Take it or leave it? Incidental appendectomy at time of gynecologic oncology laparotomy.

Nora Badiner: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation. Angela Mirzadeh: Writing – original draft, Data curation. Lauren Sword: Writing – original draft, Data curation. Mary Herberger: Data curation. Hayley Butler: Data curation. Ruofan Yao: Formal analysis, Conceptualization. Yevgeniya Ioffe: Writing – review & editing, Formal analysis, Conceptualization. Linda Hong: Writing – review & editing, Formal analysis, Conceptualization.

The authors declare that this research was completed independent of funding support, and no grants were received to support the completion of this research.

Under the approval of the Institutional Review Board of Loma Linda University Health (IRB#5210349), a retrospective chart review was performed. Electronic medical records of patients undergoing surgery by members of the Division of Gynecologic Oncology between January 2013 and August 2022 were reviewed. A total of 3,927 surgical cases met the review criteria. Exclusion criteria included exploratory laparotomy performed for the purpose of cesarean hysterectomy or reoperation after primary surgery, including for abdominal wall closure, suspected intra-abdominal hemorrhage and repeat abdominal washout. A comprehensive review of these encounters identified 169 unique patients who underwent concurrent appendectomy at the time of exploratory laparotomy with a gynecologic oncology surgeon (Appendectomy Group). The remaining encounters were then reviewed to select matched controls based on BMI, procedure date and procedure type, specifically whether bowel resection was performed. Matching criteria were selected to control for confounding as the complications of interest are increased in patients with higher BMI and when bowel resection is performed. In total, 344 controls met inclusion criteria for the study. After selection of the cases and controls, the electronic medical records were reviewed for data of interest. Demographic data abstracted from the medical record included patient age at time of surgery, race/ethnicity, body mass index (BMI), and presence of a known cancer diagnosis at time of surgery. The operative report was reviewed and abstracted for final procedure type performed, including any bowel resection other than isolated appendectomy, preoperative and postoperative diagnosis, and intraoperative appendiceal appearance, which was confirmed via the pathology report. Final pathologic diagnosis, cancer staging, and appendiceal pathology were obtained from the pathology reports. Encounters were reviewed for postoperative complications within 30 days of surgery, including bowel obstruction, peritonitis, other postoperative infection (including urinary tract infections, incisional and vaginal cuff cellulitis, intra-abdominal or superficial abscess, and pneumonia), blood transfusion, readmission, and death. Preoperative diagnoses were categorized as pelvic mass, ovarian etiology, endometrial/uterine etiology, cervical etiology, infectious etiology, gastrointestinal (GI) malignancy, and abnormal uterine bleeding (AUB) or postmenopausal bleeding (PMB). Ovarian etiology included all diagnoses of ovarian cancer, primary peritoneal carcinoma and carcinoma of the fallopian tube in addition to benign ovarian cysts and masses. Endometrial/uterine etiology included endometrial hyperplasia, fibroids, suspected or known uterine sarcoma, and endometrial carcinoma. Cervical dysplasia and cancer were classified under cervical etiology. Infectious etiology included known or suspected diagnosis of pelvic inflammatory disease (PID) and tubo-ovarian abscess (TOA). Procedure type was categorized into one of the following six variables: exploratory laparotomy, exploratory laparotomy with hysterectomy, exploratory laparotomy with hysterectomy and staging, exploratory laparotomy with staging, exploratory laparotomy with debulking, and exploratory laparotomy with hysterectomy and debulking. These categories were selected due to their inherent risk of complications, as patients undergoing hysterectomy and extensive debulking are at the highest risk of perioperative complications. We further stratified each procedure by whether hysterectomy was performed due to the increased risk of infection with clean-contaminated procedures. Data was analyzed using Stata Statistical Software, release 16 (StataCorp. 2019 Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC.). Student t test was used to analyze significance of continuous variables. Categorical data was analyzed using χ 2 test. Statistical significance was accepted at a P value ≤ 0.05.

