Acute Appendicitis: Laparoscopic Appendectomy Explained with Real Surgery Videos
- DR Dinesh Vats
- Oct 1
- 6 min read
Appendix – Definition
The appendix is a small, finger-like pouch attached to the beginning of the large intestine (cecum) in the lower right abdomen (right iliac fossa). Traditionally, it is described as a vestigial organ, meaning it has lost most of its original digestive function during evolution. However, newer studies suggest that the appendix may play a minor role in the immune system, particularly in maintaining healthy gut bacteria, though it is not essential for normal digestion or survival [1].
Acute Appendicitis – An Overview
Acute appendicitis occurs when the lumen of the appendix becomes occluded, commonly by a fecalith (stool), swelling of lymph tissue, and rarely by a tumor [2]. Blockage leads to swelling, bacterial overgrowth, and inflammation. If untreated in time, it can result in compromised blood supply, increased pressure inside the appendix, and ultimately rupture [2].
It is the most common surgical emergency globally. Lifetime risk is estimated at 7–8% of the population, and more than 17 million cases occur annually worldwide, making appendectomy one of the most frequently performed emergency abdominal surgeries [3]. In India, it is a major cause of emergency admissions in young adults, often in the productive age group of 15–35 years [4].
Timely recognition and intervention are therefore critical. Delays increase the risk of perforation, generalized peritonitis, sepsis, and, in rare cases, death [5].
Why Surgery is Needed
Once diagnosed, surgical removal of the appendix remains the gold standard of treatment. In recent years, some trials have explored conservative management with antibiotics, particularly in uncomplicated cases, but recurrence rates remain significant [6]. Interval appendectomy is now rarely recommended because of the high risk of recurrent inflammation during the waiting period [6].
Laparoscopic appendectomy has become the preferred approach in many centers because of its clear advantages over open surgery [7]:
Smaller incisions and better cosmetic outcomes
Reduced postoperative pain
Lower incidence of wound infections
Shorter hospital stay
Faster return to normal activities and work
Open appendectomy still has a role in certain situations, such as advanced peritonitis, lack of laparoscopic expertise, or resource-limited settings. However, the global trend is moving steadily toward laparoscopy as the standard [7].
Signs and Symptoms of Acute Appendicitis
The presentation often begins with periumbilical pain, which later localizes to the right iliac fossa as the parietal peritoneum becomes inflamed. This shift in pain is considered a classic feature, though the exact location may depend on the anatomical position of the appendix [2].
Associated symptoms include:
Nausea and vomiting (usually after onset of pain)
Low-grade fever
Loss of appetite (often the earliest complaint)
Altered bowel habits (constipation or diarrhea in some cases)
On clinical examination, the hallmark is tenderness at McBurney’s point, located one-third of the distance from the anterior superior iliac spine to the umbilicus. Additional signs include:
Rovsing’s sign – pain in the right iliac fossa when the left lower abdomen is palpated
Psoas sign – pain when extending the right thigh, indicating retrocecal appendix irritation
Obturator sign – pain on internal rotation of the flexed right thigh, suggesting pelvic appendix irritation
However, the presentation may be atypical. Children often present with nonspecific abdominal pain and irritability, elderly patients may show muted signs, and pregnant women can present with displaced pain due to the enlarged uterus [8].
Diagnosis of Acute Appendicitis
No single test can definitively diagnose appendicitis; rather, it is the combination of clinical judgment, laboratory results, and imaging that guides decision-making.
Blood investigations: Raised total leukocyte count with neutrophilia is a common finding. CRP elevation, especially when combined with leukocytosis, increases diagnostic accuracy [2].
Urine examination: Helps exclude urinary tract infection, ureteric stones, or gynecological causes in women, which can mimic appendicitis [2].
Ultrasonography (USG): Widely used as a first-line investigation. A swollen, non-compressible tubular structure (>6 mm in diameter) in the right iliac fossa is diagnostic [2].
