(Abstracted from J Minim Invasive Gynecol 2019;26:71–77) The primary sequelae of endometriosis are infertility and chronic pelvic pain (CPP). Nearly 40% of women with endometriosis are infertile, and 71% to 87% have CPP.

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Objective To evaluate the role of appendectomy in surgical excision of endometriosis and to assess complications associated with appendectomy. Methods Retrospective study of women undergoing appendectomy for pelvic pain and/or endometriosis during a primary gynecologic procedure. Results Record review was performed for 609 women who underwent appendectomy between 2013 and 2019 for pelvic pain (6.9%, 42/609), stage I–II endometriosis (63.7%, 388/609), or stage III–IV endometriosis (29.4%, 179/609). Appendiceal endometriosis (AppE) was present in 14.9% (91/609); 2.4% without endometriosis (1/42, reference group), 7.0% with stage I–II endometriosis (27/388, odds ratio [OR] 3.06, 95% confidence interval [CI] 0.41–23.11, P = 0.278), and 35.2% with stage III–IV endometriosis (63/179, OR 22.24, 95% CI 2.99–165.40, P = 0.002). AppE was significantly associated with endometriosis present in other locations (OR 5.27, 95% CI 2.66–10.43, P < 0.001). The predicted probability of identifying AppE ranged from 6% with 0 positive endometriosis sites to 56% when 4 or more sites were identified. There were no complications related to the performance of an appendectomy. Conclusion Women with chronic pelvic pain and/or endometriosis have an increased risk of AppE. Modern appendectomy at the time of gynecologic surgery is safe, with no associated complications in this study. Our findings support the consideration of appendectomy as part of the comprehensive surgical management of endometriosis.

To evaluate the diagnosis of appendiceal endometriosis (AppE) in coincidental appendectomy specimens using standard versus modified histopathologic analysis. Design: Prospective analysis of 300 consecutive patients undergoing coincidental appendectomy at the time of a primary gynecologic procedure. Setting: Academic tertiary referral hospital in the northeastern United States. Patients: Women aged 22 to 52 years undergoing gynecologic surgery for the management of endometriosis or chronic pelvic pain between 2013 and 2015. Interventions: Each appendix specimen underwent standard pathologic analysis with 4 sections performed. Modified pathologic analysis, consisting of standard analysis plus serial sectioning and complete evaluation of the appendix and mesoappendix, was then performed. The first pathologist reviewed all the slides to render a diagnosis. The slides of the subjects with abnormal pathology were rereviewed. On rereview, the diagnosis was confirmed, and the data on which protocol, standard or modified, achieved the diagnosis was rendered. The pathologist performing the second review was blinded to whether the slides from the standard or modified histopathology protocol achieved the original diagnosis. This allowed each specimen to serve as its own control. Measurements and Main Results: The primary outcome is the detection of AppE. The standard analysis identified endometriosis in 7.7% (n = 23) of appendiceal specimens, whereas the modified analysis identified endometriosis in 10.0% (n = 30; odds ratio 1.3; confidence interval, 1.1−1.7; p = .01). When all pathology findings were combined, the standard analysis identified abnormal pathology in 9.3% (n = 28) of the specimens, whereas the modified analysis identified abnormal pathology in 12.3% (n = 37; odds ratio 1.4; confidence interval, 1.1−1.7; p <.01). Other abnormal appendiceal pathology identified in this study included polyps, neuroendocrine tumors, and acute appendicitis. The average number of slides required for the standard analysis was 1.4 compared with 4.9 slides for the modified analysis. At this institution, the average increase in the cost of slide production for the modified protocol was $12.07. Conclusion: Modified pathologic analysis resulted in a significantly higher rate of diagnosis of endometriosis and abnormal pathology in coincidental appendectomy performed during a primary gynecologic procedure for endometriosis and/or chronic pelvic pain. The use of a standard pathologic protocol likely contributes to underdiagnosis of AppE. The implementation of a modified histopathologic protocol should be considered for improving diagnosis rates of appendiceal pathology in coincidental appendectomy specimens.

Objective: This article offers insight into an academic institute's approach to the rare phenomenon of abdominalwall endometriosis (AWE). The article also provides data on concurrent pelvic endometriosis, which has not often been assessed in previous studies. The aim here is to describe the characteristics and management of AWE at an academic institute. Materials and Methods: A retrospective chart review was conducted on 28 patients with pathologically confirmed AWE at an academic institute. Results: The most commonly reported symptoms were constant pain (19/28; 67.9%), cyclic pain (16/28; 57.1%), and palpable mass (16/28; 57.1%). All patients reported having had prior abdominal surgery. Preoperative imaging included 14 magnetic resonance imaging scans, 11 computed tomography scans, and 8 ultrasounds. Nine general surgery and 19 anesthesiology preoperative consultations occurred. AWE was found within 5 cm of a previous incision in 24 of 28 patients; these were 20 cesarean-section and 4 laparoscopic incisions. The average size of the lesions was 3.8 cm. Four patients required mesh and 26 patients underwent concurrent laparoscopy at the time of excision. Endometriosis and/or adenomyosis was noted in 25 patients (96.2%). Fifteen patients underwent regional anesthetic blocking. The average length of stay for these patients was 1158.3 versus 1705.7 minutes for those who did not. Conclusions: Pain and a mass at a previous surgical site warrants a workup for AWE. If AWE is suspected, one should consider laparoscopy for any patient with symptoms suggestive of pelvic endometriosis. Perioperative, regional anesthetic blocks should be also considered.