The İgnored İn Recurrent Endometriomas: Appendix
Objective: To characterize the involvement of the appendix by endometriosis in patients who underwent a secondary laparoscopy for recurrent endometriomas.
Design: Retrospective case series.
Setting: University ambulatory endoscopic surgery center—tertiary referral center.
Patient(s): Fifty one patients.
Intervention(s): Appendectomy during laparoscopic surgery for recurrent endometrioma.
Main Outcome Measure(s): Macroscopic and histological appendiceal endometriosis in patients who had a second laparoscopy for recurrent endometrioma.
Result(s): Fifty one patients underwent a secondary laparoscopic procedure from January 1998 to July 2007 because of a symptomatic recurrent endometrioma. Of these patients, 11 had appendectomy before and 21 of 40 (52.5%) had an appendectomy due to macroscopic pathological findings. Histologically, in 12 (57.14%) appendiceal endometriosis was documented.
Conclusion(s): The incidence of appendiceal involvement with endometriosis in surgically suspected appendiceal abnormalities during a secondary surgical procedure for recurrent endometrioma is 57.14%. We, therefore, suggest that the appendix be assessed thoroughly during a secondary surgical procedure for endometriosis, and appendectomy be considered in this unique group of patients.
Key Words: Endometriosis, recurrent endometrioma, laparoscopy, appendix, appendectomy
Introduction
Among all ethnic and social groups endometriosis represents significant health problem for women of reproductive age, with a reported incidence of 15–32% (1, 2). It has been traditionally included amongst the most important causes of chronic pelvic pain in women
Endometriosis of the gastrointestinal tract may cause a wide array of symptoms, and it is diagnosed in 3%–34% of patients affected by endometriosis (3-6). The subset of patients with endometriosis of the appendix is particularly interesting because of its acute and chronic manifestations. In addition, appendiceal endometriosis is associated with cyclic and chronic right lower quadrant pain (7), melena (8), lower intestinal hemorrhage (9), cecal intussusception (10–15), and intestinal perforation especially during pregnancy (16-17).
The reported incidence of the appendiceal involvement with endometriosis, depending on the studied group and the stage of the endometriosis, ranges from 0.8% to 34%. The accepted strategy, however, is to perform appendectomy on those cases with visibly abnormal appendixes since incidental appendectomy is not without a risk.
The objective of our current study is, therefore, to characterize the involvement of the appendix by endometriosis in patients who underwent a secondary laparoscopy for recurrent endometrioma.
Material-Method
We reviewed the medical records of all patients who applied to our clinic and underwent a secondary laparoscopic surgery for recurrent endometrioma between January 1998 and July 2007. Fifty one patients with indication of recurrent endometrioma were selected as the cases for this study. Data retrieved from the surgical notes and pathological reports of the cases who had undergone appendectomy were analyzed .The recorded data included patient demographics, previous surgical notes, patients’ abdominal-pelvic examinations, pathology reports and the most recent surgery notes. No clinical preoperative characteristics predicting the involvement of the appendix with endometriosis were identified. Postoperative data included the length of hospital stay and postoperative complications.
All procedures were performed under general anesthesia by the senior author (CN). Each patient was given a single preoperative dose of intravenous antibiotic. Upon completion of thorough laparoscopic abdominal-pelvic examination, an appendectomy was performed. The appendix was removed if the following abnormalities were observed; appendiceal adhesions, rigidity, hyperemia, congestion, induration or implants of endometriosis.
The appendectomy involved inserting grasping forceps through the RLQ trocar sleeve, and passing the bipolar electrocoagulator and the suction irrigator through the midline and lower left quadrant ports, respectively. The appendix, was then mobilized and examined after lysis of periappendiceal or pericecal adhesions when necessary. Bipolar coagulation and a cutting modality (scissors, laser, harmonic scalpel, etc.) were used to skeletonize, coagulate, and cut the mesoappendix. The Endo GIA with vascular staples was used to amputate the appendix leaving a 3- to 5-mm appendiceal stump that was copiously irrigated with Ringer’s lactate solution and evaluated for evidence of leakage (18,19).
