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June 11, 2026
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Abstract

Background. The negative appendectomy rate (NAR) the proportion of appendectomies in which the removed appendix is histologically normal is a recognized quality indicator in emergency general surgery. Despite the increasing availability of preoperative imaging, NAR remains variable, and selective rather than universal imaging strategies leave a residual burden of unnecessary operations, particularly in women of childbearing age.


Objective. To determine the NAR at a single tertiary center in the era of selective preoperative imaging, to characterize NAR across clinically relevant subgroups, and to identify independent predictors of negative appendectomy using histopathology as the reference standard.


Patients and methods. A retrospective single-center cohort study was conducted at Nasiriyah teaching hospital, Thi-Qar province, Iraq from October 2024 through February 2026 and reported in accordance with the STROBE statement. Patients aged 16 years or older undergoing appendectomy for suspected acute appendicitis with a retrievable histopathology report were included. Negative appendectomy was defined as the absence of histological inflammatory changes in the resected appendix. Multivariable logistic regression identified independent predictors; discrimination was assessed by the area under the receiver operating characteristic curve (AUC).


Results. Of 712 appendectomies screened, 583 formed the analytic cohort; 96 (16.5%, 95% CI 13.6–19.7%) were negative. NAR was 9.4% in men and 27.8% in women, rising to 33.6% in women aged 16–45 years. NAR was 6.8% when CT was performed versus 27.1% with no preoperative imaging. Independent predictors of negative appendectomy were female sex aged 16–45 years (adjusted odds ratio [aOR] 3.42, 95% CI 2.06–5.68), absence of preoperative imaging (aOR 2.98, 95% CI 1.79–4.96), Alvarado score below 7 (aOR 2.61, 95% CI 1.58–4.31), and normal white-cell count (aOR 3.05, 95% CI 1.83–5.08). The predictive model achieved an AUC of 0.81 (95% CI 0.76–0.86). 


Conclusions. NAR remained substantial under a selective-imaging strategy and was concentrated in young women and in patients operated without imaging. Wider preoperative imaging in selected high-risk subgroups may reduce unnecessary appendectomy.

Keywords

Appendectomy appendectomy rate acute appendicitis preoperative imaging computed tomography quality indicator predictors

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