Introduction

Appendicitis is one of the most common causes of a surgical abdomen. In 1894, McBurney performed a new technique in treating appendicitis, which eventually became the gold standard for acute appendicitis [1]. However, in 1980, Kurt Semm, a gynecologist from Switzerland performed the first laparoscopic appendectomy [2]. The laparoscopic approach has several advantages over the open appendectomy like lesser postoperative pain, faster recovery, fewer wound infections, and lesser incidence of adhesions. In addition, the complication rates were comparable in laparoscopic and open appendectomy. Laparoscopic appendectomy is also safe to perform in patients with perforated appendicitis, but it is dependent on the surgeon’s expertise. It offers lesser wound contamination during operation and direct visualization during peritoneal washing.

Another advantage of laparoscopy is the visualization of the abdominal cavity to rule out other pathologies and address them simultaneously. It is also preferable in women for cosmetic reasons.

Indications

  • Any patient with signs and symptoms of acute appendicitis.

  • Patient who are fit for general anesthesia.

Contraindications

  • Severely septic with generalized peritonitis.

  • Severe pulmonary disease in whom carbon dioxide pneumoperitoneum may exacerbate their condition.

  • Hemodynamic instability.

  • Patient not fit for general anesthesia.

  • Advanced stage of pregnancy wherein the intra-abdominal working space would be suboptimal.

Preoperative Preparation

  • In female patients, an adequate menstrual history and a pregnancy test.

  • The minimum ancillary diagnostic test would be a complete blood count and urinalysis.

  • CT scan may be warranted if the physical examination and laboratories are equivocal.

  • Adequate intravenous hydration.

  • Prophylactic intravenous antibiotics with coverage for gram-negative and anaerobes.

  • Insertion of a urinary catheter to decompress the urinary bladder and minimize injury to it and allow for a bigger working space.

  • Informed consent with the potential to convert to an open procedure.

OT Setup

The patient is in supine position in a Trendelenburg position with the right side up to expose the right lower quadrant. The anesthesiologist and the anesthesia machine are at the patient’s head (Fig. 1). The surgeon stands on the left side of the patient opposite the appendix and the assistant stands at the right side of the surgeon. The video monitor is positioned directly across the surgeon at the right side of the patient.

Fig. 1
An illustration of an operation theatre. A patient lies down on an operating table, his entire body covered except for the abdomen. The surgeon stands beside him, and three assistants stand behind him. A nurse holds the monitoring devices close to the patient's head. Viewing monitors and an illustration texting M.Crespi are located on the patient's left side.

OT setup

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Surgical Technique

The patient is under general anesthesia. The 10 mm port is inserted at the umbilicus using Hasson’s technique and pneumoperitoneum is created with CO2 pressure at 12 mmHg and flow rate at medium or 20 L/min. A 5 mm port is then placed at the left lower quadrant and another 5 mm trocar is inserted at the suprapubic area under direct vision to avoid any injury to any intrabdominal organs and vessels. A limited diagnostic laparoscopy is then done to exclude other pathologies.

The appendix is identified by locating the cecum and tracing the taenia coli to the base of the appendix. Careful dissection is done if there are adhesions between the appendix and the surrounding organs to avoid iatrogenic injury to the bowels. Once the appendix is freed, this is then grasped then the mesoappendix is isolated by using either one of the following:

  1. 1.

    Monopolar hook with diathermy dissection to isolate the artery.

  2. 2.

    Maryland dissector to bluntly isolate the artery.

Then the appendiceal artery is isolated and ligated using the following techniques:

  1. 1.

    Clip application using either small polymer or titanium clips.

  2. 2.

    Bipolar vessel sealing (Fig. 2).

  3. 3.

    Ultrasonic vessel sealing for a small artery less than 8 mm in size.

Fig. 2
A close-up of tissue during surgery. A clamping instrument with a curved, pincer-like tip grips a layer of tissue, while another instrument is placed above the tissue where the clamp is placed.