Postoperative instructions were routine for endoscopic gynecological procedures, and all patients resumed a regular diet within 24 hours after surgery.
All statistical analysis were performed using SPSS v15.0- a statistical package program. Categorical data such as GI complaint, existence of RLQ pain etc. were presented as percentages, and as for continuous data mean and standard deviation were taken into consideration. In comparison of age and BMI in groups with or without appendiceal endometriosis, Mann Whitney U test was used. In addition, Chi square test was applied for comparison of categorical variables with groups. Results were considered statistically significant if the p value was less than 0.05.
Results
The mean age of our cohort of patients was 36.4 year (ranging from 25 to 50), and the mean BMI of the patients was 25 (ranging from 19 to 30). All of the patients had an additional indication as well as the ultrasonoghraphic evidence of a recurrent endometrioma. The indications for the secondary laparoscopy are summarized in table 1.
Table 1- Indication for the second laparoscopy
Indications for surgery Number (%)
Infertility 36 (70.5)
Pelvic pain 46 (90.1)
Dysmenorrhea 45 (88.2)
Intraoperative findings and characteristics of the endometriomas are summarized in table 2. The extent of the disease was scored according to the revised American Society for Reproductive Medicine (r-ASRM) Classification System (American Society for Reproductive Medicine, 1997).
Table 2- Intraoperative findings during the secondary laparoscopy
Number of patients (%)
Co-existence of deep endometriosis 48 (94.1)
r-ASRM score ≥3 46 (90)
Adhesion 43 (84.3)
Adenomyosis 12 (23.5)
Presence of uterine myoma 18 (35.2)
Characteristics of endometrioma
Cyst diameter less than 5 cm 44 (86.3)
Multiple cyst 21 (41.1)
Bilateral involvement 21 (41.1)
In our cohort, 11 patients had a previous appendectomy because of various indications. We performed a laparoscopic appendectomy in 21 (52.5%) of the 40 remaining patients. The indications for the appendectomy during the secondary laparoscopy are summarized in table 3.
Table 3- Indications for appendectomy
Indication for appendectomy Number of patients Proven endometriosis
Hyperemia of the appendix 3 0
Adhesion of the appendix 4 2 (50%)
Suspected endometriosis 14 10 (71.4%)
Of the patients who underwent an appendectomy, 12 (57.14%) had pathology reports documenting histological evidence of appendiceal endometriosis. In ten out of fourteen patients (71.4%) with surgically suspected endometriosis, endometriosis was proven histologically. In two out of four (50%) patients with adhesions confirmed during the surgery, endometriosis of the appendix was histologically documented (Table 3).
Furthermore, in eleven (91.6%) of the patients, only the appendiceal serosa was involved with endometriosis, and only in two patients the muscularis propria was involved. In none of the patients, did the endometriotic lesions invade the appendiceal mucosa. In ten patients (84%), the endometriosis was histologically documented only on the tip of the appendix. In one patient, endometriotic focus was both on the body and the tip of the appendix, and in one patient, the endometriosis was documented on the base of the appendix.
No postoperative complications were reported in this series of patients, and all patients were discharged within 24 hours.
As presented in table 4 there were no significant characteristic differences between patients with and without endometriosis of the appendix
Table 4 Patients characteristics: A comparison between positive and negative appendiceal involvement with endometriosis
Appendix with endometriosis
N=12 (57.1%) Normal appendix
N=9 (42.9%) P value
Age (mean) 36.8±6.2 35.7±4.8 0.602
BMI (mean) 23.9±2.4 25.6±2.8 0.196
Stage 4 Endometriosis (%) 10 (83.3%) 7 (77.7%) 0.999
Bilateral ovarian endometrioma No (%)
6 (50%)
3 (33.3%)
0.660
GI complaint No (%) 6 (50%) 1 (11.1%) 0.159
RLQ pain No (%) 0 (0%) 2 (22.2%) 0.171
Pelvic pain No (%) 12 (100%) 9 (100%) Not applicable
Age (mean) 36.8±6.2 35.7±4.8 0.602
P≤ 0.05
Discussion:
Endometriosis occasionally affecting the appendix is a common gynecological disease in reproductive aged women. The reported prevalence of endometriosis involving the gastro-intestinal tract ranges from 2.8% to 34% (20). The reported incidence of endometriosis involving the appendix varies between 1.5% and 22% (6,21). This wide range of reported prevalence is attributed to the different indications for appendectomies in different reports.
