Overview
Definition:
Laparoscopic appendectomy is a minimally invasive surgical procedure to remove the appendix, typically performed for acute appendicitis
It involves making small incisions (usually 3-4) through which a laparoscope (a thin, lighted tube with a camera) and surgical instruments are inserted to visualize and excise the inflamed appendix.
Epidemiology:
Appendicitis is the most common surgical emergency worldwide, with an estimated lifetime incidence of 7-8%
It affects all age groups but is most common in adolescents and young adults (10-30 years)
Laparoscopic appendectomy is now the preferred approach in most centers due to its advantages over open surgery.
Clinical Significance:
Laparoscopic appendectomy is crucial for managing acute appendicitis, a condition that can lead to serious complications like perforation, abscess formation, and peritonitis if untreated
Mastering this procedure is essential for surgical residents preparing for DNB and NEET SS examinations, as it is a frequently encountered and tested surgical intervention.
Indications
Absolute Indications:
Confirmed diagnosis of acute appendicitis with clinical and/or radiological evidence
Ruptured appendicitis with generalized peritonitis
Appendiceal abscess requiring drainage.
Relative Indications:
Uncertain diagnosis where laparoscopy can aid in diagnosis and treatment
Incidental appendectomy during other laparoscopic procedures
Certain types of appendiceal neoplasia requiring exploration.
Contraindications:
Absolute contraindications are rare but include uncorrected coagulopathy, hemodynamic instability not amenable to resuscitation, and extensive abdominal adhesions from previous surgery precluding safe laparoscopic access
Peritonitis with hemodynamic instability may necessitate conversion to open surgery.
Preoperative Preparation
History And Examination:
Thorough history focusing on pain migration, anorexia, nausea, vomiting, and fever
Physical examination to elicit McBurney's point tenderness, rebound tenderness, and guarding
Assess for signs of systemic infection
Perform a pregnancy test in women of reproductive age.
Laboratory Investigations:
Complete blood count (CBC) to assess white blood cell count (leukocytosis) and differential
Electrolytes, urea, and creatinine to assess hydration and renal function
Urinalysis to rule out urinary tract infection
Liver function tests and amylase if suspicion of other abdominal pathology.
Imaging Modality:
Ultrasound of the abdomen is often the first-line imaging in younger patients and pregnant women, showing a non-compressible, dilated appendix, or periappendiceal fluid
CT scan of the abdomen and pelvis with intravenous contrast is highly sensitive and specific for appendicitis, especially in adults, revealing appendiceal wall thickening, fat stranding, and possible perforation or abscess
Plain abdominal X-rays have limited diagnostic value.
Antibiotic Prophylaxis:
Broad-spectrum intravenous antibiotics should be administered preoperatively, typically covering gram-negative rods and anaerobes
Common regimens include ceftriaxone and metronidazole, or piperacillin-tazobactam
Duration of antibiotics depends on whether the appendix is perforated or not.
Procedure Steps
Patient Positioning And Access:
Patient is placed in the supine position, usually with legs slightly abducted (lithotomy position for pelvic pathology)
A Veress needle or open Hasson technique is used to establish pneumoperitoneum (usually with CO2 insufflation to 12-15 mmHg)
A standard port placement includes a supraumbilical umbilical port for the camera, and two or three additional ports (typically in the left iliac fossa, suprapubic, and right flank) for instrument manipulation.
Identification And Mobilization:
The cecum is typically identified and retracted to expose the base of the appendix
The mesoappendix, containing the appendiceal artery, is carefully dissected and ligated using energy devices (e.g., harmonic scalpel, bipolar cautery) or clips
The base of the appendix is then divided, usually with an endoscopic stapler or by ligation with sutures.
Appendix Excision And Specimen Retrieval:
The appendix is completely excised from its base
The specimen is then placed into an endoscopic retrieval bag to prevent spillage of contaminated contents into the peritoneal cavity, especially in cases of perforation
The bag is then extracted through one of the port sites, usually the umbilical port which may be slightly enlarged if necessary.
Peritoneal Lavage And Closure:
The abdomen is thoroughly lavaged with saline to remove any purulent material or blood
The laparoscopic instruments are removed under vision
The pneumoperitoneum is released
The port sites are inspected for bleeding, and fascia at port sites larger than 10mm is usually closed
Skin incisions are closed with sutures or adhesive strips.
Postoperative Care
Pain Management:
Adequate analgesia is crucial, often involving a multimodal approach with intravenous or oral opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen
Patient-controlled analgesia (PCA) may be used in the immediate postoperative period.
Hydration And Nutrition:
Intravenous fluids are administered to maintain hydration
Oral intake is usually resumed once the patient has bowel sounds and no nausea/vomiting, typically within 24 hours
A clear liquid diet is advanced as tolerated.
Ambulation And Discharge:
Early ambulation is encouraged to prevent deep vein thrombosis and promote bowel function
Patients are typically discharged within 24-48 hours after an uncomplicated laparoscopic appendectomy, provided they are pain-controlled, tolerating oral intake, and have no signs of infection.
Monitoring For Complications:
Patients are monitored for signs of wound infection, intra-abdominal abscess, bowel obstruction, bleeding, and retained stones (if cholecystectomy was performed concurrently)
Temperature, pulse, respiration, and blood pressure are monitored regularly
Fever, increasing abdominal pain, or inability to tolerate oral intake may indicate a complication.
Complications
Early Complications:
Wound infection (most common, typically superficial)
Intra-abdominal abscess formation (especially in cases of perforation)
Bleeding from the mesoappendix or port sites
Injury to adjacent organs (bowel, bladder, ureter) although rare
Postoperative ileus
Retained appendicolith.
Late Complications:
Incisional hernia at port sites (more common with larger ports)
Chronic abdominal pain
Adhesions leading to bowel obstruction
Stump appendicitis (inflammation of the residual appendiceal stump)
Umbilical granuloma or hernia.
Prevention Strategies:
Meticulous surgical technique, including proper ligation of the mesoappendix and stump
Adequate antibiotic prophylaxis
Careful specimen retrieval in a bag for perforated cases
Prompt diagnosis and management of suspected complications
Appropriate port site closure, especially for larger defects
Careful patient selection and pre-operative assessment.
Key Points
Exam Focus:
Key differences between laparoscopic and open appendectomy
Management of perforated appendicitis with laparoscopy
Port site selection and principles of pneumoperitoneum
Complications specific to laparoscopic approach
Indications for conversion to open surgery
Management of appendiceal abscess via laparoscopy.
Clinical Pearls:
Always identify the cecum and trace the taeniae coli to find the appendix
The most common site of appendiceal artery is at the base
In obese patients, longer instruments may be necessary
Consider diverting the surgeon's gaze from the monitor to the operative field for better tactile feedback
Ensure proper retraction to avoid injury to surrounding structures.
Common Mistakes:
Inadequate visualization due to poor insufflation or port placement
Failure to control bleeding from the mesoappendix
Incomplete excision of the appendix leading to stump appendicitis
Spillage of infected contents during specimen retrieval
Over-reliance on cautery near bowel
Incorrectly identifying bowel loops as appendix.