Demographic data and surgical characteristics are presented in Table 1 . Successful matching was confirmed on statistical analysis. Patients in the appendectomy group were younger than the control group (mean age 50.82 years old ± 16.6 vs. 55.42 ± 15.2, P  = 0.003), but otherwise demographically similar. There was no difference in BMI (30.71 kg/m 2  ± 9.71 kg/m 2 vs. 31.29 kg/m 2  ± 8.28 kg/m 2 , P  = 0.506) or race/ethnicity. Table 1 Demographic and surgical characteristics of patients undergoing exploratory laparotomy with the Division of Gynecologic Oncology (2013–2021). Characteristic Ex Lap + Appy (n = 169) N (%) Ex Lap No Appy (n = 344) N (%) P Value Age (yr) a 50.82 ± 16.6 55.42 ± 15.2 0.003 * BMI (kg/m 2 ) a 30.71 ± 9.71 31.29 ± 8.28 0.506 Race/Ethnicity 0.7411  Asian 8 (4.7 %) 18 (5.2 %)  Black 20 (11.8 %) 33 (9.6 %)  Hispanic/Latino 70 (41.4 %) 136 (39.5 %)  White 70 (41.4 %) 151 (44.0 %)  Not reported 1 (0.6 %) 6 (1.7 %) Cancer diagnosis known preoperatively  Any Cancer 50 (29.6 %) 164 (47.7 %) <0.001 * Pre-Op Diagnosis  Pelvic Mass 116 (68.6 %) 163 (47.4 %) <0.001 *  Ovarian Etiology c 31 (18.3 %) 43 (12.5 %) 0.077  Endometrial Etiology d 15 (8.9 %) 63 (18.3 %) 0.005 *  Cervical Etiology e 2 (1.2 %) 18 (5.2 %) 0.026 *  PID/TOA f 3 (1.8 %) 7 (2.0 %) 0.490  GI Malignancy 2 (1.2 %) 40 (11.6 %) <0.001 *  AUB/PMB g −- 9 (2.7 %) 0.034 * Procedure Type  Ex Lap, no hysterectomy/staging/debulking 40 (23.7 %) 34 (9.9 %) <0.001 * Ex Lap with hysterectomy  Ex Lap/Staging 35 (20.7 %) 153 (44.5 %) <0.001 *  Ex Lap/Hysterectomy/Staging 9 (5.3 %) 5 (1.5 %) 0.011 *  Ex Lap/Debulking 24 (14.2 %) 72 (20.9 %) 0.066  Ex Lap/Hysterectomy/Debulking 15 (8.9 %) 24 (7.0 %) 0.447  All Procedures including Hysterectomy 46 (27.2 %) 56 (16.2 %) 0.004 *  All Procedures including debulking 105 (62.1 %) 277 (80.6 %) <0.0001 61(36.1 %) 80 (23.3 %) 0.002 * Additional Bowel Resection Performed 31 (18.3 %) 60 (17.4 %) 0.803 b Ex Lap = exploratory laparotomy. a Data presented as mean ± SD. c Ovarian Etiology = ovarian cancer, fallopian tube cancer, or primary peritoneal cancer. d Endometrial Etiology = endometrial cancer, endometrial hyperplasia, or uterine sarcoma. e Cervical Etiology = cervical cancer, cervical dysplasia. f PID/TOA = pelvic inflammatory disease or tubo-ovarian abscess. g AUB/PMB = abnormal uterine bleeding or postmenopausal bleeding. * Statistically significant ( P  ≤ 0.05). Demographic and surgical characteristics of patients undergoing exploratory laparotomy with the Division of Gynecologic Oncology (2013–2021). b Ex Lap = exploratory laparotomy. Data presented as mean ± SD. Ovarian Etiology = ovarian cancer, fallopian tube cancer, or primary peritoneal cancer. Endometrial Etiology = endometrial cancer, endometrial hyperplasia, or uterine sarcoma. Cervical Etiology = cervical cancer, cervical dysplasia. PID/TOA = pelvic inflammatory disease or tubo-ovarian abscess. AUB/PMB = abnormal uterine bleeding or postmenopausal bleeding. Statistically significant ( P  ≤ 0.05). Patients undergoing appendectomy were more likely to have a diagnosis of pelvic mass (68.6 % vs. 47.4 %, P  < 0.001). In contrast, patients in the control group were more likely to have a diagnosis of endometrial etiology (18.3 % vs. 8.9 %, P  = 0.005), cervical etiology (5.2 % vs. 1.2 %, P  = 0.026), GI malignancy (11.6 % vs. 1.2 %, P  < 0.001), or AUB/PMB (2.7 % vs. 0 %, P  = 0.034). Additionally, patients in the control group were more likely to have a known cancer diagnosis prior to surgery compared to the appendectomy group (47.7 % vs. 29.6 %, P  < 0.001). Patients in the control group were more likely to undergo concurrent hysterectomy (62.1 % vs. 80.6 %, P  < 0.0001). More patients in the appendectomy group underwent a complex procedure, with 36.1 % of patients undergoing a debulking procedure as compared to 23.3 % in the control group ( P  = 0.002). There was no significant difference in the rate of additional bowel resection between the appendectomy and control groups (18.3 % vs. 17.4 %, P  = 0.803), confirming matching on this variable was successful. Safety and outcomes data are presented in Table 2 . The mean length of hospitalization was similar between the appendectomy and control groups (6.10 days ± 5.34 days vs. 5.87 days ± 5.34 days, P  = 0.645). The appendectomy group did not have an increased rate of any of the complications of interest: bowel obstruction, peritonitis, infection, blood transfusion nor 30-day readmission ( Table 