As for the comprehensive review of the literature, we identified three specific reports suggesting even a higher incidence ranging from 22% to 32% (6,22,23). All these reports are, however, based on data obtained from referral centers and may have a significant bias of patients with gastrointestinal involvement. In addition, some other studies have revealed that when pelvic endometriosis is present, odds ratio of appendiceal endometriosis compared to the general population is 20.9 (95% confidence interval 16.6-26.4) (24).
As compared to related literature, our report seems to be the first published data concerning the incidence of appendiceal involvement in patients with recurrent symptomatic endometriomas. Our data show that when a second surgical intervention is necessary due to a symptomatic recurrent endometrioma, more than 57% of surgically suspected appendiceal abnormalities have histologically evidence of endometriosis.
This high incidence of appendiceal involvement with endometriosis in this unique group of patients should emphasize few clinical and practical issues in the surgically management of recurrent endometriomas. First, systemic inspection of the appendix as part of the laparoscopic treatment of this unique group of patients is vital. Second, a surgeon should be ready and capable of performing an appendectomy in the course of the same procedure. Third, the patient should be informed about the high incidence of appendiceal involvement with endometriosis, and be consented for a possible appendectomy. Finally, with reference to the fact that some part of the symptoms are attributed to pelvic adhesions involving the appendix in cases on whom appendiceal adhesions are surgically documented, appendectomy should be considered due to high incidence of endometriosis confirmed by histology.
Reference:
1. Mahmood TA, Templeton AA, Thomson L, Fraser C. Menstrual symptoms in women with pelvic endometriosis. Br J Obstet Gynaecol 1991;98:558–63.
2. Kresch AJ, Seifer DB, Sachs LB, Barrese I. Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol 1984;64:672–4.
3. Kratzer GL, Salvati EP. Collective review of endometriosis of the colon. Am J Surg 1955;90:866 –9.
4. Macafee CH, Greer HL. Intestinal endometriosis. A report of 29 cases and a survey of the literature. J Obstet Gynaecol Br Emp 1960;67: 539 –55.
5. Williams TJ, Pratt JH. Endometriosis in 1,000 consecutive celiotomies: incidence and
management. Am J Obstet Gynecol 1977;129:245–50.
6. Berker B, Lashay N, Davarpanah R, Marziali M, Nezhat CH, Nezhat C. Laparoscopic appendectomy in patients with endometriosis. J Minim Invasive Gynecol 2005;12:206 –9.
7. Collins DC. Endometriosis of the vermiform appendix; review of literature, with addition of nine new instances, one of which caused severe melena. AMA Arch Surg 1951;63:617–22.
8. Shome GP, Nagaraju M, Munis A, Wiese D. Appendiceal endometriosis presenting as massive lower intestinal hemorrhage. Am J Gastroenterol 1995;90:1881–3.
9. Martin LF, Tidman MK, Jamieson MA. Appendiceal intussusception and endometriosis. J Can Assoc Radiol 1980;31:276 –7.
10. Mann WJ, Fromowitz F, Saychek T, Madariaga JR, Chalas E. Endometriosis associated with appendiceal intussusception. A report of two cases. J Reprod Med 1984;29:625–9.
11. Sonnino RE, Ansari MR. Intussusception of the appendix and endome- triosis. Henry Ford Hosp Med J 1986;34:61– 4.
12. Panzer S, Pitt HA, Wallach EE, Thuluvath PJ. Intussusception of the appendix due to endometriosis. Am J Gastroenterol 1995;90:1892–3.
