Laparoscopic Appendicectomy

INTRODUCTION
Appendicitis was first recognized as a disease entity in
the 16th century and was called perityphlitis. McBurney
first described its clinical findings in 1889. Laparoscopic
appendectomy in expert hands is now quite safe and
effective and considered as an excellent alternative for
patients with acute appendicitis. Acute appendicitis is the
most common abdominal surgical emergency in the world,
with a lifetime risk of 8.6% in males and 6.9% in females. First
successful laparoscopic appendicectomy was performed by
Semm in 1982. Although open appendectomy preceded it by
almost 100 years, laparoscopic appendectomy has overtaken
its open counterpart in popularity. Although laparoscopic
appendicectomy can be performed in all groups of patients,
surgeons agree that for women of childbearing age,
laparoscopic appendectomy is unquestionably the method
of choice. Perforation is found in 13–20% of patients who
present with acute appendicitis. Perforation rate is higher
among men (18% men versus 13% women) and older adults.
LAPAROSCOPIC ANATOMY
The appendix is derived from a cecal diverticulum of
the fetus. The appendix is generally within 1.7 cm of the
ileocecal junction. Its length varies from 2 to 20 cm, average Fig. 1: Normal laparoscopic view of appendix.
A B
Figs. 2A and B: Anatomic position of appendix.
Laparoscopic Appendicectomy
9 cm (Fig. 1). Most of the time when telescope is introduced
through umbilicus, appendix is hidden behind the cecum.
The anterior tenia coli of the cecum is an important
landmark, which leads to cecum (Figs. 2 and 3). The
triangular mesoappendix tethers the appendix posteriorly,
which contains appendicular artery and veins. The
appendicular artery is a branch of the ileocolic artery.
Prof. Dr. R. K. Mishra

209
CHAPTER 15: Laparoscopic Appendicectomy
Fig. 3: Normal appendix.
TABLE 1: Indications of laparoscopic and open appendectomy.
Laparoscopic appendectomy Open appendectomy
• Female of reproductive age group
• Female of premenopausal group
• Suspected appendicitis
• High working class
• Previous lower abdominal surgery
• Obese patients
• Disease conditions such as cirrhosis
of liver and sickle cell disease
• Immunocompromised patients
• Complicated appendicitis
• COPD or cardiac disease
• Generalized peritonitis
• Hypercoagulable sites
• Stump appendicitis after
previous incomplete
appendicectomy
(COPD: chronic obstructive pulmonary disease)
Fig. 4: Patient position and setup of operating team.
Laparoscopic exposure of the appendix is facilitated by
gently pulling the cecum upward.
The base of the appendix must be visualized carefully
to avoid leaving a remnant of appendix at the time of
laparoscopic appendicectomy. Exposures of retrocecal
appendix require mobilization of right colon. The peritoneal
reflection is incised, and the cecum is pulled medially to
visualize retrocecal appendix.
Advantage of Laparoscopic Appendectomy
Thorough exposure of the peritoneal cavity is possible.
Indications
Indications of laparoscopic and open appendectomy are
described in Table 1.
Relative Contraindications

■ Complicated appendicitis

■ Stump appendicitis (develops after previous incomplete
appendectomy)

■ Poor risk for general anesthesia

■ Some cases of previous extensive pelvic surgery.
The general anesthesia and the pneumoperitoneum
required as part of the laparoscopic procedure do increase
the risk in certain groups of patients. Most surgeons would
not recommend laparoscopic appendectomy in those with
pre-existing disease conditions. Patients with moderate
cardiac diseases and chronic obstructive pulmonary disease
(COPD) should not be considered a good candidate for
laparoscopy. The laparoscopic appendectomy may also
be more difficult in patients who have had previous lower
abdominal surgery. The elderly may also be at increased risk
for complications with general anesthesia combined with
pneumoperitoneum.
Patient Position
In the laparoscopic approach, an orogastric tube is typically
placed to decompress the stomach. The bladder can be
decompressed either with a Foley catheter or by having the
patient void immediately prior to entering the operating
room. The patient is in supine position, arms tucked at
the side. The surgeon stands on the left side of the patient
with the camera-holder assistant (Fig. 4). For maintaining
coaxial alignment, surgeon should stand near left shoulder
and monitor should be placed near right hip facing toward
surgeon. In females, the lithotomy position should be
preferred because there may be necessity to use uterine
manipulator in difficult diagnosis (Figs. 5A and B).
Port Position
Various port placements have been advocated for
laparoscopic appendectomy. These methods share the
principle of triangulation of instrument ports to ensure
adequate visualization and exposure of the appendix
(Figs. 6A and B).

