Laparoscopic Appendectomy

Medically reviewed by Dr Murlidhar Boob, MS, FAIS, DLS, FMAS - Laparoscopic Surgeon & Surgical Gastroenterologist

What it is

Laparoscopic appendectomy - keyhole appendix surgery - is the removal of an inflamed appendix through three small cuts instead of one long one. The appendix is a narrow, finger-shaped tube attached to the start of the large intestine, sitting low on the right side of the abdomen. When its opening blocks, bacteria multiply inside, the wall swells, and you get appendicitis.

During the operation a telescope carrying a camera is passed through a small cut at the navel, the abdomen is gently inflated with carbon dioxide gas to create working space, and two more small ports are placed low down. The surgeon finds the appendix, seals and divides its blood supply, closes off its base where it joins the bowel, and lifts it out through one of the ports.

The operation itself has not changed much in principle since the 1890s. What has changed is the size of the opening we do it through - and that difference is most of the reason people now go home the next morning rather than after a week.

Who needs it

• Acute appendicitis - the classic pattern is a vague ache around the navel that shifts over several hours to the lower right abdomen, with loss of appetite, nausea, a low fever and pain that worsens on coughing or walking.
• Appendicitis confirmed or strongly suspected on ultrasound or CT, backed by a raised white cell count.
• A perforated appendix or an abscess around it, where surgery is done either straight away or after the infection has been settled with antibiotics and drainage.
• An appendicular lump that has been managed conservatively - some of these patients are offered an interval appendectomy a few weeks later.
• Recurrent right lower abdominal pain traced to a chronically inflamed or obstructed appendix.
• During a diagnostic laparoscopy for unexplained lower abdominal pain, particularly in young women, where the appendix turns out to be the culprit or looks abnormal.

“Can I not just take antibiotics and avoid an operation altogether?” Sometimes, yes - and I will tell you when that is a fair option. Early appendicitis with no stone in the appendix and no perforation can settle on antibiotics. But a sizeable proportion of those patients are back within the year with the same pain, and the second attack is often the worse one. If there is a stone visible on the scan, if it has already perforated, or if you live far from a hospital and cannot come back quickly, taking it out now is the safer plan.

How it is done

Preparation. You are kept fasting, given intravenous fluids and a dose of antibiotics, and taken to theatre once the diagnosis is clear and you are stable.

Access. Under general anaesthesia, a small cut is made at or just below the navel and the abdomen is inflated with carbon dioxide. The camera goes in first, and the whole abdomen is inspected - this alone occasionally changes the diagnosis.

Working ports. Two further small ports, usually five millimetres each, are placed low on the abdomen so that the instruments can reach the right lower corner comfortably.

Freeing the appendix. Any adhesions or omentum stuck to the inflamed appendix are gently separated, and the appendix is lifted up so its base and blood vessels are clearly visible.

Dividing the blood supply. The small artery running to the appendix is sealed with clips or an energy device and divided.

Securing the base. The point where the appendix meets the large bowel is closed - most often with two secure loops of suture material, sometimes with a stapler if the base is thickened or inflamed - and the appendix is cut free above it.

Removal and washout. The specimen is brought out inside a retrieval bag so that infected tissue never touches the wound. If there was pus, the area is washed out and a drain may be left. The ports come out, the gas is released, and the small cuts are closed with absorbable stitches.

The appendix is sent for histopathology as a matter of routine. It is uncommon, but a small tumour is occasionally found in an appendix removed for what looked like ordinary appendicitis, and that report matters.

Anaesthesia, duration and hospital stay

The operation is done under general anaesthesia - you are fully asleep and feel nothing.

A straightforward appendix takes roughly thirty to forty-five minutes. A perforated one, or one buried in adhesions, can take an hour or more, and that extra time is spent cleaning the abdomen properly rather than rushing.

Most patients are admitted the same day the diagnosis is made, operated on within a few hours, and go home the next morning - occasionally the same evening for a very early appendicitis. If the appendix had burst or there was pus, expect three to five days in hospital on intravenous antibiotics.

You will be allowed sips of water a few hours after surgery and normal food by the next day, sometimes sooner.

Recovery

Day 1. You will be encouraged to sit up, then walk to the bathroom, within a few hours of waking. Expect soreness at the port sites and some shoulder-tip discomfort from the gas - odd, harmless, and gone in a day or two. Painkillers by mouth are usually enough.

The first week. The soreness fades noticeably every day. Shower normally after the dressings are removed as instructed. Eat what you normally eat; there is no special appendix diet. Most people with desk jobs are back at work by day five to seven. Constipation from the anaesthetic and painkillers is common - drink well and ask us for a mild laxative rather than straining.

Weeks 2 to 4. You will feel essentially normal, which is exactly when people overdo it. Walking, stairs, light housework and driving are all fine. Keep away from heavy lifting, the gym and contact sports until four weeks, so the small openings in the muscle heal without stretching.

By six weeks. Fully healed. No restrictions, no follow-up scans, no medicines. The histopathology report is reviewed at your follow-up visit and we discuss it with you even when it is entirely normal.

