Laparoscopic Appendectomy
Daniel J. Ostlie, MD, and George W. Holcomb, III, MD, MBA
ppendicitis is a common cause of abdominal pain in
A the pediatric patient. Moreover, suspected appendi-
citis is one of the most common surgical consultations
obtained in the outpatient or emergency room setting.
This disease occurs in all age groups, but has a higher
incidence in those children between 5 and 14 years of age,
with a second peak incidence in the elderly population.
The exact etiology of appendicitis is unknown; however,
it is generally agreed that obstruction of the appendiceal
lumen is the precipitating event. The obstruction may be
a result of an appendicolith or other factors such as lym-
phoid hyperplasia, infectious agents, or, rarely, a carci-
noid tumor. Following obstruction of the appendiceal
lumen, there is appendiceal dilation/distention with in-
creased luminal pressure across the appendiceal wall.
This leads to decreased vascular perfusion with break-
down of the mucosal barrier and necrosis.1 As the appen-
dix harbors colonic flora, it is understandable that infec-
tion ensues, unless appendectomy is performed, and
eventually leads to perforation with either localized or
generalized peritonitis and/or abscess formation.
DIAGNOSIS
As with most patients under evaluation for surgical pa-
thology, a careful history and physical examination are
critical to early diagnosis and intervention, limiting the
complications associated with perforation. The classic
presentation is abdominal pain that initially begins peri-
umbilically and migrates to the right lower abdominal
quadrant (RLQ) at McBurney’s point over the ensuing 12
to 24 hours. There is associated anorexia and occasionally
one or two episodes of vomiting. More frequent vomiting
should cause the evaluating physician to consider gastro-
enteritis. Classically, the vomiting ensues after the onset
of the pain. If the vomiting occurs before the pain, gastro-
enteritis is a distinct possibility. Once the pain has moved
to the RLQ, it remains constant and will worsen as the
disease progresses. The local signs caused by the appen-
diceal inflammation/obstruction is the result of peritoneal
irritation in the vicinity of the appendix. Because of vari-
From the Department of Surgery, Children’s Mercy Hospital, Kansas City, MO.
Address reprint requests to George W. Holcomb, III, MD, MBA, Department of
Surgery, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108
© 2005 Elsevier Inc. All rights reserved.
1524-153X/04/0604-0009$30.00/0
doi:10.1053/j.optechgensurg.2004.10.008
Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 317-329
ability in appendiceal location, the pain is not always
located exactly at McBurney’s point. If the diagnosis of
acute appendicitis is not made early, the pain will
progress over 36 to 48 hours at which time there may be a
sudden decrease in pain which indicates when perfora-
tion likely occurred. This diminution in pain will be fol-
lowed by generalized peritonitis, unless the perforation is
enclosed within the omentum, small bowel, or cecum (in
a retrocecal appendix) in which case an abscess may de-
velop.
Children can present often with urinary complaints
such as dysuria, frequent urination, and urgency because
of bladder inflammation related to the appendicitis. A
urinalysis is generally obtained in all patients with sus-
pected appendicitis to eliminate a urinary tract infection
as an etiology for the abdominal pain. Fever is commonly
associated with appendicitis. Generally, the fever is mild
(38-38.5°C), unless perforation and peritonitis are
present, in which case it can be quite high (39-39.5°C).
The physical examination of a child with suspected
appendicitis can be both straightforward and difficult at
the same time. The earlier a patient is examined, the easier
it is to get a “true” examination. Tenderness over McBur-
ney’s point and the presence of a Rovsing’s sign (pain in
the RLQ with palpation of the left lower quadrant) are
hallmarks of appendicitis. There may be mild abdominal
distention; however, this is not present early in the dis-
ease process. As the appendicitis worsens, there will be
more evidence of peritoneal irritation with rebound ten-
derness and guarding. Eventually, generalized peritonitis
will develop as a result of perforation and intestinal spill-
age causing severe peritoneal irritation.
Laboratory analysis in the presence of appendicitis
should be used as confirmatory evidence for appendicitis
rather than to establish the diagnosis. The most common
finding is a leukocytosis with an associated left shift. The
leukocytosis is usually less than 20,000 WBC/mL in the
acute phase. However, it can be much higher with perfo-
ration.2 Moreover, leukopenia may be present in severe
cases of peritonitis with associated sepsis. There are gen-
erally no electrolyte abnormalities unless there is signifi-
cant dehydration. It is not uncommon to encounter
pyuria that is the result of bladder inflammation at the
time of the urinalysis. The presence of bacteria in the
