle
stimulating hormone, antral follicle count and
vascular parameters with 652 healthy women
3–5years after operation. Results showed no signicant difference between groups [33]. Another
trial compared total laparoscopic hysterectomies
with total laparoscopic hysterectomies with
PBS.After 3months follow-up, there is no signicantly difference again about ovarian function, surgical risks, and complication rates [34].
Unfortunately, PBS does not totally eliminate
the risk of ovarian cancer. Germ cell tumors, sexcord stromal tumors, and other non-epithelial
ovarian carcinomas might be arisen from ovaries
after PBS.Clinicians have the obligation to discuss these risks with their patients and should not
leave assess the ovarian carcinoma related signs
and symptoms after surgery.
Eight trials compared PBS and tubal ligation
between 2011 and 2018 with 21,709 participants
in terms of success rates, blood loss, operative
time, complication rates, re-operation and readmission rates. Additional time for PBS ranges
from 9 to 17min. Researchers declared there was
no signicant difference between two methods
for other parameters [13, 35–41].
Cadish etal. [17] investigated the surgical risk
related to PBS after vaginal hysterectomy.
Results of their study showed us that PBS after
vaginal hysterectomy does not increase the complication rates signicantly. Complication rate
was 7.68% in only vaginal hysterectomy group
and 7.95% in vaginal hysterectomy with PBS
group [17].
A multicenter prospective and observational
trial was designed by Antosh etal. [42] related
feasibility of PBS after vaginal hysterectomies.
Sixty-nine patients enrolled the study and PBS
found feasible in 75% of participants. Mean
required time for PBS after vaginal hysterectomy
was 11min [42]. It should also be underlined that
the surgeons who attended the study were
urogynecologists.
Prolonged operation time and extra instruments if they used might increase the cost
slightly [43]. However, it is obvious that PBS is
a cost- effective strategy considering possible
adnexal surgery costs in the future if tubes left in
place [17].
28.2.4 Surgical Technique
Salpingectomy denes the procedures that
extraction of the fallopian tube from mbriated
ends to the utero-tubal junction. Residual mbria
extensions should be removed from the ovaries.
Complete salpingectomy also preferred against
mbriectomy due to lesions which have the risk
of ovarian carcinoma in the all tube [44]. But,
when complete resection is not possible like
cases with dense adhesions, mbriectomy is better than nothing [45].
Antibiotic prophylaxis and thromboprophylaxis are not necessary particularly before laparoscopic PBS procedures. We prefer the use of an
umbilical port for the laparoscope and bilateral
lower quadrants ports for laparoscopic surgery.
Uterine manipulator might facilitate the operation while it is not essential. Although it seems
simple in theory, it is extremely important to recognize and to protect the infundibulopelvic ligament during the procedure. Resection should be
made just below the tube for preserving the ovarian vessels and the ovarian function. Lastly,
utero-tubal junction ought to be removed completely against the risk of cornual pregnancy
which can be life threatening. If prophylactic salpingectomy performed after gynecological surgery with benign indication, it is not necessary to
use a sterile bag for removal. But pathological
analyses of the tubes are very important to
uncover of any precursor lesions.
Finally, surgeons should not change the route
of hysterectomy for the purpose of PBS.Vaginal
hysterectomy is the most minimal invasive surgery compared to other techniques and should be
the primary option.
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28.3 Prophylactic Anti-prolapses
Surgery
One of the common causes of hysterectomies is
the pelvic organ prolapses [46]. Conversely, hysterectomy also might trigger the pelvic organ
prolapses [47]. Risk of future prolapses is high
after hysterectomies especially performed for
pelvic organ prolapses (POP) [48]. Additional
anti-prolapses surgery after hysterectomy may be
a good idea for preventing future prolapses by
restoration of Level 1 support [49].
28.3.1 Background andBenets
DeLancey [49] identied the pelvic support with
three levels. Level 1 occurs of cardinal and uterosacral ligament; Level 2 occurs of arcus tendinous fascia pelvis and endopelvic fascia; and
Level 3 occurs of perineal body [49]. Surgical
damage to the cardinal ligament, uterosacral ligament, innervations and vascularization of the pelvic oor muscles due to hysterectomy is
concluded with weakening of Level 1 support
and apical prolapses.
