The appendix is a few centimeters long protrusion that hangs from the cecum of the large intestine. It is located in the lower right part of the abdomen and is usually located immediately under the abdominal walls, although it can also occur in other locations (behind the large intestine, to the side of the large intestine and towards the gallbladder, within the pelvis). Acute appendicitis is the inflammation of the appendix, the main cause of which is a coprolite that blocks the appendix orifice, traps the appendix secretions within its lumen, disrupts first its venous and then its arterial blood supply and leads to the swelling of the appendix, the production of pus and finally to the necrosis of the appendix wall, resulting in either generalized peritonitis or the encroachment of the inflammation in the right ventricle with the creation of an inflammatory mass with the help of neighboring organs (appendicular plastron). Fortunately, the majority of cases of appendicitis are diagnosed and treated in the early stages and the rates of peritonitis are low.
The clinical picture of acute appendicitis is characterized by periumbilical pain that gradually moves to the right lower abdomen, anorexia, low-grade fever (37.5 – 38 °C), nausea and vomiting. There are also cases where the above clinical picture changes and several of the above symptoms are absent.
Laboratory tests show an increase in white blood cells in the general blood and an increase in acute phase inflammatory markers (CRP, Erythrocyte Sedimentation Rate). Diagnosis is made with abdominal computed tomography, which has an excellent efficiency exceeding 95%. In cases where computed tomography is not available, ultrasound can provide useful information and in some cases make the diagnosis, but the sensitivity rates are much lower and in no case is it the examination of choice. Treatment can be conservative with cessation of feeding, intravenous hydration and antibiotics. However, acute appendicitis is still considered a surgical condition. Surgical removal of the appendix can be done either by open surgery or by laparoscopic access. Laparoscopic access is clearly advantageous, as it allows for a more general overview of the abdomen in case the appendix proves to be normal, while laparoscopic access entails less pain, easier mobilization, faster feeding and faster discharge of the patient from the hospital.
Laparoscopic access also has a place in complicated cases of appendicitis with difficult localization or with a necrotic wall, with equally good results.
In 15% of patients who undergo surgery for acute appendicitis, it is ultimately proven that the appendix was not the cause of the pain. In this case, laparoscopy is clearly superior, as it allows the abdomen to be viewed to find another pathological cause, which cannot be done with open surgery. In these cases, removal of the appendix is indicated in order to avoid future diagnostic dilemmas.
The postoperative course of patients is usually spectacular, with patients being able to be discharged even in less than 24 hours after surgery, as the rapid mobilization and feeding and the low need for painkillers allow this.
The complications of laparoscopic appendectomy are the following:
1. Paralytic ileus. It is very rare with laparoscopic access, is treated conservatively and usually resolves within a few hours or days.
2. Surgical wound infection. It does not occur often in laparoscopic access and is treated conservatively with drainage of the surgical wound and intravenous antibiotics.
3. Intra-abdominal abscesses. They are more common in laparoscopic approach compared to the open method. They are treated conservatively with percutaneous drainage and intravenous antibiotics.
4. Enterocutaneous fistula, i.e. communication of the intestine with the skin. Rare complication. Initially treated conservatively with antibiotics, nutritional support and complete clarification of the anatomy of the fistula. In case of failure of conservative treatment, surgical intervention is indicated to remove the fistula and restore normal anatomy.