13. Schmidt FR, McCarthy JD. Intussusception of the appendix with endometriosis presenting as a cecal tumor. Arch Surg 1971;103:515–7.
14. Sakaguchi N, Ito M, Sano K, Baba T, Koyama M, Hotchi M. Intussusception of the appendix: a report of three cases with different clinical and pathologic features. Pathol Int 1995;45:757– 61.
15. Geerdsen J, Axelsson C, Weile F. Invagination of the vermiform appendix. A report of two cases associated with endometriosis. Acta Chir Scand 1976;142:417–9.
16. Gini PC, Chukudebelu WO, Onuigbo WI. Perforation of the appendix during pregnancy: a rare complication of endometriosis. Case report. Br J Obstet Gynaecol 1981;88:456 – 8.
17. Nakatani Y, Hara M, Misugi K, Korehisa H. Appendiceal endometriosis in pregnancy. Report of a case with perforation and review of the literature. Acta Pathol Jpn 1987;37:1685–90.
18. Nezhat C, Siegler A, Nezhat F, et al. Appendectomy. In: Operative Gynecologic Laparoscopy, Principles and Techniques. 2nd ed. New York: McGraw-Hill, 2000:355-63.
19. Nezhat C, Nezhat F. Incidental appendectomy during videolaseroscopy. Am J Obstet Gynecol 1991;165:559-64.
20. Gustofson RL, Kim N, Liu S, Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature. Fertil Steril 2006;86:298 –303.
21-Harper AJ, Soules MR. Appendectomy as a consideration in operations for endometriosis. Int J Gynaecol Obstet 2002;79:53– 4.
22. Mittal VK, Choudhury SP, Cortez JA. Endometriosis of the appendix presenting as acute appendicitis. Am J Surg 1981;142:519 –21.
23.AlSalilli M, Vilos GA. Prospective evaluation of laparoscopic appendectomy in women with chronic right lower quadrant pain. J Am Assoc Gynecol Laparosc 1995;2:139 – 42.
24. Agarwala N, Liu CY. Laparoscopic appendectomy. J Am Assoc Gynecol Laparosc 2003;10:166 – 8.
Design: Retrospective case series.
Setting: University ambulatory endoscopic surgery center—tertiary referral center.
Patient(s): Fifty one patients.
Intervention(s): Appendectomy during laparoscopic surgery for recurrent endometrioma.
Main Outcome Measure(s): Macroscopic and histological appendiceal endometriosis in patients who had a second laparoscopy for recurrent endometrioma.
Result(s): Fifty one patients underwent a secondary laparoscopic procedure from January 1998 to July 2007 because of a symptomatic recurrent endometrioma. Of these patients, 11 had appendectomy before and 21 of 40 (52.5%) had an appendectomy due to macroscopic pathological findings. Histologically, in 12 (57.14%) appendiceal endometriosis was documented.
Conclusion(s): The incidence of appendiceal involvement with endometriosis in surgically suspected appendiceal abnormalities during a secondary surgical procedure for recurrent endometrioma is 57.14%. We, therefore, suggest that the appendix be assessed thoroughly during a secondary surgical procedure for endometriosis, and appendectomy be considered in this unique group of patients.
Key Words: Endometriosis, recurrent endometrioma, laparoscopy, appendix, appendectomy
Introduction
Among all ethnic and social groups endometriosis represents significant health problem for women of reproductive age, with a reported incidence of 15–32% (1, 2). It has been traditionally included amongst the most important causes of chronic pelvic pain in women
Endometriosis of the gastrointestinal tract may cause a wide array of symptoms, and it is diagnosed in 3%–34% of patients affected by endometriosis (3-6). The subset of patients with endometriosis of the appendix is particularly interesting because of its acute and chronic manifestations. In addition, appendiceal endometriosis is associated with cyclic and chronic right lower quadrant pain (7), melena (8), lower intestinal hemorrhage (9), cecal intussusception (10–15), and intestinal perforation especially during pregnancy (16-17).