Marchionni et al. [50] analyzed retrospectively the data of 2600 women who had hysterectomy with benign indications to nd out the
prolapse rates over a 4-year period. The incidence
of the vaginal vault prolapses after vaginal and
abdominal hysterectomy was 12% and 2%,
respectively [50]. A national cohort study from
Denmark in which 178,000 women were investigated showed that prolapse rates after hysterectomy over a 40-year period [51] 3 times increased.
According to Barber etal. (2014), the future prolapse risks range from 0 to 3.6% and the surgeons
should counsel women who are going to be operated [52].
Hysterectomy is not a treatment option for
women who have symptomatic prolapses. Pelvic
organ prolapses need particular procedures for all
areas at the same session [53]. The question is
which patients need to be added the prophylactic
surgery after hysterectomy?
Women with asymptomatic prolapses, women
with symptomatic prolapses without any nd-
ings, and women with risk factors for POP are
expected to benet from prophylactic prolapses
surgery. Vaginal delivery, obesity, chronic constipation and cough, family history, and connective
tissue disorders are summarized as the risk factors for POP [53].
Apical suspension procedures are safe and
effective operations for women who candidates
to prophylactic prolapses surgery. McCall culdoplasty after vaginal hysterectomy and uterosacral
ligament suspension after abdominal approaches
have come forward as preferred techniques.
However, there is no powerful recommendations
about prophylactic prolapses procedures due to
lack of data [54].
28.3.2 Risks Against Benets
andFeasibility
Prophylactic prolapses surgery has particular
complication rates which range from 0 to 3.6%
[52] and these operations should preserve for
selected patients after considering risk and benets balance.
Ureteral obstruction is the most common
complications for both uterosacral ligament suspension (ULS) and McCall culdoplasty. The rates
of ureteral obstruction are 4.5% for McCall culdoplasty and 1.8% for ULS [55, 56]. In general,
ureteral complications are detected during surgery. Due to close relationship between the ureter
and uterosacral ligament, cystoscopy is highly
recommended after procedure. On the other
hand, Rardin et al. (2009) compared to vaginal
and laparoscopic approaches about apical prolapses surgery and found that ureteral obstruction
rates 4% and 0%, respectively [57]. It might be
another advantage of the laparoscopic surgery
due to superiority on visualization. Uncommon
complications of ULS are blood transfusion
(1.3%) and pelvic organ injury (0.4%). McCall
culdoplasty also have rectal injury (0.5%) and
blood loss >500mL (1.1%) risks [56, 58].
Prophylactic McCall culdoplasty and ULS
prolong the surgery in acceptable limits. Gencdal
et al. (2019) reported mean operation time is
74.3min for total laparoscopic hysterectomy and
318
S. A. Ari and A. Akdemir
86.2 min for total laparoscopic hysterectomy
with prophylactic McCall culdoplasty [59].
According to another trial, mean operation time
for total laparoscopic hysterectomy with laparoscopic ULS is 102.5min [60].
28.3.3 Surgical Technique
All culdoplasty procedures aim to restore uterosacral–cardinal ligament complex [61]. There is
no proven superiority between these two techniques over each other. Surgeons might choose
one of them according to their experience and
talent.
We prefer no. 0 or 1 delayed absorbable suture
material for McCall culdoplasty. First step of the
procedure is identifying the ureters. Ureters
should be palpated. After that Allis clamps can be
used to locate the ureters at the 5 and 7 o’clock
positions. Long Breisky retractors and head light
for surgeon can be employed for maintaining the
exposure. The rst internal McCall suture is
placed at the distal part of the uterosacral ligament (US). The suture should be continued with
several bites on the posterior peritoneum until the
opposite side. The suture is then placed to the
opposite US.One or two more sutures might be
placed at the proximal parts of US according to
the rst suture with 1 cm between each suture.
The next step of procedure is placing the external
McCall sutures. No. 0 or 1 delayed absorbable
suture is placed posterior to vaginal mucosa and
enters the abdominal cavity. After that, the suture
is placed to US and exits through anterior vaginal
mucosa. Finally, sutures can be tied with controlling intestine and omentum with index nger of
rst assistant surgeon. After all, bladder and ureteral jet ow should be checked via cystoscopy.
