Laparoscopic Appendectomy

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 modalities as adjuncts in the assessment.

Treatment consists of providing aggressive intravenous (IV) 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. The corresponding open procedure is discussed elsewhere (see Open Appendectomy). Laparoscopic approaches that use only one port have been described[3, 4] (see Single-Port Appendectomy).[5, 6, 7, 8] Transvaginal approaches have been described as well (see Transvaginal Appendectomy). 

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has published a guideline for laparoscopic appendectomy.[9]

Ever since being described by McBurney,[10] open appendectomy has been a well-established and widely performed operation indicated for patients with AA. Whether and when to perform a laparoscopic appendectomy as opposed to an open procedure remain pertinent questions.

In 2016, the World Society of Emergency Surgery (WSES) published guidelines for acute appendicitis that included recommendations regarding indications for laparoscopic appendectomy and choice of approach.[11]  These guidelines were subsequently updated in 2020[12] and included the following recommendations:

• Laparoscopic appendectomy is recommended as the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis where laparoscopic equipment and expertise are available
• Laparoscopic appendectomy should be preferred to open appendectomy in children where laparoscopic equipment and expertise are available
• Conventional three-port laparoscopic appendectomy is recommended over single-incision laparoscopic appendectomy
• In pediatric patients with acute appendicitis and favorable anatomy, single-incision/transumbilical extracorporeal laparoscopic assisted appendectomy or traditional three-port laparoscopic appendectomy is suggested, based on local skills and expertise 
• The adoption of outpatient laparoscopic appendectomy for uncomplicated appendicitis is suggested, provided that an ambulatory pathway with well-defined enhanced recovery after surgery (ERAS) protocols and patient information/consent are locally established
• Laparoscopic appendectomy is suggested over open appendectomy in obese patients, older patients, and patients with high peri- and postoperative risk factors
• Laparoscopic appendectomy should be preferred to open appendectomy in pregnant patients when surgery is indicated and laparoscopic expertise is available

In considering the indications for laparoscopic appendectomy, it may be equally or even more appropriate to focus on the contraindications, with the notion that all else falls into the indications category. (See Contraindications.)

Absolute contraindications for laparoscopic appendectomy are as follows:

• Hemodynamic instability
• Lack of surgical expertise

Relative contraindications have included 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 has advanced and surgeons' expertise has increased, many surgeons have successfully performed a multitude of laparoscopic procedures in the presence of these relative contraindications. The 2020 WSES guidelines reflect the growing acceptance of laparoscopic appendectomy in older patients, pregnant women, obese individuals, and those with high perioperative and postoperative risk factors.[12]

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.[13, 14] 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.[15]

A study from Japan found a high preoperative C-reactive protein (CRP) level to be associated with an increased likelihood of conversion from laparoscopic to open appendectomy.[16]

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 is first noted between weeks 5 and 8 of gestation.[17] It subsequently becomes fixed in the RLQ of the abdomen as the gut rotates during development.[17]

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.[17] Nevertheless, no specific function in the adult has been determined.

Positions

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.[18]

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%.[19] 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.[20] 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 has been the subject of considerable discussion in the medical literature.[21, 22, 23] Historically, the RLQ incision of open appendectomy has persisted essentially unchanged since it was pioneered by McBurney in the 19th century.[10] The use of laparoscopy in the surgical management of AA was first described in 1983, with a continued increasing trend in its use.[24]

As with other laparoscopic procedures, the literature describes decreased pain, earlier resumption of diet, and decreased length of hospital stay for laparoscopic appendectomy.[23] However, the procedure must be objectively compared with the corresponding open procedure, which already involves minimal risk, an extremely short hospital stay, and a low complication rate. Relative disadvantages of laparoscopy include increased cost and longer operating time.