urine should lead to a diagnosis of urinary tract infection
in almost all instances.
317
318
1 A CT scan can be helpful in those patients in whom the
diagnosis is in question. The presence of right lower quadrant
abdominal inflammation, appendiceal enlargement, or the
presence of a fecalith lends support to the diagnosis of appen-
dicitis with an overall sensitivity of ⬎ 95%. In this 18 month
old, the infant presented with vague abdominal complaints, but
did have some lower abdominal discomfort. The CT scan shows
a fecalith (arrow). This child underwent uneventful laparo-
scopic appendectomy and was discharged the following day.
Regarding imaging studies, a computerized tomogra-
phy (CT) scan of the abdomen and pelvis is often ob-
tained before obtaining a surgical consult. We do not
recommend that all patients being evaluated for appendi-
citis undergo CT of the abdomen and pelvis, but rather
reserve this test for those patients in whom the diagnosis
is in question (Fig 1). With this study, the presence of
RLQ inflammation and/or appendiceal enlargement lends
support to the diagnosis of appendicitis with an overall
sensitivity of greater than 95%. Less commonly, an ab-
dominal ultrasound will be used in a confirmatory fash-
ion. If the appendix is visualized and found to be dilated
to greater than 1 cm, this finding is highly suggestive of
appendicitis. If the appendix is not visualized or it is less
than 1 cm in diameter, the examination does not aid
significantly in the differential diagnosis. Plain radio-
graphs of the chest or abdomen generally are not useful
during the evaluation of acute appendicitis, and we rec-
ommend their use only for select cases, such as patients
with a possible renal stone or intestinal obstruction.3 The
clinical presentation of the child with appendicitis varies
markedly depending on the stage of the disease. Four
clinical scenarios will be described.
ACUTE,
NONPERFORATED APPENDICITIS
The most common and least morbid clinical presentation
of appendicitis occurs in the child that presents with
early, acute, nonperforated appendicitis. In this scenario,
Ostlie and Holcomb
the appendix may be acutely inflamed or suppurative, but
perforation has not occurred The typical presentation and
confirmatory signs have been presented previously in the
text. When this clinical scenario is encountered, we rec-
ommend immediate operation for appendectomy. If the
exploration is negative for acute appendicitis, we suggest
evaluation of the abdomen for any other pathology that
may be present, such as Meckel’s diverticulitis or mesen-
teric adenitis. Although a normal appendix may be found
in up to 15% of cases, we recommend the removal of all
appendices that are explored for acute appendicitis,
thereby limiting the difficulties associated with a repeat
evaluation of a patient with recurrent abdominal pain
suspicious for appendicitis in whom the appendix has
been left behind at a previous operation for appendicitis.4
NONCOMPLICATED
PERFORATED APPENDICITIS
When a patient presents with significant peritoneal irri-
tation, temperature ⬎39°C, or leukocytosis ⬎20,000
WBC/mL or a history of symptoms greater than 48 hours,
perforated appendicitis should be considered. The preop-
erative management of these children should include ad-
equate resuscitation and the administration of appropri-
ate antibiotics. We favor either traditional triple antibiotic
coverage (ampicillin, gentamicin, and clindamycin/
flagyl) or, more recently, ceftriaxone and flagyl. If the
patient is stable and the symptoms have been present for
less than 3 or 4 days, we favor proceeding with appendec-
tomy rather than trying to treat nonoperatively followed
by interval appendectomy later. Often an early abscess
will be identified and omentum has walled off the puru-
lent fluid. The main advantage of the laparoscopic ap-
proach in this clinical scenario is a markedly reduced
incidence of postoperative wound infection compared
with the traditional RLQ open approach.
PERFORATED APPENDICITIS
WITH ABSCESS AND STABLE PATIENT
A third clinical scenario can be seen in patients with
appendicitis complicated by perforation and the forma-
tion of a well-defined abscess cavity. The duration of the
perforation is important in that these patients usually
have symptoms for 1 week or longer. Typically, they have
an initial 24 to 48 hours of symptoms suggestive of ap-
pendicitis, but then begin feeling better which is when the
perforation likely occurs. Following a short interval of
feeling better, they begin to feel worse. These patients are
often teenagers, but we have seen an occasional younger
patient with this scenario. The patients are febrile and
have a well-delineated right lower abdominal mass. How-
ever, there is no evidence of small bowel obstruction or
other signs of toxemia. A CT scan is performed and reveals a
well-defined abscess. There is no evidence of bowel obstruc-
tion on the abdominal films or the CT scan (Fig 2).
Laparoscopic Appendectomy 319

