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.

INDICATIONS

• Acute appendicitis

• Chronic appendicitis

• Interval appendectomy

• Neoplasm

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

Intra-abdominal contamination. Early diagnosis of this injury is critical. Patients with missed injuries will often present to the emergency department with complaints of atypical abdominal pain, frequently associated with large amounts of drainage from the wound. Associated hematuria is also common. Imaging studies are very helpful in diagnosing this complication because a CT scan will typically demonstrate a large amount of nonloculated peritoneal fluid. Contrast extravasation may be present in the pelvis on a standard CT scan, and a CT cystogram is the most accurate method for confirmatory diagnosis of this injury. Delayed presentation of this complication can present with oliguria and acute renal failure. Patients can also go on to develop peritonitis and, eventually, sepsis.

Grade 2/3 complication

• Repair

Bladder injuries are repaired with a two-layer, primary closure and can be completed laparoscopically. If there is a question of injury during the procedure, retrograde filling of the bladder may be helpful in demonstrating the injury. The distended bladder will also allow for an easier repair of the injury. A urinary catheter should be left in place for 10 to 14 days after the repair to allow for adequate healing.¹¹ Prior to removal of the urinary catheter, a formal cystogram should be performed to confirm that the repair has healed satisfactorily.

• Prevention

Trocar insertion in the pelvis, and in all areas of the abdomen, should be done under direct vision (Fig. 27-1). A distended bladder can often reach as high as the umbilicus in some patients, and a urinary catheter should be placed prior to the start of any laparoscopic pelvic surgery. Injury to the bladder with instrumentation is uncommon during LA; however, care should always be taken when dissecting an inflamed appendix from the peritoneum.