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.[25] Li et al found that laparoscopic appendectomy, as compared with open appendectomy, was feasible and effective in pediatric patients presenting an appendiceal abscess and that it had beneficial clinical effects (eg, in terms of postoperative recovery of gastrointestinal function) and a lower rate of postoperative complications.[26]

Before the procedure begins, all equipment must be present in the surgical arena and must be checked for proper working capacity. All methods of laparoscopic appendectomy require the standard laparoscopic equipment, including the following:

• Trocars
• Blunt graspers
• Hook electrocautery
• Laparoscope, 30º, 10 mm
• Electrosurgical device (eg, electrocautery wand, Harmonic Scalpel [Ethicon, Somerville, NJ], Sonosurg [Olympus, Hamburg, Germany])

The following equipment, if available, is also helpful:

• Laparoscope, 30º, 5 mm
• Laparoscopic clip applier
• Endoscopic gastrointestinal anastomosis (Endo-GIA) 45-mm stapler, white cartridge
• Suction irrigator
• Endoscopic ligatures (Endoloop; Ethicon, Somerville, NJ)
• Endoscopic retrieval bag

Many different approaches to laparoscopic appendectomy exist, all of which involve ligating the mesoappendix, transecting the appendiceal base, and retrieving the surgical specimen; the authors' method is presented in the Technique section.

Because of the inherent surgical technique and requirements, general anesthesia is the preferred method in performing a laparoscopic appendectomy.

Administer preoperative antibiotics to cover gram-negative and anaerobic bacteria.

Place the patient supine and tuck the left arm for initial peritoneal access. A single monitor is best positioned to the right of the patient, along the line of the right anterior superior iliac spine (ASIS). Upon abdominal insufflation and laparoscope insertion, steep Trendelenburg positioning allows proper placement of the last two trocars. After all of the trocars have been placed, placing the patient with the left side down aids gravity in relocating the small bowel away from the appendiceal/cecal field of vision.

An overview of a laparoscopic appendectomy is shown in the video below.

Although not mandatory, a Foley catheter is helpful in decompressing the bladder, thereby maximizing the viewing field and improving working space.

Before the procedure, take time for a surgical time-out, highlighting the patient, the surgical team, the procedure to be performed, and the completion of all preoperative requirements. At this point, the patient is ready to be positioned as previously described and prepared and draped in a sterile fashion.

Placement of trocars

Make a 2-cm supraumbilical curvilinear incision directly above the umbilicus.

Perform meticulous dissection with the electrocautery through the subcutaneous tissue, beyond the Scarpa fascia, and down to the linea alba, skeletonizing the fascia. Snowden-Pencer Hasson S retractors provide good visualization and angulation for incising the fascia in a longitudinal direction, for approximately 2 cm. Grasp the just-incised fascial edges with two straight clamps, allowing both to be brought into the operating field.

To provide anchoring for placement of the 12-mm Hasson trocar in the future steps, place a 0 polyglactin UR stitch in the midline of both fascial edges.

Continue blunt dissection with the S retractors to allow visualization of the peritoneum. Grasp the peritoneum with two straight clamps, side by side, in a horizontal manner. Use the fingertips to palpate the newly grasped peritoneum for any intra-abdominal contents.

Use Metzenbaum scissors to cut 2-cm longitudinal incisions for entry into the peritoneal cavity. Then gently introduce the Hasson trocar through this defect and initiate carbon dioxide insufflation.

Meticulously visualize the entire abdominal cavity.

For the placement of the next two 5-mm trocars, place the patient into a steep Trendelenburg position. Place the first trocar to the left of the midline, 1 cm above the pubic ramus. Make a 1-cm horizontal incision. As in all laparoscopic procedures, trocars should be placed under direct vision, with meticulous attention to detail. Be mindful of the demarcation of the dome of the bladder, making sure to stay cephalad, when the port enters the peritoneal cavity. (See the video below.)

Place the second 5-mm port 2 cm above and medial to the left anterior superior iliac spine (ASIS). With the light of the scope, the vessels of the anterior abdominal wall can be highlighted to provide an appropriate roadmap in entering the abdominal cavity.

Visualization of mesoappendix and appendiceal base

Once all of the trocars have been placed and in order to obtain the best visualization of the proposed target, rotate the patient so that the left side is down while maintaining the steep Trendelenburg position. This maneuver allows gravity to retract the small bowel away from the operating field.

Place two atraumatic graspers through the 5-mm trocars, assisting the gravitational pull; grasping both the omentum and small bowel, place them toward the left upper quadrant (LUQ). Locating the appendix should always start with visualization of the right colon. Once the right colon has been identified, follow the taeniae coli down to the confluence at the base of the cecum; this leads directly to the appendix.

Use the grasper to clutch the tip of the appendix through the suprapubic port, holding it up and out toward the LUQ. This should provide good visualization of the mesoappendix and the appendiceal base.