2 In select cases, patients with a long-standing history consistent with perforated appendicitis may present with a well defined
abscess cavity, but may not be toxic from this disease. On the left (A), the abdominal/pelvic CT scan is seen from such a patient with
a well defined and localized abscess cavity (arrow). On the right (B), the patient’s plain abdominal film shows no evidence of
intestinal obstruction from the abscess. In this type of patient, usually a teenager, nonoperative management is initiated with
percutaneous drainage of the abscess cavity followed by 10 to 14 days of intravenous antibiotics. Most of the antibiotic therapy can
be accomplished at home. If the abscess resolves and the patient remains stable, the patient then returns at approximately 6 weeks
for a laparoscopic interval appendectomy.

In the above clinical scenario, initial nonoperative
management is favored. The abscess cavity is drained
percutaneously and a PICC (percutaneous intravenous
central catheter) line is introduced for home antibiotic
administration. If the patient stabilizes and is able to tol-
erate a regular diet, he/she can be discharged and the
antibiotics continued for 10 days. The patient is usually
seen in the outpatient setting approximately 1 week fol-
lowing the drainage procedure and a repeat CT scan per-
formed. If there is no evidence of a residual abscess cavity
and the patient is clinically improving, the drain is re-
moved. The patient is often continued on oral antibiotics
for another week or two with plans for an interval lapa-
roscopic appendectomy 6 weeks following the initial
drainage procedure.
It should be emphasized that patients managed in
this fashion comprise a select group. Very few (⬍5%)
of all patients who have presented to our hospital with
appendicitis have been managed in this fashion. Also,
there is some controversy about whether or not the
interval appendectomy needs to be performed. How-
ever, in our experience, we have seen several patients
with a long, tubular appendix at the time of the interval
laparoscopic procedure with a fecalith found in the
specimen (Fig 3). This operative finding leads us to
believe that these patients are at risk for developing
another episode of appendicitis. Thus, we believe that
the interval laparoscopic appendectomy is an impor-
tant part of the overall treatment plan of these patients.
Most of the patients that we have managed in this
320
3 This operative photograph shows a long, tubular appendix in
a patient who had previously undergone nonoperative manage-
ment for perforated appendicitis and abscess. At the time of the
interval appendectomy 6 weeks following the development of the
abscess, the appendix was removed. It is not unusual to find a
rather significant residual appendix at the time of the laparoscopic
interval appendectomy that leads us to believe that all patients
treated in this manner should undergo interval appendectomy to
prevent a second episode of acute appendicitis.
fashion have been ready for discharge on either the first
or second day following their interval laparoscopic
procedure although one patient had a prolonged post-
Ostlie and Holcomb
operative course of 5 days because of unexplained nau-
sea and vomiting.
PERFORATED APPENDICITIS IN
AN UNSTABLE AND TOXIC PATIENT
Once or twice a year, we find a patient with perforated
appendicitis who is in critical condition requiring a
massive amount of intravenous fluid, nasogastric suc-
tion and, on some occasions, vasopressive medication.
These patients represent the extreme result of un-
abated perforated appendicitis with generalized perito-
nitis. In such patients, following stabilization, an ex-
ploratory laparotomy is performed through a lower
midline incision, the appendix is removed and inter-
loop abscesses manipulated and drained. Usually, 4 or
5 liters of saline are used to irrigate and cleanse the
abdominal cavity in these patients. Drains are placed
along each lateral colonic gutter and exteriorized
through the lower aspect of the incision. Also, a pelvic
drain is often placed. It is not unusual for these patients
to require 10 to 14 days, or even longer in some in-
stances, of hospitalization as they are quite ill and slow
to recover. Occasionally, they will also develop another
intra-abdominal abscess that requires percutaneous
drainage. However, over the last 5 years, we have not
had any mortality in this patient population and no
significant morbidity.
Laparoscopic Appendectomy 321