The reported incidence of the appendiceal involvement with endometriosis, depending on the studied group and the stage of the endometriosis, ranges from 0.8% to 34%. The accepted strategy, however, is to perform appendectomy on those cases with visibly abnormal appendixes since incidental appendectomy is not without a risk.
The objective of our current study is, therefore, to characterize the involvement of the appendix by endometriosis in patients who underwent a secondary laparoscopy for recurrent endometrioma.
Material-Method
We reviewed the medical records of all patients who applied to our clinic and underwent a secondary laparoscopic surgery for recurrent endometrioma between January 1998 and July 2007. Fifty one patients with indication of recurrent endometrioma were selected as the cases for this study. Data retrieved from the surgical notes and pathological reports of the cases who had undergone appendectomy were analyzed .The recorded data included patient demographics, previous surgical notes, patients’ abdominal-pelvic examinations, pathology reports and the most recent surgery notes. No clinical preoperative characteristics predicting the involvement of the appendix with endometriosis were identified. Postoperative data included the length of hospital stay and postoperative complications.
All procedures were performed under general anesthesia by the senior author (CN). Each patient was given a single preoperative dose of intravenous antibiotic. Upon completion of thorough laparoscopic abdominal-pelvic examination, an appendectomy was performed. The appendix was removed if the following abnormalities were observed; appendiceal adhesions, rigidity, hyperemia, congestion, induration or implants of endometriosis.
The appendectomy involved inserting grasping forceps through the RLQ trocar sleeve, and passing the bipolar electrocoagulator and the suction irrigator through the midline and lower left quadrant ports, respectively. The appendix, was then mobilized and examined after lysis of periappendiceal or pericecal adhesions when necessary. Bipolar coagulation and a cutting modality (scissors, laser, harmonic scalpel, etc.) were used to skeletonize, coagulate, and cut the mesoappendix. The Endo GIA with vascular staples was used to amputate the appendix leaving a 3- to 5-mm appendiceal stump that was copiously irrigated with Ringer’s lactate solution and evaluated for evidence of leakage (18,19).
Postoperative instructions were routine for endoscopic gynecological procedures, and all patients resumed a regular diet within 24 hours after surgery.
All statistical analysis were performed using SPSS v15.0- a statistical package program. Categorical data such as GI complaint, existence of RLQ pain etc. were presented as percentages, and as for continuous data mean and standard deviation were taken into consideration. In comparison of age and BMI in groups with or without appendiceal endometriosis, Mann Whitney U test was used. In addition, Chi square test was applied for comparison of categorical variables with groups. Results were considered statistically significant if the p value was less than 0.05.
Results
The mean age of our cohort of patients was 36.4 year (ranging from 25 to 50), and the mean BMI of the patients was 25 (ranging from 19 to 30). All of the patients had an additional indication as well as the ultrasonoghraphic evidence of a recurrent endometrioma. The indications for the secondary laparoscopy are summarized in table 1.
Table 1- Indication for the second laparoscopy
Indications for surgery Number (%)
Infertility 36 (70.5)
Pelvic pain 46 (90.1)
Dysmenorrhea 45 (88.2)
Intraoperative findings and characteristics of the endometriomas are summarized in table 2. The extent of the disease was scored according to the revised American Society for Reproductive Medicine (r-ASRM) Classification System (American Society for Reproductive Medicine, 1997).
Table 2- Intraoperative findings during the secondary laparoscopy
Number of patients (%)
Co-existence of deep endometriosis 48 (94.1)
r-ASRM score ≥3 46 (90)
Adhesion 43 (84.3)
Adenomyosis 12 (23.5)
Presence of uterine myoma 18 (35.2)
Characteristics of endometrioma
Cyst diameter less than 5 cm 44 (86.3)
Multiple cyst 21 (41.1)
Bilateral involvement 21 (41.1)
In our cohort, 11 patients had a previous appendectomy because of various indications. We performed a laparoscopic appendectomy in 21 (52.5%) of the 40 remaining patients. The indications for the appendectomy during the secondary laparoscopy are summarized in table 3.