■ Total three trocars should be used

■ Two 10-mm, umbilical and left lower quadrant (LLQ)
trocars

■ One 5 mm right upper quadrant (RUQ) trocar

■ The RUQ trocar can be moved below the bikini line in
females.

210 SECTION 2: Laparoscopic General Surgical Procedures
A B
Figs. 5A and B: (A) Patient position in female; (B) Variation in position of appendix.
A B
Figs. 6A and B: (A) Position of surgical team in appendectomy; (B) Port position in appendicectomy.
Fig. 7: Alternative port position.
Alternative Port and Theater Setup
In beauty conscious females, for cosmetic reason, the
baseball diamond concept of port position can be altered
fromcontralateraltoipsilateralportandthreeportsshouldbe
placed in such a way so that the two 5-mm ports will be below
bikini line. Access should be performed by 10 mm umbilical
port. Once the telescope is inside, one 5-mm port should be
placed in left iliac fossa below the bikini line under vision.
Second 5-mm port should be placed in right iliac fossa, just
mirror image of left port. After fixing all the ports in position,
one another 5-mm telescope is introduced through left iliac
fossa and surgery should be performed through umbilical
port (for right hand) and left iliac fossa port (for left hand)
(Fig. 7). In this alternative port position, 60° manipulation
angle cannot be achieved and it is ergonomically difficult for
surgeon, but patient gets cosmetic benefit.
This alternative port position for laparoscopic
appendicectomy should not be performed in case of
retrocecal appendix or perforated appendix (Fig. 5B).
Alternative port position in beauty conscious female is
shown in Figure 7.
OPERATIVE TECHNIQUES
Pneumoperitoneum is created in the usual fashion. Three
ports are used. An atraumatic grasper (Endo Babcock or
Dolphin Nose Grasper) is inserted via the RUQ port, if
contralateral ports are used, and through the suprapubic
port, if ipsilateral port is used. The cecum is retracted upward
toward the liver. In most cases, this maneuver will elevate the
appendix in the optical field of the telescope.

211
Fig. 8: Retraction of appendix.
C D
A B
Figs. 9A to D: Retraction of appendix and creation of a window over mesoappendix.
Fig. 10: Window in mesoappendix.
Retraction of Appendix
Once the diseased appendix is identified, any adhesions
to surrounding structures can be lysed with a combination
of blunt and sharp dissection. If a retrocecal appendix is
encountered, division of the lateral peritoneal attachments
of the cecum to the abdominal wall often improves
visualization. The appendix is grasped at its tip with a
5-mm claw grasper via the RUQ trocar. It is held in upward
position. After the pelvis is inspected, the appendix is
identified, mobilized, and examined properly (Figs. 8
and 9). Periappendiceal or pericecal adhesions are lysed
using either bipolar or harmonics and scissors. LLQ grasper
is used to create a mesenteric window behind the base of the
appendix.
A dolphin nose grasper or Maryland dissector is used
to create a mesenteric window under the base of the
appendix. The window should be made as close as possible
to the base of the appendix and should be approximately
1 cm in size (Fig. 10).

Figs. 11A to H: Successive dissection of mesoappendix by harmonic scalpel.
A
C
E
G
B
D
F
H
The appendiceal artery, or mesoappendix containing
it, can be divided sharply between hemostatic clips, with
a laparoscopic gastrointestinal anastomosis (GIA) stapler,
monopolar cautery, or one of the advanced vessel ligation
devices such as ultrasonic scalpel or LigaSure (Figs. 11
and 12).
Extracorporeal knotting can be performed (Roeder’s,
Mishra, Meltzer, or Tayside knot) for mesoappendix as well
as appendix. Two endoloop sutures are passed sequentially
through one of the 5-mm ports and pushed around the base
of appendix on top of each other at a distance of 3–5 mm.
A third endoloop suture can be applied 6 mm distal to the
second suture so that surgeon will cut between second and
third knot (Figs. 13A to F). If harmonic scalpel is used, only
one extracorporeal knot can be used at the base of appendix
and then it is cut with the harmonic scalpel 6 mm away
from the knot. Harmonic will seal the appendicular end
preventing any spillage.

