14
Laparoscopic Appendectomy
Eugene D. McGahren
CHAPTER OUTLINE
INDICATIONS FOR WORKUP AND OPERATION
OPERATIVE TECHNIQUE
PEARLS
PITFALLS
RESULTS
SELECTED REFERENCES
A ppendicitis affects children of all ages. It is one of
the first conditions to have been treated with the
laparoscopic approach because the procedure is rela-
tively straightforward and does not require intracorpo-
real suturing. Laparoscopy has also served as a useful
technique for teaching the principles of minimally inva-
sive surgery.
A particular benefit of laparoscopy for the treatment
of appendicitis is that it allows a full view of the appen-
dix and the surrounding affected area. Also, it allows
identification of all areas of purulence that may need to
be irrigated and debrided. It allows the use of small
incisions, particularly in patients with a generous
amount of soft tissue, and this leads to a reduction in
wound infections. Finally, it allows a general examina-
tion of the entire abdomen, which is particularly useful
if laparoscopy is undertaken for suspected appendicitis
but the appendix is normal.
INDICATIONS FOR WORKUP
AND OPERATION
Appendicitis is one of the most commonly encountered
conditions in pediatric surgery. A child typically pre-
sents with nonspecific abdominal pain that localizes to
the right lower portion of the abdomen over a 24- to
48-hour period. This is often accompanied by some or
all of the following: fever, anorexia, a desire to remain
still, nausea, vomiting, diarrhea, dysuria. However, the
symptoms may be quite nonspecific in smaller children
and toddlers. Children of this age group often do not
wish to walk and desire comfort from their parents.
Helpful laboratory tests include a leukocyte count
with differential, a urinalysis (to exclude the urinary
tract as a source of the symptoms), and a pregnancy test
in any female of child-bearing age. Historically, these
tests and a good history and physical examination have
been sufficient to determine whether a child should
undergo operation for appendicitis or be observed.
Increasingly, imaging studies such as ultrasound, and
particularly computed tomography (CT), are being used
in evaluating for appendicitis. The CT scan is quite sen-
sitive and specific for appendicitis and has supplanted
the ultrasound in most centers. CT is also useful for
distinguishing well-formed abscesses from a perforated
appendix, or for identifying other causes of the patient’s
discomfort.
When the diagnosis of appendicitis is suspected or
made, operative intervention is indicated for removal of
the appendix in most cases. The patient is intravenously
hydrated and appropriate antibiotics are administered
before operation. If a well-formed abscess is found,
appendectomy may be delayed in favor of CT-guided
drainage of the abscess combined with antibiotic
therapy. Antibiotic therapy alone may be appropriate
for such a patient. Laparoscopic appendectomy can then
be performed 6 to 8 weeks later.
Laparoscopy can be used in any child who is being
operated on for appendicitis, whether as an urgent or
an interval procedure. Occasionally, I use an open tech-
nique in thin, young boys when the diagnosis of acute,
nonperforated appendicitis is certain. Such an opera-
tion can be performed with an incision of less than 1
inch, with no difference in postoperative hospital stay
or outcome compared with laparoscopy. It also allows
training in the open technique. In general, however,
76 Atlas of Pediatric Laparoscopy and Thoracoscopy