Vessel sealing

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The sealed artery can be cut using laparoscopic shears or the included cutter in the advanced bipolar instruments. As with open appendectomy, the base of the appendix must be exposed completely and should be devoid of fat in preparation for its ligation via the following techniques:

  1. 1.

    Simple suture ligation via intracorporeal suturing with a 2–0 braided suture on a round half circle needle with two sutures on the patient side and one on the specimen side [3].

  2. 2.

    Simple suture ligation via extracorporeal knot tying of a 2–0 braided suture in creating a loop ligation around the base of the appendix. Applying 2 sutures on the patient side and one on the specimen side.

  3. 3.

    Commercially available preformed suture loops (i.e., Endoloop™, Johnson & Johnson, USA) of a 2–0 braided suture in creating a loop ligation around the base of the appendix. Applying two sutures on the patient side and one on the specimen side (Fig. 3).

  4. 4.

    Plastic clips (i.e., hem-o-lok™, Teleflex Medical, USA) with two clips at the patient side and one at the specimen side [4].

Fig. 3
A close-up of the abdomen during surgery. The tip of a medical instrument is placed near a specific area of the inner abdominal area.

Endoloop for ligation at the base of the appendix

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The ligated appendiceal base can now be cut using the laparoscopic shears (Fig. 4). The appendiceal mucosa on the stump is suctioned to make sure that no fecalith remains and is burned with bipolar energy to prevent the rare incidence of mucocele formation [5].

Fig. 4
A close-up image of the abdominal area during an operation. A medical instrument with a pincer-like tip is clamping a piece of tissue.

Cutting the appendiceal base with shears

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Inspection of the stump and nearby surrounding area for fecal soilage, bleeding and bowel perforation is done. Suction is used for pooled clotted blood and a few purulent materials. Copious use of lavage is optional depending on the presence of fecal soilage.

A sterile 10 × 5 cm plastic bag with a 35 cm nonabsorbable suture with a Roeder’s knot attached is placed in the umbilical port. The appendix is placed in the bag, closed and extracted together at the umbilical port. This is done to decrease the incidence of infection at the umbilical incision [6].

Alternative options can be the following:

  1. 1.

    The appendix is extracted from the abdomen with the use of a condom, which is inserted at the umbilical port. The appendix is placed inside the condom and then telescoped into the 10 mm port as the camera is pulled out.

  2. 2.

    Use of a commercially available specimen bag which is inserted through the umbilical port. A 5 mm scope is placed in the left lower quadrant trocar while a bowel grasper is in the suprapubic port to assist in placing the specimen in the bag. The bag is closed and retracted under direct vision together with the trocar.

  3. 3.

    If the appendix is thin (<1 cm) and not grossly purulent, a 5 mm scope is placed at the left lower quadrant while a bowel grasper at the suprapubic trocar feeds the specimen to the grasper in the umbilical port for direct withdrawal of the specimen.

Peritoneal lavage can be done if needed. A closed suction drain is inserted in cases of perforated appendix. After extracting the specimen, desufflation is done together with direct visualization through a scope in the umbilicus of the working trocars to check for port site bleeding. Appropriate hemostasis is achieved prior to a figure of eight sutures with a 2–0 braided, absorbable suture at the fascial level of the umbilical incision. Subdermal interrupted skin closure with 4–0, monofilament, absorbable sutures are done to close the skin incisions. Film dressings are applied to the incision sites.

Complications and Management

The most common postoperative complication in laparoscopic appendectomy is wound infection, which can be treated by antibiotics and/or drainage. However, compared to open appendectomy, this is markedly lower with a rate of less than 2%.

Other complications which might occur is intra-abdominal abscess, which can be managed by percutaneous drainage.

Late complications include the following: incisional hernia, stump appendicitis, and small bowel obstruction due to postoperative adhesions.

Post-op Care

Patient is advised to ambulate once fully awake and with adequate pain control. Diet is progressed as tolerated and the patient is expected to be discharged on the first postoperative day for uncomplicated appendicitis.

Patient is then seen 1 week after for follow up.