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Laparoscopic Appendicectomy

prof. Usman Jafferprof. Usman Jaffer

Introduction

What is it?

An appendectomy refers to the procedure of surgically removing the appendix. It is a common procedure most commonly performed in the acute emergency setting to treat acute appendicitis, where the appendix gets inflamed. Without urgent removal of the inflamed appendix, rupture can occur and result in serious complications such as peritonitis.  

Laparoscopic Appendicectomy is a form of Minimally Invasive Surgery and is usually performed under General Anaesthesia, and unlike Open Appendicectomy, most patients are discharged within 1-2 days, with a 2-4 week full recovery period. Post-operative recovery involves return to normal activities as one feels ready alongside use of pain medication and sometimes antibiotics. 

Complications of the surgery are relatively rare, yet may include surgical site infections, abscess formation, and hernias at the incision sites (1). 

Appendicectomy refers to the surgical removal of the appendix (vermiform appendix); the end portion of the large intestine. The appendix is in the lower right side of your belly (abdomen).  

Diagram of the appendix.

There are two main approaches to appendicectomy; open appendicectomy which involves making an incision below and to the right of the belly button, and laparoscopic appendicectomy which is minimally invasive and involves inserting a tube through a small hole in your belly. 

The surgery is most commonly performed laparoscopically, such that in the United Kingdom over 95% of appendectomies are conducted in this manner. Laparoscopic appendicectomy (Keyhole surgery) is a minimally invasive technique where a laparoscope with a camera is inserted through a hole made in the abdomen; and the surgeon uses a TV monitor to visualise and perform the operation. Gas in the form of carbon dioxide is pumped into your abdomen to create the space in which to operate, making it easier to complete (2).   

Why is it done?

The appendix can get infected and inflamed, resulting in a condition known as appendicitis. This occurs when the entrance of the appendix is blocked with stool and other debris, causing a build-up of bacteria. This results in relatively rapid inflammation and swelling. If action is not taken, this can cause the appendix to burst and perforate, which is known as complicated appendicitis. This can cause all the debris and bacteria to spread in your abdomen and cause serious complications such as peritonitis and abscess formation (3).  

Hence early action should be taken to remove the appendix while it is in the uncomplicated phase (non-perforated) when the risks and complications are lower. If the appendicitis is mild, antibiotics alone may be sufficient to treat it, however you will be kept in hospital and observed to check for any deterioration and to undergo surgery if required. Appendicectomy may also be conducted if appendicitis is suspected without a confirmed diagnosis, as it is safer to remove the appendix than risk the chance of perforation. The appendix does not perform any major function in humans, and hence you do not need to worry about any long-term consequences of not having an appendix (4). 

Laparoscopic appendectomy can also be performed to remove appendiceal tumours. There are many different types of appendiceal tumours, with the most common being Neuroendocrine tumours. These are very rare yet can often present with signs of appendicitis, or as an incidental finding on imaging, and are removed to prevent tumour spread (metastasis) to other parts of the body (5). 

Will I need to do any preparation?

You will be able to go through the procedure with the doctor before the surgery and ask any questions. This is a good opportunity to discuss any concerns and become familiar with what will happen in the surgery and what to expect afterwards. The doctor will discuss the different options of an open/laparoscopic approach with you.  

Before the surgery, you may be given antibiotics to help protect against infectious complications, as there will be 3 small (0.5-1cm) cuts made to your skin for the laparoscopic equipment to enter your abdomen. 

Because the procedure is conducted under General Anaesthesia, you will be given compression stockings to prevent clots forming in the deep veins of the leg and resulting in Deep Vein Thrombosis or clots on the lung. You will also receive an injection once a day to thin the blood slightly to reduce this risk further. 

It is important to remember that you must stop eating 6 hours before your surgery to minimise any risks of the surgery.  

Technique

Anaesthesia

Laparoscopic appendectomy is performed under general anaesthesia. This means you will be unconscious during the surgery. The anaesthesia will be administered via a controlled ventilator. A tube will be placed down your throat to help you breathe while unconscious; you will not be aware of this (7).   

What does it involve?

Once you have been prepared and anesthetized for the operation, the procedure will begin. The steps of the procedure are as follows:  

1) You will be lying in the bed face up (supine), where you will be anaesthetised under general anaesthetic, and a tube will be placed down your throat to help you breathe. Additionally, an orogastric tube may also be placed through your oesophagus to help remove any remaining stomach contents and reduce the risk of any aspiration related complications.  

2) The TV Screen will be placed on your right side, with the surgeon being on the left side. 

3) Between 1-3 incisions will be made in your belly to allow for the tools (ports) to enter. These will occur in various places of your abdomen (see diagram below). Most surgeons use the three incision technique, with the one incision procedure being a newer method of conducting the surgery. The most common places for port placement include: 

-Umbilical Region (Belly-Button) 

-Supra-pubic area (lowest port incision) 

-Left Lower Abdomen 

Diagram of laparoscopic appendicectomy surgical layout. Inclusive of camera screen, camera scope, instruments and the anatomical position of the appendix.

4) Gas will be pumped through a tube inserted into your abdomen through one of the incisions to lift the wall of your belly up to create space in which to operate. This makes the appendix and other organs in the abdomen easier to operate on. 

5) The Laparoscope will be inserted through one of the incisions and will be used to locate the appendix using a camera attached to its end. 

6) If there are any adhesions of organs to surrounding skin and tissue, these will be lysed with dissecting tools such as a scalpel. This process ensures that the appendix is mobilised and can be safely taken out. 