213
A B
Figs. 12A and B: Dissection of mesoappendix by monopolar hook.
Figs. 13A to F: Tying Roeder’s, Meltzer’s, or Mishra’s knot over appendix.
A
C
E
B
D
F
The Aesculap DS Titanium Ligation Clips can also be
used sometimes to secure the proximal or distal portion
of the appendix. The luminal portion of the appendiceal
stump is sterilized with electrosurgery to prevent spillage
and contamination of peritoneal cavity. In case of perforated
appendix with peritonitis, Betadine can be applied over the

A B C
Figs. 14A to C: Stapler appendicectomy.
stump of appendix and thorough suction and irrigation is
performed either by normal saline or by Ringer’s lactate
solution.
After extracting the appendix out of abdominal cavity,
surgeon should examine the abdomen for any possible
bowel injury or hemorrhage.
Stapler Appendicectomy
The stapling devices make laparoscopic appendectomy
simpler and faster. The Multifire stapler is introduced
though a 12-mm port. The appendix may be transacted by
inserting an ENDO GIA instrument via the RUQ trocar (blue
cartridge, 3.5), closing it around the base of the appendix
and firing it. For perforated appendicitis with or without an
intra-abdominal abscess, a drain is left in the RLQ and pelvis
(Figs. 14A to C). In stapler appendicectomy, the appendix is
clearedtoitsattachmentwiththececum,andtheappendiceal
base is divided using a laparoscopic GIA stapler, taking care
not to leave a significant stump. It is sometimes necessary to
include part of the cecum within the stapler to ensure that
the staples are placed in healthy, uninfected tissue.
Extracorporeal knot (Meltzer, Roeder, or Tayside knot)
should be preferred over stapler, depending on the surgeon’s
expertise.
Extraction of Appendix
The appendix can be removed from the abdomen with the
help of grasping forceps placed through one of the 10-mm
ports. However, this may contaminate both the cannula and
instrument. Alternatively, an endoloop suture, which was
tied last, can be used instead of grasping forceps to pull the
appendix out.
Abdomen should be examined for any possible bowel
injury or hemorrhage. All the instruments should be
removed carefully. The wound should be closed with suture.
Use Vicryl for rectus and unabsorbable intradermal or
stapler for skin. Adhesive sterile dressing should be applied
over the wound.
POSTOPERATIVE CARE AFTER
APPENDECTOMY
Patients may be discharged once they tolerate a regular
diet, usually in 2 days. Three to five days of intravenous or
oral antibiotics is recommended for perforated appendicitis
after appendectomy. Patients with perforated appendicitis
often develop an ileus postoperatively regardless of the
surgical approach. Thus, diet should only be advanced as the
clinical situation warrants.
RISK FACTORS IN LAPAROSCOPIC
APPENDECTOMY
The mortality associated with appendicitis is low but can
vary by geographic locations. In developed countries, the
mortality rate is between 0.09 and 0.24%. In developing
countries, the mortality rate is higher, between 1 and 4%.
Overall complication rates of 8.2–31.4%, wound infection
rates of 3.3–10.3%, and pelvic abscess rates of 9.4% have been
reported following appendectomy.
Missed Diagnosis
There is report also of mucinous cystadenoma of the cecum
missed at laparoscopic appendectomy. Less than 1% of all
patients with suspected acute appendicitis are found to
have an associated malignant process. During conventional
appendectomy, through a laparotomy incision, the cecum
and the appendix are easily palpated, and an obvious
mass can be detected and properly managed at the time
of appendectomy. The inability to palpate any mass is an
inherent inadequacy of laparoscopic surgery.
Bleeding
Bleeding may occur from the mesoappendix, omental
vessels, or retroperitoneum. Bleeding is usually recognized
intraoperativelyviaadequateexposure,lighting,andsuction.
It is recognized postoperatively by tachycardia, hypotension,
decreased urine output, anemia, or other evidence of
hemorrhagic shock.

215
Fig. 15: Retrocecal appendix.
Fig. 16: Roeder’s knot at the time of appendicectomy.
Fig. 17: Three Roeder’s or Meltzer’s knots over appendix.
Visceral Injury
Risk of accidental burns is higher with monopolar system
because electricity seeks the path of least resistance, which
may be adjacent bowel. In a bipolar system since the
current does not have to travel through the patient, there
is little chance of injury to remote viscera. In laparoscopic
appendectomy, only bipolar current should be used.
Laparoscopists should also routinely explore the rest of the
abdomen.
Wound Infection
Proper tissue retrieval technique is required to prevent
wound infection after appendectomy.
If ensues, it is recognized by erythema, fluctuation,
and purulent drainage from port sites. The absence of
wound infections after laparoscopic appendectomy can
be attributed to the practice of placing the appendix in a
sterile bag or into the trocar sleeve prior to removal from
the abdomen. The regular use of retrieval bag is a very good
practice for preventing infection of the wound.
Incomplete Appendectomy
If surgeon is not experienced, he/she is likely to leave the
stump of the appendix too long. There is a report of intra-
abdominal abscess formation due to retained fecalith after
laparoscopicappendectomy.Itisimportantthatthesurgeons
performing laparoscopic appendectomy should remove
fecalith if found, and the stump of appendix should not be
big enough to contain any remaining fecalith. Incomplete
appendectomy is a result of ligation of the appendix too far
from the base.
It may lead to recurrent appendicitis, which presents with
symptoms and signs of appendicitis even after laparoscopic
appendectomy.
Some surgeons prefer stapling of the appendiceal stump
for laparoscopic appendectomy for the treatment of all forms
of appendicitis (Figs. 14 and 15). But most of the surgeons
now agree that ligation of the appendectomy stump is the
best approach (Figs. 16 to 18). There is report of slippage
of clip, residual appendicitis followed by abscess formation
after using clip for appendiceal stump. The ligation should
be performed by using endoloop, an intracorporeal
surgeon’s knot, or done extracorporeally using a Meltzer’s
knot or Tayside knot. The security of the knot is essential. It
is influenced by the proper port location and experience of
the surgeon.
Leakage of Purulent Exudates
It is usually seen intraoperatively while dissecting appendix.
Copious irrigation and suction followed by continued
antibiotics can prevent this complication until patient is
afebrile with a normal white blood cell count. Retrieval bag
should be used to prevent the spillage of infected material
from the appendiceal lumen.