2 ). Furthermore, the rate of postoperative infection (18.7 % vs. 11.2 %, P  = 0.031) and postoperative anemia requiring blood transfusion (21.5 % vs. 14.2 %, P  = 0.048) were significantly higher in the control group. Table 2 Length of Stay and Rates of postoperative complications of interest within 30 days of surgery. Appendectomy did not result in an increase in length of hospitalization or rate of postoperative complications. Complication Ex Lap + Appy (n = 169) N (%) Ex Lap no Appy (n = 344) N (%) P Value LOS (days) a 6.10 ± 5.34 5.87 ± 5.34 0.645 Postoperative Complication  Bowel obstruction 3 (1.8 %) 14 (4.0 %) 0.172  Peritonitis 1 (0.6 %) 5 (1.5 %) 0.394  Infection 19 (11.2 %) 64 (18.7 %) 0.031 *  Blood transfusion 24 (14.2 %) 74 (21.5 %) 0.048 *  Readmission 13 (7.7 %) 24 (6.9 %) 0.768 a LOS = Length of stay, Data presented as mean ± SD. * Statistically significant ( P ≤  0.05). Length of Stay and Rates of postoperative complications of interest within 30 days of surgery. Appendectomy did not result in an increase in length of hospitalization or rate of postoperative complications. LOS = Length of stay, Data presented as mean ± SD. Statistically significant ( P ≤  0.05). Summary of appendectomy indications and descriptors of intraoperative appendiceal appearances are presented in Table 3 . 61 patients (36.1 %) underwent appendectomy to achieve optimal cytoreduction, 54 (32 %) for other gross appendiceal abnormality, 44 (25 %) for a diagnosis of mucinous ovarian neoplasm, and 10 patients (5.9 %) did not have an explicitly documented indication ( Table 3 ). At final pathology, 62 (36.7 %) of all appendiceal specimens were found to be histologically abnormal: 26 (15.4 %) had metastasis from a gynecologic cancer and primary appendiceal neoplasm was found in 16 (9.5 %). Other histologic findings included focal endometriosis (9), acute appendicitis (4), peri -appendiceal abscess (1) and immature teratoma (1). Of the 57 patients who were confirmed to have advanced stage (stage III/IV) gynecologic cancer after surgery, 22 (38.6 %) were found to have metastasis to the appendix. No patients with apparent pelvic confined (stage I/II) gynecologic cancer were upstaged solely due to metastasis to the appendix on final pathology. Table 3 Indications for performing appendectomy, documented intraoperative appearance of appendix, and final appendiceal pathologic diagnosis. Appendectomy Indications & Appendiceal Findings Ex Lap + Appy (n = 169) N (%) Indication for Appendectomy  Completion of Gynecologic Surgery 29 (17.2 %)  Abnormal appearance 90 (53.3 %)  Mucinous ovarian tumor 39 (23.1 %)  Prophylactic 5 (3.0 %)  Not stated/Other 2 (1.2 %) Intraoperative Findings  Normal 50 (29.6 %)  Enlarged/Edematous 28 (16.6 %)  Nodular 25 (14.8 %)  Tumor/Carcinomatosis 39 (23.1 %)  Adherent/Scarred 22 (13.0 %)  Fecalith 5 (3.0 %) Pathologic Diagnosis of Appendix  Benign/No Finding 107 (63.3 %)  Gynecologic Cancer Metastasis 26 (15.4 %)  Primary Appendiceal Neoplasm 16 (9.5 %)  Infection/Inflammation 11 (6.5 %)  Endometriosis 9 (5.3 %) Indications for performing appendectomy, documented intraoperative appearance of appendix, and final appendiceal pathologic diagnosis. 50 (29.6 %) patients undergoing appendectomy were described as having grossly normal appendiceal appearance, while 119 (70.4 %) had an abnormal appearance: enlarged or edematous (28, 16.6 %), nodular (25, 14.8 %), macroscopic tumor or carcinomatosis (39, 23.1 %), adherent or scarred (22, 13.0 %), or fecalith (5, 3.0 %) ( Table 4 , Fig. 1 ). Of the appendiceal specimens that were grossly normal, six (12 %) had an occult finding only diagnosed on final pathology: primary appendiceal neoplasm (3), appendicitis (1), gynecologic cancer metastasis (1), endometriosis (1) ( Fig. 1 , Table 4 ). Of the patients with abnormal gross appearance of the appendix, 65 (54.6 %) had no significant pathologic findings. Other histologic findings in the appendixes with abnormal appearance were metastasis from gynecologic cancer (25, 21.0 %), primary appendiceal neoplasm (12, 10.1 %), infection/inflammation (9, 7.6 %), and endometriosis (8, 6.7 %). Table 4 Appendiceal pathology by intraoperative appearance. The majority of appendiceal specimens were benign regardless of intraoperative appearance. 