Operative Guide

Laparoscopic Appendicectomy

General Surgery · MRCS Part B · Core Trainee

⏱ 30–60 min operative time◎ 3 ports▤ 15 steps

5–10%

Conversion to open

~5%

Wound infection

0.3%

Incidental carcinoid

Indications

Acute appendicitisPerforated appendicitisInterval appendicectomyChronic appendicitis

Contraindications / caution

Dense adhesionsCoagulopathySevere cardiorespiratory diseaseHaemodynamic instability

Interactive

Operative Simulator

Work through the procedure step by step. Tick every item on each checklist to unlock the next step.

Pre-inductionStep 1 / 15

Illustration

WHO Sign In

Before induction, confirm identity, site marking, consent, allergies, airway and aspiration risk with anaesthetist.

Tick to proceed

Reference

Operative Guide

Bloods: FBC, U&E, CRP, G&S (and clotting if relevant).
Urine dip to help exclude UTI / renal colic as a mimic.
Pregnancy test is mandatory in all women of childbearing age.
Imaging where diagnosis uncertain: USS first line in women / children, CT in older or atypical patients.
Alvarado score supports clinical risk stratification for appendicitis.
IV antibiotics given at induction as prophylaxis.

Equipment

Instruments

Laparoscopic appendicectomy instrument tray

Veress needle	Pneumoperitoneum access
10–12mm trocar	Umbilical camera port
5mm trocars ×2	Working ports
30° laparoscope	Better view than 0° around the caecum
Atraumatic grasper	Handle the appendix without serosal tears
Maryland dissector	Dissecting the mesoappendix
LigaSure / Harmonic	Dividing mesoappendix with haemostasis
Endoloops ×2–3	Securing the appendix base
Retrieval bag	No port-site contamination
Suction / irrigation	Washout in perforated cases
J-needle / port closure	Closing the 10mm fascial defect

Caution

Anatomy Danger Zones

Appendicular artery

A branch of the ileocolic artery. If not secured before division it retracts into the mesoappendix and causes significant bleeding.

Inferior epigastric vessels

Run in the anterior abdominal wall. Insert working ports lateral to these vessels, transilluminating where possible.

Right ureter

Crosses over the pelvic brim. At risk during deep or retrocaecal dissection, identify and protect it.

Iliac vessels

Lie deep to the operative field. At risk with Veress entry and with deep dissection in the pelvis.

Outcomes

Complications

Early

•Wound / port-site infection (~5%)
•Intra-abdominal collection (3–5%)
•Ileus, common, usually self-limiting
•Bleeding, rare
•Bowel injury, rare
•Stump leak, rare

Late

•Port-site hernia (if fascia not closed)
•Adhesional bowel obstruction
•Chronic right iliac fossa pain
•Stump appendicitis
•Carcinoid (0.3%), if >2cm refer to colorectal MDT for right hemicolectomy

Test yourself

MCQ Quiz

Question 1

Where must the endoloops be placed when securing the appendix base?

Question 2

You find a macroscopically normal appendix in a woman undergoing laparoscopy for suspected appendicitis. What do you do?

Question 3

The appendicular artery is divided before haemostasis is achieved and it retracts. What is the main risk?

Question 4

Histology reports a 2.4 cm carcinoid (neuroendocrine tumour) of the appendix. What is the next step?

Question 5

The appendix base is necrotic and friable. What is the best method of control?

Aftercare

Post-op Care

Immediate

›Paracetamol + ibuprofen for analgesia
›Early mobilisation
›IV antibiotics 24h if perforated, then switch to oral
›Monitor for pyrexia after day 3 (suggests collection)

Discharge

›Uncomplicated: same day or next day
›Perforated: 2–4 days
›Oral co-amoxiclav 5 days if perforated
›Safety-net advice on collection / wound infection

Follow-up

›Histology review for all specimens
›Carcinoid / neoplasm referral if indicated
›GP wound check

Sick note

›Office work: 1–2 weeks
›Manual work: 4–6 weeks
›No heavy lifting for 4–6 weeks