In certain situations, for better visualization of the appendix, the right colon may have to be mobilized in addition to the ileocolic junction. This can be done with either the hook electrocautery or the ultrasonic scalpel. Again, to accomplish this mobilization along the white line of Toldt, grasp the colon through the ASIS port with the right hand, holding the colon up and out toward the LUQ. This clearly reveals the demarcation of the retroperitoneal attachments, allowing dissection through the suprapubic port.[27] (See the video below.)

Division of mesoappendix and excision of appendix

The next step is division of the mesoappendix. With the tip of the appendix grasped and placed in the proper position, an ultrasonic device is used to divide the mesoappendix toward the base of the appendix.

The authors prefer the Harmonic Scalpel or the Sonosurg to the Endo-GIA because of inconsistent thickness, which causes a wide disparity in surface area and hence can lead to hemorrhage after the stapler's deployment. In particular, the Sonosurg is excellent at controlling the appendiceal vessels even when the mesentery is acutely inflamed; moreover, it is a reposable instrument and thus is very cost-effective. Besides the Endo-GIA 45-mm white cartridge, endoscopic clips are another option for controlling the appendiceal vessels.

Once the entire mesoappendix has been coagulated and transected, the appendix should be well skeletonized. (See the video below.)

Remove the scope from the umbilical port, and change to a 30º 5-mm scope for placement into the left ASIS port. Place an Endo-GIA 45-mm white cartridge through the umbilical port, and, under direct vision, position it across the now clearly delineated base of the appendix/cecum.

Capitalizing on the angulation of the 30º scope, carefully check all sides of the stapler. Make sure the stapler is in the appropriate position with nothing accidentally caught in its jaws.

Through this entire process, the left hand remains on the tip of the appendix, maintaining the position of up and out toward the LUQ, thereby delineating the crucial anatomy (elevation of the cecum from its retroperitoneal attachments, with the mesoappendix and appendiceal base in clear sight) for future coagulation and transecting.

Close the stapler, and allow 15 seconds to transpire before firing; this permits the surface area to become consistent throughout the entirety of the appendix. (See the video below.)

Carefully inspect both the mesoappendiceal transection line and the appendiceal stump staple line. If any points of hemorrhage are noted, an endoscopic clip (10 mm) or sutures can be applied to the bleeding points. The authors have found that a more cost-effective method for controlling the appendiceal stump is placement of two 0 polyglactin endoscopic loops around the base, rather than use of the stapler. (See the video below.) The use of self-locking polymeric clips for closure of the stump has been suggested as a cost-saving measure that is comparably safe and effective.[28, 29]

Place an endoscopic retrieval bag through the umbilical port, and deploy it in the right upper quadrant (RUQ). With the appendix placed inside, close the bag under direct vision. The authors do not remove the specimen at this time, because this would require that the trocar be removed and then reinserted. It is preferable to leave the bag hanging from the umbilical port and place a Kelly clamp on the end of the string for later retrieval.

Switch the scopes again (substituting the 5 mm for the 10 mm), and place into the original Hasson supraumbilical port. Again, visualize the appendiceal staple line and the mesoappendix for any abnormalities.

Irrigation and suction

Irrigate[30] and suction this area, as well as the pelvis. (See the video below.) Irrigating and suctioning of the pelvis are best performed with the surgeon's body repositioned so that his or her back faces cephalad. With the right hand, place the suction irrigator through the suprapubic port into the pelvis. With the left hand, using an atraumatic grasper with its jaws spread apart, hold away the pelvic contents through the ASIS port. Once irrigation and suction are completed, remove all instruments from the abdominal cavity.

Removal of ports and retrieval of specimen

Under direct visualization, remove all ports beyond the fascia, helping to visualize any active hemorrhage. Cease abdominal insufflation, and turn off the light source to the camera/scope. Release the Hasson trocar, and remove it from the abdominal cavity. Retrieve the bag containing the appendix, inspect the specimen thoroughly, and send it to pathology. If difficulty is encountered trying to remove the specimen, the fascial incision may be extended.

Closure

For closure, place a 0 polyglactin UR stitch, in a figure-eight fashion, through the linea alba/fascia to close the supraumbilical port. Infiltration of local analgesia at the trocar sites at the completion of the procedure is helpful for postoperative pain control.[31]  All incisions are closed with interrupted 4-0 polyglactin or poliglecaprone sutures. Apply Dermabond to reinforce closure of the skin.