12 % of normal appendices had an occult histopathologic diagnosis. Pathologic Diagnosis by Appendiceal Intraoperative Appearance Normal 50  Benign/No finding 44 (88.0 %)  Gynecologic Cancer Metastasis 1 (2.0 %)  Primary Appendiceal Neoplasm 3 (6.0 %)  Infection/Inflammation 1 (2.0 %)  Endometriosis 1 (2.0 %) Abnormal 119  Benign/No finding 65 (54.6 %)  Gynecologic Cancer Metastasis 25 (21.0 %)  Primary Appendiceal Neoplasm 12 (10.1 %)  Infection/Inflammation 9 (7.6 %)  Endometriosis 8 (6.7 %) Fig. 1 Appendiceal pathology by intraoperative appearance. Despite normal intraoperative appearance, 12 % of specimens were found to have an occult abnormality only diagnosed on histopathologic analysis. Appendiceal pathology by intraoperative appearance. The majority of appendiceal specimens were benign regardless of intraoperative appearance. 12 % of normal appendices had an occult histopathologic diagnosis. Appendiceal pathology by intraoperative appearance. Despite normal intraoperative appearance, 12 % of specimens were found to have an occult abnormality only diagnosed on histopathologic analysis.

Current practice recommendations for gynecologic oncologists are to perform appendectomy only when the gross appearance of the appendix is abnormal, even in cases of mucinous ovarian pathology. Overall, 36.7 % of patients in this study had an appendiceal abnormality on final pathology, consistent with prior studies ( Salom et al., 2003 ). Our findings presented above illustrate that assessment of intraoperative appearance does not consistently correlate with final histopathology: over 50 % of specimens identified as grossly abnormal intraoperatively had no abnormal findings on final pathology. Conversely, 12 % of appendixes that were normal in appearance had an occult finding diagnosed only on final pathology, including metastasis from gynecologic malignancy and primary appendiceal neoplasm. Our study corroborates earlier findings described in the literature. Salom et al investigated the safety and postoperative complication rates of appendectomy at the time of abdominal hysterectomy for benign indications and did not find an increase in complications ( Salom et al., 2003 ). Similar to Salom et al, we did not find a significant increase in any of the studied postoperative complications, including the length of hospital stay, in the appendectomy group. This supports the argument for incidental appendectomy in gynecologic oncology patients undergoing exploratory laparotomy. Furthermore, removal of the appendix translates into future risk reduction of repeat surgery and resulting perioperative morbidity. The role of routine incidental appendectomy had come into question due to the risk of complications from the procedure, including hemorrhage, bowel perforation, and infection; these may be of particular concern if performed by a surgeon who does not frequently perform appendectomies ( Moore et al., 2016 ). Gynecologic oncologists are trained to perform complex bowel resections during their subspecialty training and are experienced in multiple appendectomy completion techniques. In our exploratory study, the common complication rate was not increased in the appendectomy group, however we recognize that this is a small-single institution study. A larger, multi-institutional study could be undertaken with appropriate power to formally address the question of increased complications among gynecologic oncology patients undergoing concurrent appendectomy. Additionally, our study found that final pathology revealed an incidental diagnosis of acute appendicitis in one patient despite grossly normal appearance intraoperatively. Patients undergoing gynecologic oncology procedures are a particularly vulnerable population due to their advanced age and may be immunocompromised due to neoadjuvant chemotherapy. Although the incidence of acute appendicitis decreases with age, there is a higher rate of complications from acute appendicitis in older patients, including longer hospitalization, death, and wound or pelvic infection, due in part to the elevated risk of perforation (50–60 %) in patients over the age of 50 ( Salom et al., 2003 , Saillard et al., 2018 , Stevens et al., 2022 ). Incidental appendectomy at the time of gynecologic oncology surgery eliminates the future risk of developing appendicitis, which can be complicated by patient age and immunosuppression secondary to chemotherapy. The role of incidental appendectomy during gynecologic oncology staging procedures to rule out upstaging of gynecologic cancers due to isolated appendiceal involvement is an area of ongoing debate. Although five studies have