Contrast-enhanced CT scan: Considered the gold standard with >90% sensitivity and specificity. It is particularly useful in obese patients or when the clinical picture is unclear [9].
Scoring systems: The Alvarado score and Appendicitis Inflammatory Response (AIR) score are clinical tools that combine symptoms, signs, and lab values to stratify patients and support diagnosis [10].
Together, these methods help reduce negative appendectomy rates and ensure patients are taken up for surgery at the right time.
Case Example – Laparoscopic Appendectomy
In our practice, a 33-year-old male presented with right lower abdominal pain. Ultrasonography revealed a distended, non-compressible tubular structure in the right iliac fossa consistent with an inflamed appendix, with mild periappendiceal fat stranding. Based on these findings and clinical suspicion, the patient was referred for laparoscopic surgery.
Under general anesthesia, a standard three-port laparoscopic appendectomy was performed. The appendix was found inflamed but intact, without perforation or abscess. The mesoappendix was carefully dissected, vessels were secured, and the appendix was ligated at its base and removed. The operative field was irrigated, checked for contamination, and ports were closed.
The patient tolerated the procedure well, recovered uneventfully, and was discharged the next day with advice on diet, wound care, and follow-up.
Laparoscopic Appendectomy Step by step videos
Postoperative Recovery and Follow-Up
Recovery after laparoscopic appendectomy is usually smooth. Most patients are allowed to start oral liquids within 12–24 hours and progress to a normal diet shortly after [7]. Patients are also advised to walk the next day, as early mobilization helps prevent complications such as deep vein thrombosis.
Discharge is often possible within 24–48 hours for uncomplicated cases. Pain is generally mild and controlled with oral analgesics. Patients are advised to avoid heavy weight lifting for 2–3 weeks but can return to their jobs within a few days [7].
Long-term outcomes are excellent, and recurrence is not possible once the appendix is removed. Rare complications include wound infection, intra-abdominal abscess, or adhesions, but these are less common with laparoscopic than with open surgery [7].
Conclusion
Acute appendicitis remains a major global and national health burden, affecting millions each year. It is a condition that demands early recognition and timely surgery. The shift from open to laparoscopic appendectomy has revolutionized patient care, offering faster recovery, fewer complications, and better outcomes.
For patients, understanding the signs and symptoms is crucial, as delays in seeking care can have serious consequences. For medical learners, real-world surgical videos provide invaluable exposure to operative techniques. Sharing clinical cases, as illustrated here, bridges the gap between textbook knowledge and practical application.
Ultimately, timely diagnosis, prompt referral, and modern laparoscopic techniques ensure that appendicitis, once a potentially fatal disease, is now routinely and safely treated worldwide [5].
Author’s Profile
Dr. Varun Verma, MBBS, MS (General Surgery)Dr. Varun Verma is a highly experienced General and Minimal Access Surgeon with over 13 years of expertise in performing advanced surgical procedures. He holds special training in minimal access (laparoscopic) surgery and currently serves as Consultant Surgeon at Mandav Hospital, Gutkar. Dr. Verma has managed a wide range of general and emergency surgeries, with a particular focus on laparoscopic techniques that offer patients faster recovery and better outcomes.
References
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Indian Journal of Surgery. Burden of appendicitis in Indian population. Available: https://www.ijsurgery.com/index.php/isj/article/view/1137
Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15:27.
Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis. JAMA. 2015;313(23):2340–2348.
Hori T, Machimoto T, Kadokawa Y, et al. Laparoscopic appendectomy for acute appendicitis: how to improve outcomes. World J Gastroenterol. 2017;23(20):3752–3763.
Yale SH, Tekiner H, Yale ES. Signs and syndromes in acute appendicitis: A pathophysiologic approach. World J Gastrointest Surg. 2022;14(7):729–738. PMID: 362292301.
van Randen A, Bipat S, Zwinderman AH, et al. Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology. 2008;249(1):97–106.
Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med. 2011;9:139.
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