laparoscopy is the technique of choice for surgical treat-
ment of appendicitis.
OPERATIVE TECHNIQUE
The patient is placed supine on the operating table, and
general endotracheal anesthesia is administered. An
orogastric tube is placed by the anesthesiologist for
decompression of the stomach. The patient was encour-
aged to empty the bladder before coming to the operat-
ing room, but if that was not accomplished, it can be
done via a Credé maneuver or insertion of a urinary
catheter after the patient is anesthetized. The abdomen
is then prepped and draped widely. Antibiotics are
administered if they were not given before the patient’s
arrival in the operating room. I typically use one monitor
placed at the right foot of the table. Cannula positions
are in the infraumbilical area (5 mm), right upper lateral
area (5 mm), and left lower quadrant (12 mm) of the
abdomen (Fig. 14-1). The surgeon manipulates the
appendix through the left lower quadrant site, and
the assisting surgeon may use the instrument inserted
through the right upper quadrant port while controlling
the camera. This provides the classic “baseball diamond”
orientation of instruments and camera relative to the
target organ.
However, depending on the surgeon’s preference,
other orientations of the ports may be preferred. An
orientation with both operating ports on the left side
may allow the surgeon to work with both hands while
an assistant controls the camera (Fig. 14-2). Some
authors have reported using two, and even one, port to
perform the operation.
Local anesthetic (0.2% ropivacaine without epineph-
rine) is infiltrated into all cannula sites before incision
and also before closure. In our preferred technique, an
infraumbilical 5-mm skin incision is made. Dissection
is then carried down to the midline fascia. Care is taken
to provide traction on the fascia with stay sutures or
appropriate forceps to avoid injury to underlying struc-
tures. A small incision is made in the fascia. I use the
Step cannula system (Covidien, Mansfield, MA). The
blunt-tipped Veress needle with an expandable sheath
is introduced directly through the fascial incision. Once
the needle has penetrated the fascia and peritoneum, a
glass-tipped syringe with saline is connected to the port
of the needle. Aspiration is done to detect any blood or
enteric content. If no such findings are encountered, the
saline is allowed to drop passively into the abdominal
cavity, indicating that the needle is free in the cavity.
The abdomen is then insufflated with CO2 to a pressure
appropriate for the size of the child.
If necessary or preferred, a direct opening into the
peritoneal cavity can also be created. This is particularly
useful if significant inflammation is suspected by pre-
operative imaging studies. Once the abdomen is insuf-
flated (or the peritoneum is visualized if the opening is
direct), a 5-mm cannula with blunt trocar is inserted
through the expandable sheath. The blunt trocar is
removed and a 30-degree, 5-mm laparoscope is intro-
duced through the cannula.

SA C

S
5
5
M 12

A B
Figure 14-1. A, Preferred positioning of personnel for a laparoscopic approach. The surgical assistant (SA) is situated to the patient’s
right at the level of the right-sided port. The surgeon (S) stands to the patient’s left and uses the instrument placed through the 12-
mm left lower quadrant port. The camera holder (C) is usually to the right of the surgeon. The scrub nurse (N) stands to the surgeon’s
left at the foot of the bed. A, anesthesiologist; M, monitor. B, Three ports are used with this approach. The assistant uses a retracting
grasper through a 5-mm port in the patient’s right upper abdomen. The 5-mm camera is inserted through the umbilical port. The
surgeon works through the 12-mm left lower abdominal port, through which the stapler is introduced and removed.
 Laparoscopic Appendectomy 77

SA/C

S
M

Figure 14-2. An alternative arrangement of personnel and port placement is seen on the left. The surgeon (S) again stands to the left
of the patient. The surgical assistant/camera holder (SA/C) stands cephalad to the surgeon and the scrub nurse (N) is to the surgeon’s
left. A, anesthesiologist; M, monitor. On the right is a photograph using this port positioning. A 12-mm port is inserted through the
umbilicus. This is the port through which the stapler and endoscopic retrieval bag (if used) are introduced and removed. The 5-mm
telescope is introduced through the 5-mm left mid-abdominal port. The surgeon works instruments placed through the umbilical port
and the left suprapubic port. In this way, a baseball diamond configuration has been accomplished with the camera port at home
base, the working ports at first and third base, and the target organ at second base with the monitor in center field.

A B
Figure 14-3. A, Once the appendix has been freed from its inflammatory adhesions, a blunt dissecting instrument is used to develop
a window in the avascular portion of the mesoappendix near the base of the appendix. B, The stapler is then introduced and placed
through this window and across the base of the appendix. The appendix is usually ligated and divided first, although sometimes it is
easier to initially ligate and divide the mesoappendix.