SURGICAL TECHNIQUE
We utilize a three instrument technique for laparo-
scopic appendectomy. A broad spectrum antibiotic
(such as cefoxitin) is given to cover Gram-negative
organisms and anaerobic bacteria. The operation is ini-
tiated with the patient in the supine position after the
induction of general anesthesia. If possible, we have
the patient urinate before their transfer to the operating
room. For smaller children, a Credè maneuver is em-
ployed to obtain bladder decompression, thus elimi-
nating the need for bladder catheterization. If the blad-
der is distended and cannot be emptied, urinary
catheterization is performed.

4 Following a vertical incision in the center of the umbilical skin, the cautery is used to incise the fascia and peritoneum. A 12 mm blunt
tip Step (US Surgical, Norwalk, CT) cannula is introduced into the peritoneal cavity and the abdomen is insufflated with CO2. (A 12 mm
Step cannula is placed in the umbilicus because the 10 mm endoscopic stapler is too large for a 10 mm Step cannula.) A 5 mm 70 degree
angled telescope is then introduced through the umbilical cannula. A 5 mm Step cannula is inserted through a left lower abdominal
incision, lateral to the inferior epigastric vessels. The craniocaudal position of this cannula is determined by the size of the child, but a
general guideline is to position this cannula approximately one-half the distance from the symphysis pubis to the umbilicus. The third
instrument is placed in the left suprapubic location. With the telescope inserted through the umbilical port, the collapsed bladder is
visualized, and a 5 mm Step cannula is inserted just above the peritoneal reflection of the bladder and to the left of the patient’s midline.
322 Ostlie and Holcomb

5 After insertion of the three cannulas, the abdomen is fully inspected, including the RLQ for signs of appendicitis (inflammation,
omental adhesions, appendiceal injection, or perforation, purulent peritoneal fluid), the gallbladder and liver, and the terminal
ileum for evidence of a Meckel’s diverticulum (especially in the face of a normal appearing appendix). In adolescent females, the
ovaries and fallopian tubes are visualized to eliminate a gonadal etiology for the abdominal pain. If an abscess has developed, the
walls are gently separated and the purulent fluid suctioned to prevent contamination of the rest of the peritoneal cavity. If the
appendix is retrocecal, the lateral peritoneal attachments to the cecum are incised to mobilize the cecum and appendix. This
dissection is usually performed sharply.
Laparoscopic Appendectomy 323

6 After incising the peritoneal attachments, the rest of the cecal mobilization can be accomplished bluntly.
324 Ostlie and Holcomb

7 Once the appendix is mobilized, an opening is made in the mesoappendix just distal to the junction between the appendix and
the cecum. Using the two instruments (a Maryland dissecting instrument and an atraumatic grasper) through the two 5 mm
cannulas, this window is made large enough to accommodate a 35 mm endoscopic stapler.
Laparoscopic Appendectomy 325

8 The telescope is then rotated to the left lower quadrant 5 mm cannula and the stapler is introduced into the abdomen through
the 12 mm umbilical cannula. In many instances, it is easier to staple the base of the appendix before proceeding with division of
the mesoappendix.
326 Ostlie and Holcomb