7) The connection of the appendix to the large intestine is held with one pair of forceps, and the appendix is mobilised from the connective abdominal tissue. 

8) Internal stitches using cotton thread will be made on the base of the appendix to tie it off and remove it using a hook introduced through one of the other port incision sites. 

9) The appendix is then taken out through one of the incisions; usually the umbilical incision. 

10) The area of dissection is inspected for any signs of wound infection, and the remaining stump is closed off using a surgeon's preferred technique and can include staples or endoloops. Closing off the remaining stump in this way helps prevent stump appendicitis (8). 

11) The tube, laparoscope, and any other equipment for the procedure will be taken out of your abdomen and the gas will be let out. At this point, a drain may be inserted into your abdomen to collect any remaining fluids. 

12) Any surgical incisions will be closed with staples or stitches depending on surgeon practice and preference. These stitches may either be dissolvable or regular stitches which require removal later. 

13) Your wound will be cleaned and dressed, and the appendix will be sent to the lab to undergo testing as a routine (9). 




Post operation course (follow up)


Immediately after the operation you will be taken to a recovery room and your vital signs monitored to ensure you are stable before returning to the ward. You will be provided with pain relief and sometimes further doses of antibiotics. You will be able to drink then eat when you feel ready. Pain surrounding the incision sites in your abdomen is relatively common, alongside pain being felt in the shoulder region (10). 

Once the pain is manageable so you can mobilise with tablet painkillers only and you are eating and drinking, then you will be ready for discharge. You will have to get a friend/family member to drive you home.

How long will I stay in hospital?

Because Laparoscopic Appendicectomy is a minimally invasive procedure, it follows that the recovery time is relatively short, and most people leave hospital within 1-2 days.    

What care will I need at home?


On discharge, you may be prescribed pain medication to help with the soreness that may result in the short period after the operation. You may also be prescribed antibiotics to reduce the risk of any infection.  

You may experience constipation within the first few days after discharge. Hence it is important not to take any codeine-based painkillers, which may cause the constipation to worsen. Additional steps to take include eating a healthy amount of fibre and ensuring that you drink plenty of fluids (11). If you do need codeine-based painkillers, you may need to take a mild laxative. 



Will I need someone to stay with me?

No particular need, you should. be fully independent.  

Will I need any special equipment to take home?

Because surgical site infections can result from appendicectomies, the medical team in charge of your care will give you advice on how to properly care for your wound and minimise chances of infection.   

What follow up care is needed?

Depending on which types of stitches were used to close the incision sites; you may have to visit your GP between 7-10 days after the surgery to have them removed. Your surgeon will discuss this with you before discharge. If dissolvable stitches were used, then these do not require to be taken out (12).   

When can I start normal activities again (e.g. sports, work)

It takes between 2-4 weeks to fully recover from an appendectomy. Return to your normal daily activities as you feel comfortable; during which time any strenuous physical activity will initially be limited by the discomfort from the wounds. Your surgeons may invite you back for a follow up appointment 4-6 weeks after discharge to check the progress of your recovery.   

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prof. Usman Jafferprof. Usman Jaffer

Cholecystectomy

A cholecystectomy is mostly performed to treat gallstones which are small stone formed for no reasons in the gallbladder consisting of cholesterol or bile salt. Risk factors include 4F i.e Female, Fertile Forty and Family (history). These stone may cause blockage of bile duct in turn causing and irritation of gallbladder resulting in sharp pain in the abdomen in the right upper quadrant associated with vomiting, indigestion and sometimes fever. Cholecystectomy is usually performed through a minimal invasive procedure known as laproscopic cholecystectomy. Open cholecystectomy is the choice of the surgeon either before or during the laproscopic cholecytectomy strictly based on patient safety. Cholecystectomy is primarily indicated in following conditions; • Stone in gall bladder (cholelithiasis) • Stone in the bile duct(choledocolithiasis) • Gallbladder calcification (porcelain gallbladder) • Inflammation of gall bladder (cholecystitis) • Inflammation of pancrease due to stone blockage (biliary pancreatitis) • Lack of movement of bilary channels (bilary dyskinesia) • Gallbladder cancer Indications for Consideration of Prophylactic Cholecystectomy • Risk factors for carcinoma.1 • Anomalous pancreatic–biliary ductal junctions.[1] • Choledochal cysts.[1] • Gallbladder adenomas.1 • Native North or South American background.2 • Porcelain gallbladder.1 • Solitary gallbladder polyp larger than 1 cm.2 Other indications • Choledocholithiasis.2 • Gallstones larger than 3 cm.2 • Patient lives in remote location from health care facility.2 • Sickle cell disease/spherocytosis.1 • Transplant or immunosuppressant therapy.2 • Young age.3 How to perform the procedure: Under general anesthesia, so the patient is asleep throughout the procedure. Using a cannula (a narrow tube-like instrument), the surgeon enters the abdomen in the area of the belly-button.A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient’s internal organs on a television screen. Other cannulas are inserted which allow your surgeon to delicately separate the gallbladder from its attachments and then remove it through one of the openings. An X-ray called a cholangiogram may be performed during the operation to identify stones which may be lodged in the bile channels or to verify the anatomy of structures that have been identified. If the surgeon finds one or more stones in the common bile duct, he/she may remove them with a special scope, may choose to have them removed later through an endoscope placed through the mouth into the stomach using a procedure called ERCP or may convert to an open operation in order to remove all the stones during the operation.After the surgeon removes the gallbladder, the small incisions are closed with absorbable stitches or with surgical tape or glue.