A general survey of the abdominal cavity is performed
to be sure there has not been injury from placement of
the initial cannula. The additional ports are then placed
under direct visualization. Atraumatic grasping instru-
ments are inserted through the right upper quadrant
and left lower quadrant ports. Often there is significant
inflammation and adherence of bowel to the appendix.
Positioning the patient in Trendelenburg position may
facilitate exposure. The bowel, and overlying omentum
if present, can usually be swept away rather than grasped.
If grasping is necessary to expose the appendix, care
must be taken to avoid undue tension and pressure to
avoid injury to the intestine or the appendix resulting
in spillage of enteric contents. If the appendix is retro-
peritoneal, care must be taken to avoid injury to the
cecum and ureter during dissection.
Attention is paid to identifying the appendix all the
way to the base so as not to leave a significant stump.
Once the appendix is mobilized, it is lifted to allow
dissection to its base. This is sometimes difficult if there
is extensive inflammation. By identifying the base,
complete removal of the appendix is ensured. In addi-
tion, the base is usually relatively healthy and allows
for a secure dividing point. In my technique, the
appendix or mesoappendix is supported by a grasper
through the right upper quadrant port. A blunt dissect-
ing instrument, inserted through the left lower port,
is used to dissect through the avascular portion of
the mesoappendix next to the base of the appendix
(Fig. 14-3A). The appendix and mesoappendix are then
sequentially divided using an endoscopic stapler. The
stapler is placed through the 12-mm left lower port. (An
78 Atlas of Pediatric Laparoscopy and Thoracoscopy

alternative port arrangement is to have the 12-mm port
in the infraumbilical position with a 5-mm port in the
left lower quadrant. With this arrangement at the time
of stapling, the camera is rotated to the left port. Removal
of the specimen with the endoscopic bag is sometimes
easier through the more easily stretched infraumbilical
site.) It is usually easier to divide the appendix first
(Fig. 14-3B). After the stapler is secured, examination is
always undertaken to be sure there are no other involved
structures before activating the stapler. After the stapler
is activated, it is helpful to orient it so that the staple
tray is dependent. This helps prevent spillage of unfired
staples into the abdomen when the stapler is opened.
After ligation and division of the appendix, the meso-
appendix is ligated and divided with the stapler and
vascular load (Fig. 14-4).
An endoscopic bag is then passed through the 12-mm
port and the appendix is dropped into it (Fig. 14-5). The
bag with the appendix typically cannot fit through the
cannula because of the size of the inflamed appendix.
Therefore, the cannula is withdrawn and then the
bag is withdrawn directly through the port site. The
site may need to be expanded with a clamp to allow
passage of the bag. To avoid spillage of the appendiceal
contents into the abdomen or the cannula tract, care
is taken not to rupture the bag. Once the bag is removed,
the cannula is replaced. The pelvis and abdomen
are surveyed for any purulent fluid that needs to be
removed. The pelvis and suprahepatic space are irri-
gated and suctioned (Fig. 14-6). The appendiceal stump
and the staple line of the mesoappendix are examined
for hemostasis. All cannulas are removed under direct
vision, and the CO2 is allowed to express from the
abdomen.
The infraumbilical fascia and the fascia of the
12-mm port site are closed with absorbable sutures. If
the patient has a thick body wall, a Carter-Thomason
device (Inlet Medical, Eden Prairie, MN) is useful to

Figure 14-5. Often, the appendix is either too large or too

friable to be delivered through the largest cannula. In this
Figure 14-4. After ligation and division of the appendix, the situation, an endoscopic retrieval bag is inserted and the
mesoappendix is ligated and divided with the stapler, using a appendix is placed in the bag. The bag is then exteriorized after
vascular cartridge. removal of the cannula.

A B
Figure 14-6. When the appendix is perforated and purulent material is throughout the abdominal cavity, the laparoscopic approach
is advantageous for evacuation of the purulent material and irrigation. A, The purulent material in the suprahepatic area is being
evacuated. B, The pelvis is being irrigated.

