What are the steps involved in a laparoscopic appendectomy for a patient undergoing surgery for appendicitis?

Laparoscopic Appendectomy: Procedural Steps

Laparoscopic appendectomy should be performed using the conventional three-port technique, as this approach provides superior outcomes with shorter operative times, less postoperative pain, and lower wound infection rates compared to single-incision techniques. 1

Pre-Operative Setup

Patient Positioning and Team Configuration:

• Position the patient supine with arms tucked at sides 2
• Place the surgical team with the surgeon and camera operator on the patient's left side 2
• The assistant stands on the patient's right side 2

Port Placement (Three-Port Technique)

Trocar Configuration:

• Insert a 12-mm infraumbilical port for the camera and specimen extraction 2
• Place a 5-mm port in the left lower quadrant for working instruments 2
• Insert a 5-mm port in the suprapubic region for retraction and manipulation 2

Critical Point: The conventional three-port approach is strongly recommended over single-incision laparoscopic appendectomy, which requires longer operative times and higher analgesic doses 1

Diagnostic Laparoscopy

• Perform systematic exploration of the abdomen upon entry 2
• Visualize the appendix and assess for perforation, abscess, or peritonitis 2
• If the appendix appears normal but no other pathology is identified, proceed with appendectomy regardless, as macroscopic assessment of early appendicitis is often inaccurate 3, 4

Mesoappendix Dissection

Recommended Technique:

• Use monopolar electrocoagulation or bipolar energy for mesoappendix dissection, as these are the most cost-effective techniques 1, 3
• Other energy devices (ultrasonic shears, advanced bipolar devices) may be used based on surgeon judgment and resource availability 1
• There are no significant clinical differences in outcomes between various dissection techniques 1

Appendiceal Base Management

Stump Closure Method:

• Secure the appendiceal base using endoloops/suture ligation or polymeric clips 1, 3
• Polymeric clips are the most cost-effective option with shorter operative times for uncomplicated appendicitis 1, 3
• Avoid endostaplers for routine cases, as they provide no clinical advantage over endoloops except potentially in complicated cases where surgeon judgment dictates their use 1

Critical Technique:

• Perform simple ligation without stump inversion, as this is associated with shorter operative times, less postoperative ileus, and quicker recovery 1

Management of Intra-Abdominal Collections

For Complicated Appendicitis:

• Perform suction alone without peritoneal irrigation when intra-abdominal collections are present 1, 3
• Peritoneal irrigation provides no benefit in preventing intra-abdominal abscesses or wound infections 1, 3

Drainage Considerations:

• Do not place abdominal drains after appendectomy for perforated appendicitis, as drains lead to longer hospitalization and potentially increased 30-day morbidity and mortality 1, 3, 4

Specimen Extraction

• Remove the appendix through the umbilical port using an extraction bag to prevent wound contamination 2
• Always send the specimen for histopathological examination to identify unexpected findings, including neoplasms 3, 4

Special Population Considerations

High-Risk Patients:

• Laparoscopic approach is particularly beneficial for obese patients, elderly patients, those with comorbidities, and pregnant patients 1, 3, 4
• In pregnancy, laparoscopy is safe and feasible throughout gestation when expertise is available 1

Pediatric Patients:

• Use the same three-port technique as in adults 1
• Laparoscopic approach provides lower postoperative pain, lower surgical site infection rates, and higher quality of life compared to open surgery 1

Timing Considerations

Critical Pitfall to Avoid:

• Perform appendectomy within 24 hours of hospital admission to minimize complications 3, 4, 5
• For complicated appendicitis in children, early appendectomy within 8 hours is recommended 3, 4
• Delaying surgery beyond 24 hours significantly increases the risk of adverse outcomes 3, 4

Postoperative Management

Outpatient Consideration:

• Selected patients with uncomplicated appendicitis may be discharged the same day when well-defined ERAS protocols are established 1, 3, 4, 6
• This approach is associated with earlier recovery and lower costs without increased readmission rates 1