Table 3- Indications for appendectomy
Indication for appendectomy Number of patients Proven endometriosis
Hyperemia of the appendix 3 0
Adhesion of the appendix 4 2 (50%)
Suspected endometriosis 14 10 (71.4%)
Of the patients who underwent an appendectomy, 12 (57.14%) had pathology reports documenting histological evidence of appendiceal endometriosis. In ten out of fourteen patients (71.4%) with surgically suspected endometriosis, endometriosis was proven histologically. In two out of four (50%) patients with adhesions confirmed during the surgery, endometriosis of the appendix was histologically documented (Table 3).
Furthermore, in eleven (91.6%) of the patients, only the appendiceal serosa was involved with endometriosis, and only in two patients the muscularis propria was involved. In none of the patients, did the endometriotic lesions invade the appendiceal mucosa. In ten patients (84%), the endometriosis was histologically documented only on the tip of the appendix. In one patient, endometriotic focus was both on the body and the tip of the appendix, and in one patient, the endometriosis was documented on the base of the appendix.
No postoperative complications were reported in this series of patients, and all patients were discharged within 24 hours.
As presented in table 4 there were no significant characteristic differences between patients with and without endometriosis of the appendix
Table 4 Patients characteristics: A comparison between positive and negative appendiceal involvement with endometriosis
Appendix with endometriosis
N=12 (57.1%) Normal appendix
N=9 (42.9%) P value
Age (mean) 36.8±6.2 35.7±4.8 0.602
BMI (mean) 23.9±2.4 25.6±2.8 0.196
Stage 4 Endometriosis (%) 10 (83.3%) 7 (77.7%) 0.999
Bilateral ovarian endometrioma No (%)
6 (50%)
3 (33.3%)
0.660
GI complaint No (%) 6 (50%) 1 (11.1%) 0.159
RLQ pain No (%) 0 (0%) 2 (22.2%) 0.171
Pelvic pain No (%) 12 (100%) 9 (100%) Not applicable
Age (mean) 36.8±6.2 35.7±4.8 0.602
P≤ 0.05
Discussion:
Endometriosis occasionally affecting the appendix is a common gynecological disease in reproductive aged women. The reported prevalence of endometriosis involving the gastro-intestinal tract ranges from 2.8% to 34% (20). The reported incidence of endometriosis involving the appendix varies between 1.5% and 22% (6,21). This wide range of reported prevalence is attributed to the different indications for appendectomies in different reports.
As for the comprehensive review of the literature, we identified three specific reports suggesting even a higher incidence ranging from 22% to 32% (6,22,23). All these reports are, however, based on data obtained from referral centers and may have a significant bias of patients with gastrointestinal involvement. In addition, some other studies have revealed that when pelvic endometriosis is present, odds ratio of appendiceal endometriosis compared to the general population is 20.9 (95% confidence interval 16.6-26.4) (24).
As compared to related literature, our report seems to be the first published data concerning the incidence of appendiceal involvement in patients with recurrent symptomatic endometriomas. Our data show that when a second surgical intervention is necessary due to a symptomatic recurrent endometrioma, more than 57% of surgically suspected appendiceal abnormalities have histologically evidence of endometriosis.
This high incidence of appendiceal involvement with endometriosis in this unique group of patients should emphasize few clinical and practical issues in the surgically management of recurrent endometriomas. First, systemic inspection of the appendix as part of the laparoscopic treatment of this unique group of patients is vital. Second, a surgeon should be ready and capable of performing an appendectomy in the course of the same procedure. Third, the patient should be informed about the high incidence of appendiceal involvement with endometriosis, and be consented for a possible appendectomy. Finally, with reference to the fact that some part of the symptoms are attributed to pelvic adhesions involving the appendix in cases on whom appendiceal adhesions are surgically documented, appendectomy should be considered due to high incidence of endometriosis confirmed by histology.
Reference:
1. Mahmood TA, Templeton AA, Thomson L, Fraser C. Menstrual symptoms in women with pelvic endometriosis. Br J Obstet Gynaecol 1991;98:558–63.