Uterosacral ligament suspension can be performed with both vaginal and laparoscopic
approaches. Although it is according to the surgeon’s experience, laparoscopic visualization is
often better than vaginal techniques. First of all,
surgeon should provide exposure and check the
ureters. We prefer no. 0 or 1 delayed absorbable
suture for uterosacral ligament suspension. After
hysterectomy, 1–3 sutures can be placed US and
attached to ipsilateral vaginal cuff. This step is
repeated for counter side. Of course, cystoscopy
for checking the ureters is the part of the
procedure.
28.4 Prophylactic Cerclage
Prevention of preterm delivery is one of the issues
without absolute solutions in modern obstetrics.
Neonatal morbidity and mortality increased due
to preterm delivery and pushes the health systems
economically. Cervical insufciency is one of the
reasons of preterm delivery and the incidence is
0.1–1% of all pregnancies.
28.4.1 Background andBenets
Deciency of the uterine cervix to sustain a pregnancy in the second trimester without preterm
premature rupture of membranes or uterine contraction is dened as cervical insufciency [62].
Obstetric lacerations, conization, mechanical
dilatation, congenital Müllerian anomalies, collagen and elastin deciencies are the etiologies of
the cervical insufciency [62, 63].
Vaginal pessary is the only one non-invasive
option for the prevention of preterm birth due to
cervical insufciency. However, the effect of
vaginal pessary to prevent preterm delivery is not
clear. Saccone etal. (2017) showed that vaginal
pessary could not improve the obstetrics outcomes while increasing vaginal discharge in singleton pregnancies [64].
Cervical cerclage is the operative option for
the prevention of preterm birth due to cervical
insufciency. Cerclage aims to increase cervical
support and preserve pregnancy via strengthening sutures. Emergency/rescue cerclage and prophylactic cerclage are the types of cervical
cerclage. Women who have cervical dilatation or
prolapses membranes in the second trimester of
pregnancy at high risk for preterm delivery and
they are candidates for rescue cerclage.
Conversely, prophylactic cerclage is an elective
procedure and preformed based on history of cervical insufciency.
28 Prophylactic Surgery forBenign Gynecologic Pathologies
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Painless cervical dilation on physical examination in the second trimester and cervical length
less than 25mm before 24weeks of gestation with
a history of preterm birth are the indications for
rescue cerclage. Women with history of cervical
insufciency and history of prior cerclage require
prophylactic cerclage. Due to increasing effect for
preterm delivery, cerclage is not appropriate for
twin pregnancies and not recommended [62].
The success rate of prophylactic cerclage for
the prevention of preterm delivery is very high.
Take home baby ratio after abdominal cerclage is
95%. Vaginal cerclage follows abdominal ones
with 73% success rate. Take home baby ratio
without any intervention is only 33% [65].
28.4.2 Risks Against Benets
andFeasibility
Complications and risks of cerclage changes
related to the time and type of procedure.
Emergent or elective situation, cervical dilatations, and gestational age are the parameters.
Premature preterm rupture of membranes is the
most common complication and the rate is 38%.
The infection rates for rescue and prophylactic
cerclage is 12.7% and 4.7%, respectively [66].
Maternal septicemia and uterine rupture are
rarely seen [67].
Abdominal cerclage with all risks of open surgery has higher complication rates compared to
vaginal cerclage [68]. Hemorrhage, bladder and
bowel injury, and rectovaginal stula are the
operative risks of abdominal cerclage. However,
while operating a gravid woman, surgeon should
consider pregnancy-related complications due to
abdominal cerclage. But, prophylactic preconceptional transabdominal cerclage eliminates
the pregnancy-related complications [69]. A prospective cohort study from the United Kingdom
showed that prophylactic pre-conceptional transabdominal cerclage is more successful in preventing preterm delivery than rst trimester
abdominal cerclage with lower complication
rates [70]. Fortunately, cerclage before conception does not affect the fertility [70, 71].
Both vaginal and abdominal cerclages are safe
and feasible procedures in experienced hands.
Abdominal cerclage also performed via laparoscopy. Laparoscopic approaches with superior
visualization should be considered with high success rates and low risk especially in preconceptional period.
28.4.3 Surgical Technique
Cerclage can be placed by transvaginal or transabdominal route in order to prevent preterm birth.
McDonald and Shirodkar techniques are adopted
approaches for transvaginal cerclage. Ten to 14
weeks of gestation after getting results of rst trimester, screening test might be the right time for
placing prophylactic cerclage.