failed to find any incidences in which patients with apparent early-stage epithelial ovarian cancer were upstaged due to isolated appendiceal involvement ( Sari et al., 2017 , Malfetano, 1987 , Fontanelli et al., 1992 , Ramirez et al., 2006 , Lee et al., 2010 ), two studies contradict these results. One study found a rate of appendiceal metastasis of 4.3 % in patients with disease apparently confined to the pelvis, and a nearly 70 % rate of appendiceal involvement in patients with advanced stage ovarian malignancies, leading to the conclusion that appendectomy should be performed routinely as part of staging procedures for ovarian malignancies ( Rose et al., 1991 ). Supporting this argument, in a study of 285 patients with epithelial ovarian carcinoma, Ayhan et al. found that 4.9 % of patients with apparent stage I-II disease had microscopic isolated appendiceal metastases resulting in upstaging on final pathology ( Ayhan et al., 2005 ). In our study, the rate of occult pathology was 12 %, supportive of proceeding with incidental appendectomy at the time of gynecologic oncology staging procedures to rule out occult metastatic disease or other pathologic abnormalities. Patients in the control group were more likely to undergo hysterectomy than patients in the appendectomy group. There are two likely explanations for this finding. The first is that the appendectomy group was younger than the control group, and younger patients are less likely to have completed childbearing and are therefore more likely to undergo fertility-sparing procedures. Additionally, there were higher rates of endometrial pathology in the control group, which likely contributed significantly to the higher rates of hysterectomy seen in the control group. Interestingly, we identified increased rates of postoperative anemia requiring blood transfusion and postoperative infection in the control group. This may have been confounded by the fact that 62.1 % of the patients in the appendectomy group underwent hysterectomy, as compared to 80.6 % in the control group. Hysterectomy involves ligation and transection of major vessels, which may contribute to higher intraoperative blood loss. Another possible source of confounding contributing to the higher rates of postoperative blood transfusion is pre-existing anemia. There were more patients with a known cancer diagnosis at time of surgery in the control group, especially higher rates of endometrial and cervical cancer. Patients with endometrial and cervical cancer are more likely to experience heavy vaginal bleeding and preoperative baseline anemia as compared to patients with other diagnoses. Patients with a known diagnosis of malignancy may have undergone neoadjuvant chemotherapy, contributing to immunosuppression and pre-operative anemia. It is a limitation of our study that we did not analyze rates of preoperative anemia, intraoperative blood loss, or administration of neoadjuvant chemotherapy, all of which may have contributed to the higher rates of postoperative blood transfusion and infection seen in the control group. A study of incidental appendectomy performed at the time of benign gynecologic surgery noted that patients undergoing appendectomy were younger and had a lower BMI than patients that did not undergo appendectomy ( Salom et al., 2003 ). This difference disappeared upon adjustment for age and BMI, leading the authors to conclude that surgeons were more likely to perform incidental appendectomy in younger and leaner patients due to technical feasibility ( Salom et al., 2003 ). We also noted that patients undergoing appendectomy were younger than controls, which may have confounded the rates of postoperative infection. The capacity of the immune system to combat infection and promote wound healing is diminished with increased age, which may contribute to the higher rates of infection seen in the control group in this study. The lack of extensive data regarding medical comorbidities is a recognizable limitation of our study. There was no significant difference in the rate of surgeries performed for infection, including PID/TOA, between the two groups in our study. Therefore, we do not suspect that preoperative infection contributed to the difference in the rate of postoperative infection. Although not addressed here, future studies should include surgical wound classification as well as details of the prophylactic antibiotic regimen used, as these may be confounding variables.