pre-place these stitches before removal of the cannulas.
Subcutaneous tissue is closed with an absorbable
suture. The skin is then closed with subcuticular running
sutures. Butterfly bandage strips or a skin-bonding agent
is then used.
PEARLS
1. Sweeping motions are preferred when exposing the
appendix.
2. If the appendix is to be grasped, find a healthy or
intact portion to avoid rupture and spillage.
3. Use the stapler to divide the appendix to avoid spill-
age from the appendix.
4. After activating the stapler, orient it with the staples
dependent to prevent loose staples from falling when
the device is opened.
5. Expand the largest cannula site, if necessary, to
remove the endoscopic bag and appendix with the
specimen.
PITFALLS
1. Be careful to avoid injuring bowel when exposing the
appendix.
2. There is a potential for injury to the ureter when
exposing a retroperitoneal or retrocecal appendix.
3. Spillage from the appendix may occur while manipu-
lating it.
4. Be sure to dissect all the way to the base of the appen-
dix before dividing it.
5. The endoscopic bag can break as it is removed from
the abdomen. The spillage can lead to intra-abdomi-
nal or port site infection.
RESULTS
In the past 10 years, I had 139 cases (82 male patients,
57 female patients) with appendicitis as the primary
complaint. Acute appendicitis was suspected in 131
cases, interval appendectomy was planned in five cases,
and appendectomy was planned during laparoscopic
examination for chronic right lower quadrant pain in
three cases. Patient ages ranged from 1 year to 22 years,
with a mean age of 11.9 ± 4.5 years. One hundred five
cases (75.5%) were planned laparoscopically. Six opera-
tions (5.7%) were converted to open cases: two cases
involved hostile anatomy, one patient had Meckel’s
diverticulitis, two patients were toddler-size infants in
whom laparoscopic examination revealed that the
appendix could be removed through a small right lower
quadrant incision, and one case was converted when the
dissection coursed into adherent bowel under the umbi-
Laparoscopic Appendectomy 79
licus). Thirty-four cases (24.4%) were planned as an
open approach.
Of the 131 suspected cases of acute appendicitis, 113
(86.3%) were positive. Twenty (17%) of the positive
cases were perforated. Eighteen cases (15.9%) were
negative, although a substantial proportion of these
patients had symptom relief after appendectomy despite
an appendix that appeared normal on histologic
examination.
Of three patients who underwent laparoscopic exami-
nation and appendectomy for chronic right lower quad-
rant pain, two had histologically confirmed acute or
chronic appendicitis, and one had localized endome-
triosis that was excised. All had symptomatic relief of
their pain.
The following complications were seen in the open
group: one rupture of the appendix during removal,
necessitating extended antibiotic therapy; one abscess
requiring CT-guided drainage; one superficial wound
infection; and one readmission for pain (13 days post-
operatively) that resolved spontaneously. Of those
patients treated laparoscopically for perforated appen-
dicitis, 3 of 13 patients (23%) experienced a postopera-
tive abscess requiring drainage, but none of the seven
other patients treated with an open approach experi-
enced this. However, it is important to remember that
in this series, the patients treated with open technique
were a selected population, generally thin males or
small children.
These data indicate the utility and safety of the
laparoscopic approach for removal of a diseased
appendix in all pediatric age groups. It has become
our favored approach for removal of the appendix in
children.
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role for laparoscopic appendectomy in pediatric surgery?
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2. Esposito C: One-trocar appendectomy in pediatric surgery.
Surg Endosc 12:177-178, 1998
3. Newman K, Ponsky T, Kittle K, et al: Appendicitis 2000:
Variability in practice, outcomes, and resource utilization
at thirty pediatric hospitals. J Pediatr Surg 38:371-379,
2003
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game: An evaluation of general surgery residents’ partici-
pation in pediatric laparoscopic surgery. J Pediatr Surg
39:78-80, 2004
5. Oka T, Kurkchubasche AG, Bussey JG, et al: Open and
laparoscopic appendectomy are equally safe and accept-
able in children. Surg Endosc 18:242-245, 2004
6. Vernon AH, Georgeson KE, Harmon CH: Pediatric
laparoscopic appendectomy for acute appendicitis. Surg
Endosc 18:75-79, 2004
80 Atlas of Pediatric Laparoscopy and Thoracoscopy
7. Phillips S, Walton JM, Chin I, et al: Ten-year experience
with pediatric laparoscopic appendectomy: Are we getting
better? J Pediatr Surg 40:842-845, 2005
8. Aziz O, Athanasiou T, Tekkis PP, et al: Laparoscopic versus
open appendectomy in children: A meta-analysis. Ann
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dectomies. J Pediatr Surg 41:1809-1813, 2006
10. Tsao KJ, St Peter SD, Valusek PA, et al: Adhesive small
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Comparison between the laparoscopic and open approach.
J Pediatr Surg 42:939-942, 2007