A single non-absorbable purse-string suture is
placed at cervico-vaginal junction in the
McDonald technique. In the Shirodkar technique,
suture is placed at more proximal part of cervix
after dissection of vesico-cervical mucosa. But,
there is no superiority between these two techniques and different suture types [72].
However, prophylactic transabdominal cerclage should be reserved for women who have
previous cerclage failure or anatomical limitations [73]. Placing suture at the level of internal
cervical os and the lower risk of suture migration
are the advantages of transabdominal route
compared to transvaginal cerclage [74].
Transabdominal cerclage might be placed via
laparotomy or laparoscopy. Although performing
transabdominal prophylactic cerclage for gravid
uterus is possible, pre-conceptional time is safer
and more effective.
We prefer prophylactic laparoscopic cerclage
before pregnancy in our institution. A 10-mm
optic port and three 5-mm trocars are employed
for operation. First step of surgery is the dissection of bladder from cervix. After that, the uterine
arteries are identied. A 5-mm permanent tape
with at needles should be placed medial to uterine artery and lateral to venous plexus in order to
prevent possible bleeding. After placing other
ends of suture to opposite side, the suture can be
320
S. A. Ari and A. Akdemir
tied anteriorly. The operation ends with covering
the visceral peritoneum [75].
28.5 Prophylactic Appendectomy
inObstetrics
andGynecology
Elective coincidental appendectomy is removing
appendix during unrelated surgical procedure.
Prophylactic appendectomy especially in obstetrics and gynecological surgery is an issue that has
been debated for more than 60years and it is still
unclear.
28.5.1 Background andBenets
Preventing a future possible appendectomy and
appendicitis related complications are the benets of prophylactic appendectomy. Due to lack of
data related to cost-effectivity and changing benecial effect according to age, patient selection
should be individualized for coincidental appendectomy [76].
Estimated risk of appendicitis in women is
under 7% [77]. The incidence of appendicitis is
maximum between ages 10 and 19 and decreases
with age [77]. According to Snyder [78], the
greatest benet was in patients younger than
35years old who had coincidental appendectomy
during unrelated gynecological procedure.
Another conclusion of this study is limiting the
prophylactic appendectomy in specic indications in women between ages 35 and 50.
Moreover, their data did not support coincidental
appendectomy for patients older than 50s [78].
Chronic pelvic pain is a condition that the
benet of prophylactic appendectomy is relatively more certain in gynecological practice.
Chronic pelvic pain denes as pelvic pain that
persists over 6 months and requires multidisciplinary management. Laparoscopic surgery can
be good option for women who have chronic pelvic pain for diagnosis of endometriosis, uterine
anomalies such as myomas and adnexal pathologies. In a retrospective cohort study, effectiveness
of coincidental appendectomy during diagnostic
laparoscopy in women with chronic pelvic pain
was assessed. Patient with any pelvic pathology
such as endometriosis or uterine anomalies was
excluded from study. The study concluded that
patients without any identiable pelvic pathology
beneted from prophylactic appendectomy compared to patient who did not have appendectomy
during laparoscopy [79].
Women who will have pelvic or abdominal
radiation or chemotherapy, women who will have
major operations in which dense adhesions are
anticipated postoperatively, and disabled patients
who will have difculty for explaining possible
appendicitis symptoms also benet from prophylactic appendectomy [76].
Patients with endometriosis are candidates for
coincidental appendectomy if they will have an
operation related to their symptoms, as well. The
incidence of endometriosis in appendix in
patients who suffering from endometriosis ranges
between 9.3 and 39.0% [80, 81]. Although prophylactic appendectomy reduces pain signicantly in patient with chronic pelvic pain, patient
selection for endometriosis cases should be individualized. Full investigation including MRI
before deep endometriosis surgery ought to be
performed. If bowel endometriosis is detected,
addressed surgery should be performed including
segmental resection of bowel considering the
benets and harms to the patient. It should be
kept in mind that reputable associations do not
have precise opinions for coincidental appendectomy during endometriosis surgery. However,
appendix should be evaluated during the endometriosis operations and if necessary, opinion of
general surgeons should be requested.
Finally, the most controversial issue is appendectomy during cesarean section and during
postpartum sterilization. Greatest benet is in
patients younger than 35years old for coincidental appendectomy. These two surgical procedures
seem to be compatible in terms of age.
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