After completion of the surgical procedure, the patient is out of bed, ambulating, with appropriate pain control. Diet is advanced as tolerated, with plans for discharge on postoperative day 1 for noncomplicated appendicitis. Resumption of normal activity occurs within 1 day following the procedure; adequate analgesia allows safe return to daily duty.

Discharge instructions consist of pain management, instructions on the future signs and symptoms indicating potential complications (see below), and an office appointment in 1 week's time. The postoperative outpatient office visit evaluates the patient's improved progression with a detailed history and physical examination, discussion of the final pathology, and evaluation of the surgical wound.

In a systematic review and meta-analysis (five studies; N = 7079) comparing ambulatory laparoscopic appendectomy with conventional laparoscopic appendectomy, Trejo-Avila et al found evidence to suggest that ambulatory laparoscopic appendectomy may be safe and feasible as compared with the conventional equivalent but noted that conclusive recommendations could not yet be made, owing to a lack of high-quality comparative studies.[32]

In a study that included 1441 children who underwent laparoscopic appendectomy for nonperforated appendicitis, Kashyap et al found that same-day discharge (n = 511) was comparable to overnight obervation (n = 930) with respect to safety, did not lead to more postoperative emergency department visits or hospital readmissions, and provided a significant cost benefit.[33]

The morbidity and mortality of acute appendicitis are related to the stage of disease at presentation, and they increase in cases of perforation. The mortality figures for nonperforated and perforated appendicitis are 0.8 and 5.1 per 1000 cases, respectively.[34] The average rate of perforation at presentation is 16-30%, but it is significantly increased in elderly and young patients, secondary to a delay in diagnosis.[35]

Early

Common early complications include the following:

• Bleeding
• Surgical-site infection (SSI)
• Intra-abdominal abscess
• Unrecognized enteric injury
• Fistula formation

SSIs are determined by the level of intraoperative wound contamination, with rates of infection ranging from less than 5% in patients with simple appendicitis to 20% in patients with perforations. A study by Ma et al found that visceral obesity was a risk factor for incisional infection after laparoscopic appendectomy.[36] In a meta-analysis of 54 randomized clinical trials comparing laparoscopic with open appendectomy, SSIs were less likely after laparoscopic appendectomy than after open appendectomy.[23] Whichever surgical approach is chosen, preoperative intravenous (IV) antibiotics have been shown to decrease the postoperative SSI rate.[37]

In the postoperative period, fluctuating pyrexia, along with worsening diarrhea, may give clues to the formation of intra-abdominal or pelvic abscesses, specifically after gross contamination of the peritoneal cavity. The incidence of intra-abdominal abscesses is increased nearly threefold after laparoscopic appendectomy.[23]  Peritoneal irrigation appears to be a risk factor for intra-abdominal abscess after laparoscopic appendectomy.[38]

The diagnosis can be confirmed by means of either ultrasonography (US) or computed tomography (CT); treatment consists of radiologic drainage, along with continued IV antibiotics. The use of preoperative antibiotics has also been shown to decrease the incidence of abscess formation.[37]

Late

Late complications include the following:

• Incisional hernia
• Stump appendicitis
• Recurrent infections from a retained appendiceal stump
• Small-bowel obstruction

A historical cohort study found that small-bowel obstruction occurs in fewer than 1% of patients after appendectomy for uncomplicated appendicitis and in 3% of patients with perforated appendicitis who are monitored for 30 years.[39] About one half of these patients present with bowel obstruction during the first year.

Complicated appendicitis

Complicated appendicitis includes gangrenous perforated appendicitis or the presence of an appendicular abscess or phlegmon. These cases are traditionally managed conservatively by giving IV antibiotics and draining an evolving abscess,[11] if indicated, though this approach has been questioned in the medical literature.[40] Because of delays in seeking diagnosis and treatment, the recovery time and corresponding length of hospital stay are significantly longer with this method than with appendectomy at presentation.

An interval appendectomy in the presence of a diagnosed fecalith is commonly performed in current practice. Patients aged 40 years or older require further investigations, including colonoscopy, barium enema, and CT, along with close follow-up to rule out the possibility of coexisting disease (eg, carcinoma).