Come back to us sooner for fever, increasing rather than decreasing abdominal pain, redness or discharge from a wound, persistent vomiting, or if you have not passed wind or stool for more than two days.

Why keyhole rather than open surgery

The open operation still works, and in a few situations it is the right choice. But for most patients the keyhole approach gives a better week.

• Less pain, because the abdominal wall muscles are not cut across.
• Smaller scars - three tiny marks instead of one six to eight centimetre scar.
• Fewer wound infections, particularly when the appendix has already burst, since the specimen comes out in a bag rather than being dragged through the wound.
• A shorter stay and a faster return to work, typically by several days.
• A proper look at the whole abdomen. This matters more than people expect. In women especially, lower right abdominal pain can come from an ovarian cyst, a twisted ovary, endometriosis or pelvic infection, and the camera shows us the pelvis clearly through the same three cuts.

Open surgery is chosen when the abdomen is severely distended, when there is dense scarring from previous operations, when the patient is too unstable for the gas pressure, or occasionally when the anatomy is so distorted that continuing through the keyhole would be unsafe. Being converted from keyhole to open during surgery is not a failure or a complication - it is a judgement call made in your interest, and it happens in a small minority of cases.

Risks and complications

Appendicectomy is one of the safest abdominal operations performed anywhere, but no operation is risk-free and you deserve the honest list.

• Wound infection at a port site - the commonest problem, usually managed with dressings and antibiotics.
• Collection of pus inside the abdomen after a perforated appendix, sometimes needing drainage.
• Bleeding, uncommon and usually controlled during the operation itself.
• Leak from the appendix base, rare, but serious enough to need a further operation.
• Injury to nearby bowel, bladder or blood vessels - very uncommon in experienced hands.
• Prolonged bowel slowdown (ileus) with bloating and vomiting for a few days.
• Conversion to open surgery, as described above.
• Anaesthetic risks, higher in older patients and those with heart or lung disease.
• Port-site hernia, unusual, and more likely at the navel site.
• A normal appendix at operation. Even with scans, a small number of appendices removed for convincing appendicitis turn out to be normal. We accept that small margin because the alternative - waiting until we are certain - means more ruptured appendices.

Alternatives

Antibiotics alone. A reasonable option for early, uncomplicated appendicitis in selected patients, with the honest caveat that a good number will have another attack and need surgery later.

Drainage first, surgery later. When you arrive with an appendicular abscess or a lump that has been there for several days, operating immediately can be more dangerous than waiting. We settle the infection with antibiotics, drain the collection if needed, and take the appendix out several weeks later when the tissues are healthy.

Open appendectomy through a single cut in the right lower abdomen. Still a sound operation, and the right one in specific circumstances.

Watchful waiting with a different diagnosis in mind. Not all right-sided pain is appendicitis. Ureteric stones, ovarian cysts, ectopic pregnancy, pelvic infection, mesenteric lymphadenitis in children and Crohn’s disease can all imitate it, and treating the correct condition is a genuine alternative to an unnecessary operation. If your pain is recurrent rather than acute, we would rather investigate properly than operate hopefully. You can see all the procedures we perform or read more on our general surgery and gastroenterology page, and if your pain has been intermittent and related to fatty meals, gallbladder disease is worth ruling out too.

What it costs

Laparoscopic appendectomy: ₹40,000 - ₹66,000, all-inclusive.

Please note: The figures above are indicative estimates for a typical case. The final cost depends on your individual condition, the complexity of the surgery, the room category you choose, how long you stay, and any complications that arise. Deluxe and super-deluxe rooms are charged higher. Emergency admissions and night or holiday surgery attract additional charges. These charges are subject to change without prior intimation. Please call us on +91-8668954915 for a written estimate for your own case before you decide anything.

This range covers the surgeon, operation theatre, anaesthesia, room rent for a typical stay, medicines and investigations. A perforated appendix needing a longer stay and prolonged intravenous antibiotics will sit at the higher end or above it, and we will tell you as soon as we know.

Preparing for your surgery

Appendicitis is usually an emergency, so there is rarely time for elaborate preparation - but a few things help:

• Do not eat or drink once appendicitis is suspected. A full stomach delays anaesthesia.
• Avoid painkillers before you are examined. They mask the very signs we use to make the diagnosis.
• Bring your medicine list, especially blood thinners, diabetes medicines and inhalers, and tell us about any allergies.
• Mention previous abdominal surgery, which affects how we plan the ports.
• Tell us if there is any chance you are pregnant. This changes both the scan we order and the way we operate.
• Bring any earlier scans or reports relating to abdominal pain.
• Arrange for someone to stay with you for the first night at home and to drive you back.
• Plan a light week afterwards - nothing dramatic, just no heavy lifting and no gym.
• Ask us your questions before the operation, however small they seem. Nobody thinks of the good ones on the trolley.

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If you or someone at home has abdominal pain that has settled in the lower right side and is getting worse, please do not wait it out. The surgical team at Shubham Hi-Tech Hospital and Test Tube Baby Centre, Amravati, will examine you, arrange the tests that actually help, and tell you plainly whether you need an operation or not. Call +91-8668954915 or get in touch here.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.