9 However, in some cases, it is more advantageous to proceed with mesoappendiceal division before appendiceal division.
Regardless of the order, a vascular load is utilized to perform the mesoappendiceal ligation and division, and a gastrointestinal load
is used to perform the appendiceal division.
Laparoscopic Appendectomy 327

10 In cases of acute, nonperforated appendicitis, we do not routinely use an endoscopic retrieval bag for removal of the
appendix, but rather grasp the stapled base of the appendix with the stapler and remove it through the 12 mm umbilical cannula.
328 Ostlie and Holcomb

11 However, if perforation has occurred or if the appendix is too large to permit its removal through the 12 mm cannula, it is
placed into an endoscopic bag, which is inserted through the umbilical cannula. The cannula and bag are exteriorized along with
the appendix through the umbilical incision. Following local, but not generalized, irrigation, the instruments are removed under
direct vision and the subcutaneous tissues are infiltrated with 0.25% bupivocaine. The umbilical cannula is removed, the fascia is
closed with an absorbable suture, and the umbilical skin is approximated with absorbable suture such as plain catgut. If possible,
the fascia of the other two instrument sites is closed with an absorbable suture and the skin is closed in a subcuticular fashion. A
nasogastric tube is usually not needed and the patient is advanced to a regular diet as tolerated. The antibiotic is continued for 24
hours for nonperforated appendicitis. For perforated appendicitis, broad spectrum coverage is utilized and is continued for at least
7 days or until the patient is afebrile with a normal leukocyte count.5
Laparoscopic Appendectomy
CONCLUSION
The laparoscopic approach for appendicitis is advanta-
geous in a number of clinical scenarios. For the child with
simple, acute appendicitis, the operation is well tolerated
with reduced postoperative discomfort and a short post-
operative hospitalization. Moreover, the incidence of
postoperative wound infections approaches zero.
Patients, especially children, can present with perfo-
rated appendicitis in a wide variety of clinical scenarios.
Unfortunately, approximately 30% to 40% of children
seen with appendicitis have already developed perfora-
tion. For those patients with acute appendicitis with
rather recent perforation, the laparoscopic approach is
utilized. The main advantages for this approach center on
the ability to directly suction all purulent material under
visualization and lyse small intestinal adhesions formed
by the inflammatory response. Also, the greatest advan-
tage of the laparoscopic over the open approach for this
patient population with early perforation is the almost
nonexistent incidence of wound infections. Moreover,
the incisions do not need to be left open and, should a
wound infection develop which requires drainage, inci-
sion and drainage can easily be accomplished in the out-
patient setting under local anesthesia. However, there is
likely not a significant reduction in hospital stay with the
laparoscopic approach for these patients with perforated
329
appendicitis as the patient still requires recovery from an
ileus and the prolonged instillation of intravenous antibi-
otics.
For the patient with perforation and a well-defined
abscess of relatively long-standing duration, initial non-
operative management followed by interval laparoscopic
appendectomy has been a very efficient approach in a
small segment of patients. Also, for patients who are crit-
ically ill from perforated appendicitis, laparotomy
through a lower midline incision affords the surgeon the
best chance for evacuating the purulent material and abat-
ing the significant peritonitis in these patients.
REFERENCES
1. Wangensteen OH, Dennis C: Experimental proof of obstructive
origin of appendicitis in man. Ann Surg 110:629, 1939
2. Samuel M: Pediatric appendicitis score. J Pediatr Surg 37:877-881,
2002
3. Garcia Pena BM, Cook EF, Mandl KD: Selective imaging strategies
for the diagnosis of appendicitis in children. Pediatrics 113:24-28,
2004
4. DeCou JM, Gauderer MW, Boyle JT, et al: Diagnostic laparoscopy
with planned appendectomy: An integral step in the evaluation of
unexplained right lower quadrant pain. Pediatr Surg Int 20:123-
126, 2004
5. Meier DE, Guzzetta PC, Barber RG, et al: Perforated appendicitis in
children: Is there a best treatment? J Pediatr Surg 38:1520-1524,
2003