2. Kresch AJ, Seifer DB, Sachs LB, Barrese I. Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol 1984;64:672–4.
3. Kratzer GL, Salvati EP. Collective review of endometriosis of the colon. Am J Surg 1955;90:866 –9.
4. Macafee CH, Greer HL. Intestinal endometriosis. A report of 29 cases and a survey of the literature. J Obstet Gynaecol Br Emp 1960;67: 539 –55.
5. Williams TJ, Pratt JH. Endometriosis in 1,000 consecutive celiotomies: incidence and
management. Am J Obstet Gynecol 1977;129:245–50.
6. Berker B, Lashay N, Davarpanah R, Marziali M, Nezhat CH, Nezhat C. Laparoscopic appendectomy in patients with endometriosis. J Minim Invasive Gynecol 2005;12:206 –9.
7. Collins DC. Endometriosis of the vermiform appendix; review of literature, with addition of nine new instances, one of which caused severe melena. AMA Arch Surg 1951;63:617–22.
8. Shome GP, Nagaraju M, Munis A, Wiese D. Appendiceal endometriosis presenting as massive lower intestinal hemorrhage. Am J Gastroenterol 1995;90:1881–3.
9. Martin LF, Tidman MK, Jamieson MA. Appendiceal intussusception and endometriosis. J Can Assoc Radiol 1980;31:276 –7.
10. Mann WJ, Fromowitz F, Saychek T, Madariaga JR, Chalas E. Endometriosis associated with appendiceal intussusception. A report of two cases. J Reprod Med 1984;29:625–9.
11. Sonnino RE, Ansari MR. Intussusception of the appendix and endome- triosis. Henry Ford Hosp Med J 1986;34:61– 4.
12. Panzer S, Pitt HA, Wallach EE, Thuluvath PJ. Intussusception of the appendix due to endometriosis. Am J Gastroenterol 1995;90:1892–3.
13. Schmidt FR, McCarthy JD. Intussusception of the appendix with endometriosis presenting as a cecal tumor. Arch Surg 1971;103:515–7.
14. Sakaguchi N, Ito M, Sano K, Baba T, Koyama M, Hotchi M. Intussusception of the appendix: a report of three cases with different clinical and pathologic features. Pathol Int 1995;45:757– 61.
15. Geerdsen J, Axelsson C, Weile F. Invagination of the vermiform appendix. A report of two cases associated with endometriosis. Acta Chir Scand 1976;142:417–9.
16. Gini PC, Chukudebelu WO, Onuigbo WI. Perforation of the appendix during pregnancy: a rare complication of endometriosis. Case report. Br J Obstet Gynaecol 1981;88:456 – 8.
17. Nakatani Y, Hara M, Misugi K, Korehisa H. Appendiceal endometriosis in pregnancy. Report of a case with perforation and review of the literature. Acta Pathol Jpn 1987;37:1685–90.
18. Nezhat C, Siegler A, Nezhat F, et al. Appendectomy. In: Operative Gynecologic Laparoscopy, Principles and Techniques. 2nd ed. New York: McGraw-Hill, 2000:355-63.
19. Nezhat C, Nezhat F. Incidental appendectomy during videolaseroscopy. Am J Obstet Gynecol 1991;165:559-64.
20. Gustofson RL, Kim N, Liu S, Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature. Fertil Steril 2006;86:298 –303.
21-Harper AJ, Soules MR. Appendectomy as a consideration in operations for endometriosis. Int J Gynaecol Obstet 2002;79:53– 4.
22. Mittal VK, Choudhury SP, Cortez JA. Endometriosis of the appendix presenting as acute appendicitis. Am J Surg 1981;142:519 –21.
23.AlSalilli M, Vilos GA. Prospective evaluation of laparoscopic appendectomy in women with chronic right lower quadrant pain. J Am Assoc Gynecol Laparosc 1995;2:139 – 42.
24. Agarwala N, Liu CY. Laparoscopic appendectomy. J Am Assoc Gynecol Laparosc 2003;10:166 – 8.
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