Chapter 27 Laparoscopic Appendectomy
INTRODUCTION
Laparoscopic appendectomy (LA) is rapidly becoming the standard of care for surgical removal of the appendix. Acute appendicitis is a diagnostic possibility in nearly every patient who presents emergently with abdominal pain. Despite the recent improvements in diagnostic imaging, appendicitis is often confused with other inflammatory processes, and it presents a challenging clinical diagnosis. Ovarian torsion/abscess, diverticulitis, inflammatory bowel disease, and other conditions can all present with symptoms similar to those of acute appendicitis.1
A thorough history and physical examination continue to be the most efficient methods of clinical diagnosis. Generalized abdominal pain migrating to the right lower quadrant (RLQ) with associated leukocytosis is the classic presentation for acute appendicitis. Frequently, however, the source of abdominal pain is less certain, especially in the female patient. Diagnostic studies such as computed tomography (CT) scan and ultrasound have been shown to be beneficial when the diagnosis is not clear.2,3 Yet no imaging study has been able to replace careful evaluation of the patient’s symptoms and physical examination findings.4
Indications for LA remain the same as those for open appendectomy (OA), with acute appendicitis being the most common reason for appendectomy. Chronic appendicitis is a more controversial diagnosis, most commonly associated with patients in the pediatric population. Recurrent RLQ pain, which does not go on to develop into severe pain or localized peritonitis, is the most frequent complaint associated with chronic appendicitis. Some surgeons advocate elective appendectomy in this group and have demonstrated relief of symptoms in many patients.5 Perforated appendicitis with subsequent abscess formation can be safely managed with percutaneous drainage and interval appendectomy once the acute inflammation has resolved. Tumors of the appendix can demonstrate a wide variety of pathology. The presence of a lesion in the appendix is an indication for appendectomy, and the differential diagnosis includes appendiceal cysts, adenocarcinoma, and carcinoid tumors.
The addition of the laparoscopic approach over traditional appendectomy has yielded many benefits. Improved visualization of the abdominal cavity obtained with laparoscopy is particularly beneficial when the diagnosis of acute appendicitis is uncertain. LA has been found to have a decreased length of stay, a lower readmission rate, and a decrease in overall complications.6 In recent articles, there has not been a significant increase in cost between LA and OA. As with many laparoscopic procedures, LA has been demonstrated to have a decrease in narcotic use and an earlier return to work than OA.7
Complications from LA may be increased in patients who are elderly or morbidly obese or in those with perforated appendicitis.8 Also, the previously operated abdomen can add further challenge to any laparoscopic procedure. Consideration must be given to peritoneal access and port placement depending on previous surgical history. The overall complication rates of LA range from 6% to 13% with a very low risk of mortality.9,10 Careful identification of structures and careful dissection will help avoid many intraoperative and postoperative complications.
OPERATIVE PROCEDURE
Trocar Insertion
Trocar Insertion Injuries
For general injuries related to trocar placement, refer to Section I, Chapter 7, Laparoscopic Surgery.
Bladder Injury
• Consequence
• Repair
• Prevention
Epigastric Vessel Injury
• Consequence
• Repair
Wound Infection
• Consequence
• Repair
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