Selective Appendectomy in Patients Undergoing Minimally Invasive Surgery for Endometriosis: A Retrospective Cohort Study

<b>Background/Objectives:</b> Endometriosis is a chronic inflammatory systemic disease that commonly affects bowel structures, including the appendix, where it may mimic or coexist with chronic appendicitis. Visual inspection alone often fails to detect appendiceal involvement, leading to underdiagnosis and suboptimal management. This study investigates the prevalence and histopathologic spectrum of appendiceal abnormalities in patients undergoing minimally invasive laparoscopic surgery for endometriosis and evaluates the safety and postoperative outcomes of selective appendectomy. <b>Methods:</b> We conducted a retrospective cohort study of 236 patients who underwent a selective appendectomy concurrent with laparoscopic surgery for endometriosis with and without robotic assistance from January 2024 to April 2025. Preoperative evaluation included clinical assessment, imaging, and risk stratification using the Nezhat Endometriosis Risk Advisor tool, with some patients referred after positive ReceptivaDx testing. Intraoperatively, the appendix was examined for endometriosis, adhesions, or obliteration, and abnormal findings warranted removal using a vascular stapler. Postoperative outcomes and histopathologic results were assessed over six months, with appendiceal involvement analyzed in relation to endometriosis stage. <b>Results:</b> Of 236 patients who underwent selective laparoscopic appendectomy during surgical treatment for endometriosis, abnormal appendiceal pathology was identified in 216 (91.53%) patients. Histopathology revealed appendiceal endometriosis in 34 patients (14.41%), adhesions in 140 (59.32%), fibrous obliteration in 82 (34.75%), inflammation in 20 (8.47%), and neuroendocrine tumors in 3 (1.27%), one of which was malignant. Endometriotic lesions of the appendix showed a significant association with advanced-stage (III-IV) disease (<i>p</i> = 0.05), while other pathologies were not stage-dependent. No intraoperative complications occurred, and postoperative outcomes were favorable, with only one readmission unrelated to the appendectomy. <b>Conclusions:</b> Selective appendectomy during laparoscopic surgery for endometriosis revealed a high prevalence (91.5%) of appendiceal pathology. Even without visible implants, the appendix may contribute to symptoms, underscoring the importance of thorough intraoperative evaluation. Selective appendectomy based on surgical findings may aid symptom relief, prevent missed diagnoses, and enhance comprehensive management of endometriosis, but these potential benefits must be weighed against the small risks of concurrent appendectomy.