Acute appendicitis is one of the most common pathologies treated by surgeons in worldwide emergency departments. Surgical treatment with appendectomy is the gold standard of care unless in the presence of an appendicular plastron.
Since the emergence of laparoscopy, many procedures have been performed by minimally invasive surgery. Cholecystectomy, colectomy, bariatric surgery, antireflux fundoplication, are nowadays performed mostly by laparoscopy. In these procedures, the main advantages of laparoscopy, namely less postoperative pain, early oral intake, faster recovery, less surgical site infection, decreased rate of incisional hernia, were easily accepted by doctors and patients. In some cases laparoscopy turned the surgical procedures easier to perform (ex. cholecystectomy or fundoplication).
However, when treating acute appendicitis, the acceptance of laparoscopic approach for all patients is not unanimous between surgeons. Why? Because those advantages are not so evident when comparing laparoscopic appendectomy to laparotomic appendectomy.
Open appendectomy only needs one small incision which, has a low rate of incisional hernia, first oral intake and recovery as in laparoscopic appendectomy, patients are discharged home 24 to 48 hours after surgery, and pain is minimal. Additionally, laparotomic appendectomy is cheaper.
However, there is a huge advantage of laparoscopy comparing to laparotomy. If intraoperatively a normal ileocecal appendix is found, it is easier to explore the entire abdominal cavity with the laparoscope allowing for a correct diagnosis. So, a young female patient with signs and symptoms of acute appendicitis should be treated by laparoscopy, because a gynaecological pathology can be the cause of all complaints and the acute appendicitis a misdiagnosis. Additionally, older patients should be treated by laparoscopy if an acute appendicitis is suspected, so that a complete abdominal scan looking for tumor masses can be performed.
In the presence of a young male patient with signs and symptoms of acute appendicitis, eventually with a CT scan confirming the diagnosis, option for laparoscopy or laparotomy is harder. Although both options will give a fast recovery and good results if the appendix is found in a pelvic position, some times ileocecal appendix can be retrocecal with dense adhesions, being difficult to mobilize with traditional open surgery. In those cases laparoscopy can be of good help allowing a correct and safe ileocecal mobilisation and appendix dissection, I think.
In this setting I am sharing a recent video of a laparoscopic appendectomy performed in a young female patient. Phlegmonous appendicitis was found in a partially retrocecal appendix with inflammatory adhesions. I think this video represents a good example of how laparoscopy can be of good help.
Links to the video:
Dr. Carlos Eduardo Costa Almeida
General Surgeon