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Laparoscopic Appendectomy

  • Author: Yevgeny Shuhatovich, DO; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Oct 26, 2015
 

Background

Acute appendicitis (AA), a common intra-abdominal surgical pathology, requires a comprehensive understanding of its presentation, evaluation, diagnosis, and overall operative management.

In the United States, the overall incidence of AA is approximately 7%, with a mortality of 0.2-0.8%.[1] The morbidity and mortality are related to the presenting stage of disease and are higher in cases of perforation.

Briefly, the pathophysiology and progressive timeline of AA are attributed to luminal obstruction, causing distention, ineffective venous and lymphatic drainage, bacterial invasion, and, finally, perforation with associated leakage of contents into the peritoneal cavity.

The presentation, evaluation, and diagnosis of AA are notoriously inconsistent; many factors attribute to these discrepancies. The classic history consists of anorexia and periumbilical pain, followed by nausea, right-lower-quadrant (RLQ) pain, and vomiting, as well as leukocytosis.[2] History and physical examination should provide enough clinical information to diagnose AA, with the use of imaging as adjuncts in the assessment.

Treatment consists of providing aggressive intravenous fluid resuscitation and antibiotics, placing the patient on nil per os (NPO) status and on pain control, and obtaining a general surgical consultation for definitive operative management (either open or laparoscopic).

The authors' institution, a residency training facility, primarily uses the laparoscopic approach to AA, as is described in this article. For a discussion of the open procedure, see Open Appendectomy. For discussion of a laparoscopic approach that uses only one port, see Single-Port Appendectomy.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has published a Guideline for Laparoscopic Appendectomy.

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Indications

Ever since being described by McBurney,[3] open appendectomy has been a well-established and widely performed operation indicated for patients with acute appendicitis. Whether and when to perform a laparoscopic appendectomy as opposed to an open procedure remains a pertinent question.

To consider the indications for laparoscopic appendectomy, it is more fitting to describe the contraindications, with the notion that all else falls into the indications category. (See Contraindications.)

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Contraindications

Absolute contraindications to laparoscopic appendectomy are as follows:

  • Hemodynamic instability
  • Lack of surgical expertise

Relative contraindications include the following:

  • Severe abdominal distention that causes operative view obstruction or complicates abdominal entry and bowel manipulation
  • Generalized peritonitis
  • Multiple previous surgical procedures
  • Severe pulmonary disease
  • Pregnancy
  • Extreme obesity

That said, as laparoscopic technology advances and surgeons' expertise increases, many surgeons have successfully performed a multitude of laparoscopic procedures in the presence of these relative contraindications. In a study comparing laparoscopic and open appendectomy for complicated appendicitis in adult patients, Taguchi et al found that the minimally invasive approach was safe and feasible in this setting, though it did not significantly reduce complications.[4]

If intraoperative complications that cannot be handled with laparoscopy arise during laparoscopic appendectomy, conversion to an open appendectomy is indicated. It is crucial to understand the circumstances in which such conversion is warranted.[5, 6] Relative indications for conversion include the following:

  • Dense adhesions due to inflammation or prior surgical procedures
  • Perforated or gangrenous appendicitis
  • Gangrenous or necrotic base
  • Generalized peritonitis
  • Retrocecal appendix
  • Inability to visualize the appendix
  • Uncontrolled bleeding
  • Tumor of the appendix extending into base
  • Other pathology, including malrotation, carcinoma, diverticula of cecum, endometriosis, pelvic inflammatory diseases, torsion of tubo-ovarian cyst
  • Unexpected diagnosis

In a high-volume prospective cohort study by Antonacci et al, multivariate analysis indicated that preoperative comorbidities, appendiceal perforation, a retrocecal appendix, appendicular abscess, and diffuse peritonitis were factors significantly related to conversion from laparoscopic to open appendectomy.[7]

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Technical Considerations

Anatomy

The appendix is an elongated outpouching of the cecum, found at its posteromedial aspect about 2.5 cm below the ileocecal valve. It is derived embryologically from the midgut and first noted between weeks 5 and 8 of gestation.[8] It subsequently becomes fixed in the RLQ of the abdomen as the gut rotates during development.[8]

Function

Histologically, the walls of the appendix contain not only mucus-secreting goblet cells but also lymphoid tissue (developing during weeks 14 and 15 of gestation), implying immune function in early development.[8] Nevertheless, no specific function in the adult has been determined.