A B
C
Figs. 18A to C: Amputation of appendix with harmonic scalpel.
Fig. 19: Amputated appendix inside the cannula.
Intra-abdominal Abscess
This postoperative morbidity is recognized by prolonged
ileus, sluggish recovery, rising leukocytosis, spiking fevers,
tachycardia, and rarely a palpable mass. After confirmation
of the intra-abdominal abscess, drainage of pus followed by
antibiotic therapy is essential. Rarely, laparotomy may be
required.
Hernia
Trocar site hernia as visible or palpable bulge is sometimes
encountered. Possible occult hernia is manifested by pain or
symptoms of bowel obstruction.
Laparoscopic-assisted Appendectomy
It has been described for cases in which the proper
endoscopic instruments and sutures are unavailable. The
laparoscope facilitates the diagnosis of acute appendicitis
and a grasper is passed through an accessory trocar located
just over the McBurney’s point. The tip of the appendix is
grasped and then pulled along with cannula and grasper
(Figs. 19 and 20). Once the appendix is exteriorized, the
routine appendectomy is performed through this small
abdominal incision. This procedure usually takes less time
than total laparoscopic appendectomy, but it has more
incidence of incomplete appendectomy.
Perforated Appendix
Perforation of the appendix can cause intraperitoneal
dissemination of pus and fecal material and generalized
peritonitis. These patients are typically quite ill and may
be septic or hemodynamically unstable, thus requiring
preoperative resuscitation. The diagnosis is not always
appreciated before exploration.
For patients who are septic or unstable, and for those
who have perforation of the appendix or generalized
peritonitis, emergency appendectomy is required, as well as
drainage and irrigation of the peritoneal cavity. Emergency
appendectomy in this setting can be accomplished open
or laparoscopically; the choice is determined by surgeon
preference with consideration of patient condition and local
resources.

217
Fig. 20: Appendix hidden in cannula is ejected out.
DISCUSSION
Laparoscopic appendectomy has gained lot of attention
around the world. However, the role of laparoscopy for
appendectomy, one of the most common indications,
remains controversial. Several controlled trials have been
conducted, of which some are in favor of laparoscopy,
and others not. There is also diversity in the quality of the
randomized controlled trials. The main variable in these
trials are following parameters:

■ Number of patients in trial

■ Withdrawal of cases

■ Exclusion of cases

■ Blinding

■ Intention to treat analysis

■ Publication biases

■ Local practice variation

■ Prophylactic antibiotic used

■ Follow-up failure.
Without proper attention to the detail of all the
parameters, it is very difficult to draw a conclusion. It has
been found that there is a hidden competition between
laparoscopic surgeons and the surgeons who are still doing
conventional surgery, and this competition influences the
result of study. One should always think of laparoscopic
surgery and open procedures as being complimentary to
each other.
A successful outcome requires greater skills from the
operator. The results of many comparative studies have
shown that outcome of laparoscopic appendectomy
was influenced by the experience and technique of the
operator. Minimal access surgery requires different skills
and technological knowledge. With a clear diagnosis of
complicated appendicitis, the skill and experience of the
surgeon should be considered for the selection of operating
method. Surgeons should perform the procedure with which
they are more comfortable.
Laparoscopic appendectomy is equally safe and can
provide less postoperative morbidity in experienced hands,
as in open appendectomy. Most cases of acute appendicitis
canbetreatedlaparoscopically.Laparoscopicappendectomy
is a useful method for reducing hospital stay, complications,
and early return to normal activity. With better training in
minimal access surgery now available, the time has arrived
for it to take its place in the surgeon’s repertoire. As surgeons
gained more experience with the technique, laparoscopic
appendectomy became feasible for patients with perforated
appendicitis undergoing immediate surgery.
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