What is the recommended operation technique for appendicitis?

Recommended Surgical Technique for Appendicitis

Laparoscopic appendectomy using the conventional three-port technique is the gold standard surgical approach for both uncomplicated and complicated acute appendicitis in adults and children. 1

Primary Surgical Approach

Laparoscopic appendectomy should be performed as the preferred technique over open appendectomy when equipment and expertise are available, offering superior outcomes including:

• Less postoperative pain 1
• Lower surgical site infection rates (70% reduction compared to open) 1, 2
• Shorter hospital stays (1-2 days shorter) 1, 3
• Earlier return to work (approximately 4-5 days earlier) 1, 4
• Better quality of life scores 1

This recommendation carries a strong 1A evidence rating from the World Journal of Emergency Surgery guidelines. 1

Specific Laparoscopic Technique

Port Placement

Use the conventional three-port laparoscopic technique rather than single-incision approaches. 1 The three-port method provides:

• Shorter operative times (approximately 6 minutes faster) 1
• Less postoperative pain 1
• Lower wound infection rates 1

Single-incision laparoscopic appendectomy (SILA) requires higher analgesic doses and has longer operative times without providing meaningful cosmetic or clinical advantages. 1

Mesoappendix Dissection

Use monopolar electrocoagulation or bipolar energy for mesoappendix dissection, as these are the most cost-effective techniques with equivalent safety profiles. 5, 6 There are no clinically significant differences in outcomes between various energy devices, so choice can be based on surgeon preference and available resources. 6

Appendiceal Stump Closure

Use endoloops/suture ligation or polymeric clips for stump closure in both uncomplicated and complicated appendicitis. 5, 6 Key technical points:

• Polymeric clips are most cost-effective with shorter operative times for uncomplicated cases 6
• Avoid endostaplers as they provide no clinical benefit over endoloops but increase costs 6
• Simple ligation is preferred over stump inversion in both laparoscopic and open techniques 5

Management of Intra-abdominal Collections

Perform suction alone without peritoneal irrigation when encountering intra-abdominal collections during laparoscopic appendectomy for complicated appendicitis. 1, 5, 6 Irrigation does not prevent intra-abdominal abscesses or wound infections and provides no additional benefit. 1, 6

Special Populations

Pediatric Patients

Laparoscopic appendectomy is strongly recommended for children with the same benefits as adults, including lower postoperative pain, reduced surgical site infections, and improved quality of life. 1, 7 Use the conventional three-port technique rather than single-incision approaches. 1

High-Risk Populations

Laparoscopic approach is particularly beneficial for:

• Obese patients 1, 5, 6
• Elderly patients 1, 5, 6
• Patients with comorbidities 1, 5, 6
• Pregnant patients (safe and feasible when expertise available) 1, 5

Complicated Appendicitis

Laparoscopic appendectomy remains the preferred approach even for complicated appendicitis (gangrenous, perforated, or abscess). 1 While there is a slightly increased risk of postoperative intra-abdominal abscess (approximately 2-fold) compared to open surgery, this is outweighed by the significant reduction in wound infections and faster recovery. 2, 8

Surgical Timing

Perform appendectomy within 24 hours of hospital admission to minimize complications. 5, 6, 7 For complicated appendicitis in children, early appendectomy within 8 hours is recommended. 5, 7 Delaying surgery beyond 24 hours significantly increases adverse outcomes. 5, 6

Drainage Considerations

Do not place abdominal drains following appendectomy for complicated appendicitis in either adults or children, as prophylactic drainage provides no benefit. 5, 6

Common Pitfalls and Technical Caveats

• Always remove the appendix even if it appears normal during surgery in symptomatic patients when no other pathology is found, as macroscopic assessment of early appendicitis is often inaccurate. 5, 6
• Conversion to open surgery occurs in approximately 9.5% of cases and should not be considered a failure—convert when necessary for patient safety. 4
• Be aware that intra-abdominal abscess rates are slightly higher with laparoscopy (approximately 5-6% vs 4% with open), but this is offset by the 70% reduction in wound infections. 2, 8
• Operating time is approximately 12-15 minutes longer with laparoscopic approach, but this difference has been decreasing with improved surgical experience. 3, 9, 4

Outpatient Management

Outpatient laparoscopic appendectomy can be performed for uncomplicated appendicitis when an ambulatory setting with well-defined Enhanced Recovery After Surgery (ERAS) protocols is established. 1, 5, 6