Positions of appendix

The base of the appendix can be identified during surgery by following the convergence of the taeniae coli toward the inferior portion of the cecum, which forms a continuous muscular layer surrounding the appendix. The position of the appendicular tip is inconstant and can be in various locations, including retrocecal (65%); descending pelvic (31%); transverse and retrocecal (2.5%); ascending, paracecal, and preileal (1%); and ascending, paracecal, and postileal (0.4%). This varied location explains the vast array of presentations.[9]

Blood supply

The blood supply of the appendix is derived from the appendicular artery, originating from the iliac ramus in 35% of cases, the ileocolic artery in 31%, the anterior cecal artery in 20%, the posterior cecal artery in 12%, and the ascending colic ramus in 2%.[10] The venous drainage parallels that of the arterial supply.

Associated structures

The mesoappendix consists of the mesentery of the appendix, containing all of the appendicular nerves and vasculature, which is ligated during an appendectomy. The fold of Treves, another useful anatomic landmark in locating the appendix during surgery, not only represents an avascular structure but is the only epiploic appendage located at the antimesenteric border of the small intestine.[11] It also serves as a marker indicating the junction of the ileum and cecum.

Procedural planning

The operative technique for AA consists of appendectomy; however, the choice between an open and a laparoscopic operation continues to be challenged in the medical literature.[12, 13, 14] Historically, the RLQ incision of open appendectomy has persisted essentially unchanged since it was pioneered by McBurney in the 19th century.[3] The use of laparoscopy in the surgical management of AA was first described in 1983, with a continued increasing trend in its use.[15]

As with other laparoscopic procedures, the literature describes decreased pain, earlier resumption of diet, and decreased length of hospital stay for laparoscopic appendectomy.[14] However, this must be objectively contrasted to the open procedure, which already involves minimal risk, extremely short length of hospital stay, and a low rate of complications. Additional disadvantages of laparoscopy include increased cost and longer operating times.

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Contributor Information and Disclosures
Author

Yevgeny Shuhatovich, DO Resident Physician, Department of Surgery, Maimonides Medical Center

Yevgeny Shuhatovich, DO is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Danny A Sherwinter, MD Attending Surgeon, Department of Mimially Invasive Surgery and Bariatrics, Associate Program Director, Department of Surgery, Maimonides Medical Center; Director of Minimally Invasive and Bariatric Surgery, American Society for Metabolic and Bariatric Surgery (ASMBS) Center of Excellence

Danny A Sherwinter, MD is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Harry L Adler, MD Assistant Clinical Professor of Surgery, Mount Sinai Hospital; Assistant Director and Consulting Physician, Maimonides Medical Center

Harry L Adler, MD is a member of the following medical societies: American Association for Physician Leadership, American College of Surgeons, Association for Academic Surgery

Disclosure: Nothing to disclose.

Evan Brad Goldstein, DO Assistant Professor of Surgery, Department of Surgery, State University of New York Downstate Medical Center College of Medicine; Attending Surgeon, Department of Surgery, Maimonides Medical Center

Evan Brad Goldstein, DO is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Association of Program Directors in Surgery

Disclosure: Nothing to disclose.

Joseph Michael R Zuniga, MD Resident Physician, Department of Surgery, Maimonides Medical Center

Disclosure: Nothing to disclose.

Aleksander Bernshteyn, MD Chief Resident, Department of Surgery, Maimonides Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Jerzy M Macura, MD Chief of Advanced Laparoscopic Surgery, Director of Bariatric Surgery, Maimonides Medical Center

Jerzy M Macura, MD, is a member of the following medical societies: American Society for Metabolic and Bariatric Surgery, American Society of Abdominal Surgeons, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

References
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Suprapubic trocar insertion. Great care must be employed to avoid bladder injury.
A case of an acutely inflamed retrocecal appendix. Harmonic scalpel dissection to reveal the appendiceal base/cecal base as indicated by confluence of the taenia.
The Harmonic scalpel is then used to cauterize and divide the mesoappendix. Note the excellent view of the cecal/appendiceal base.
Deployment of an Endoloop around the base of the appendix.
Division of the appendix from the cecum above the 2 Endoloops.
Suctioning and irrigation of surgical site and survey of the dissection for hemostasis.
 
 
 
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