When performed by gynecologic oncologists, we did not find an increase in postoperative complications when appendectomy was performed at time of laparotomy. Despite abnormal appearance, over 50 % of specimens had no abnormal findings on pathology. Furthermore, our results demonstrate a high rate of occult abnormal histology despite normal intraoperative appearance, indicating that intraoperative assessment of appearance is unreliable and an insufficient method to detect pathology. The results of our exploratory study support performing incidental appendectomy at the time of gynecologic oncology exploratory laparotomy procedures, however further studies will need to be powered to detect differences in complication rates and clinical benefit to patients.

When a patient presents for initial evaluation of a pelvic mass or peritoneal carcinomatosis, the differential diagnosis includes appendiceal pathology, both benign and malignant. This stems from the anatomical position of the appendix, immediately above the right ovary, in close proximity to the right paracolic gutter. Located in a primary drainage site of pelvic ascitic fluid, the appendix is prone to metastasis from gynecologic primary cancers ( Ayhan et al., 2005 , Sonnendecker, 1982 ). At the time of staging and debulking surgery, gynecologic oncologists must evaluate the appendix for disease involvement, as this would upstage pelvic confined cancer and may impact the feasibility of optimal cytoreduction ( Ayhan et al., 1994 , Beşe et al., 1996 ). Conversely, metastasis from a primary appendiceal carcinoma can mimic the appearance of epithelial ovarian carcinoma and is not immediately clinically distinguishable. Incidental appendectomy is defined as the removal of the vermiform appendix without evidence of acute appendicitis at the time of surgical intervention for another indication and is generally performed to eliminate the risk of acute appendicitis in the future ( Healy et al., 2016 ). The role of incidental appendectomy has long been studied and debated ( Salom et al., 2003 , Choksuwattanasakul, 2017 , Lee et al., 2011 ). The role of appendectomy in gynecologic oncology surgery has been predominantly studied in mucinous ovarian pathologies. Currently, the NCCN guidelines recommend proceeding with appendectomy in confirmed mucinous ovarian neoplasms only if the appearance is visibly abnormal ( NCCN Ovary Guidelines 1.2025 ). Arguments in support of incidental appendectomy include the simplicity of the technical procedure without significant prolongation in operative time, low rates of complication from appendectomy, and elimination of the risk of future appendicitis and associated morbidity, including additional surgeries, anesthesia exposures, and hospital admissions ( Akbulut et al., 2020 , Salom et al., 2003 , Corfitsen et al., 1991 , Silvert and Meares, 1976 ). These arguments warrant consideration in gynecologic oncology patients, who are intrinsically high risk for complications from subsequent appendiceal pathology due to age, immunosuppression, and postoperative adhesions that may form after laparotomy ( Stevens et al., 2022 , Kim et al., 2024 , Mortellaro et al., 2011 , Saillard et al., 2018 ). Appendectomy and the resulting histopathologic evaluation can facilitate an early diagnosis of appendiceal diseases, including low-grade appendiceal mucinous neoplasms, neuroendocrine tumors and acute appendicitis ( Akbulut et al., 2020 ). Some studies have shown the presence of microscopic appendiceal abnormalities even in cases where the appendix appeared macroscopically normal ( Cheng et al., 2017 , Nanthamongkolkul et al., 2022 , Sari et al., 2017 , Papageorgopoulou et al., 2023 ). We aimed to assess the safety of appendectomy at the time of laparotomy by gynecologic oncologists, regardless of the indication for surgery, while concurrently assessing the overall benefits of appendectomy to gynecologic oncology patients.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.