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Acute appendicitis is a medical condition where the appendix becomes inflamed and causes pain in the lower right quadrant of the abdomen. In addition to pain, appendicitis can cause peritonitis, perforations, and can lead to death if left untreated. Laparoscopic appendectomy is the standard surgical procedure to treat the symptoms of appendicitis as well as prevent further spread of infection. While appendicitis typically advances in an irreversible fashion necessitating surgery, conservative management with antibiotic therapy can sometimes resolve symptoms. In this case, a 24-year-old patient had a delayed presentation with acute perforated appendicitis. Following successful non-operative treatment with antibiotics, she presented for a laparoscopic interval appendectomy. She also had a non-symptomatic umbilical hernia, which was repaired following removal of the laparoscopic ports for the appendectomy.
Laparoscopic appendectomy, hernia, acute appendicitis, surgery.
A laparoscopic appendectomy is the standard surgical approach performed on patients suffering from acute appendicitis. The incidence of appendicitis is 8.6% in men and 6.7% in women resulting in close to 300,000 hospital visits per year.1 Appendicitis often develops as the result of an obstruction of the appendiceal orifice that leads to inflammation, ischemia, and/or abscesses, which can present clinically as severe right lower quadrant pain.1 After the initial obstruction, mucus builds up and the lack of blood flow permits an environment where bacteria such as Escherichia coli, Bacteroides fragilis, and Pseudomonas aeruginosa can grow.1 If left untreated, peritonitis can arise from the localized infection.
Umbilical hernias are characterized as a ventral bulging or protrusion seen above or in the umbilical region of the abdomen. Umbilical hernias occur in roughly 2% of the adult population.2 Major risk factors for umbilical hernias include obesity, ascites, and increased abdominal pressure during pregnancy.2 Treatment of umbilical hernias is essential in preventing further complications and is required in symptomatic patients. Umbilical hernias can be treated surgically via use of laparoscopic repair methods or open umbilical hernia repair; however, laparoscopic repair is considered the gold standard approach due to its statistically proven capability to shorten procedure time and reduce recurrence rates.2,3
The patient in this case is a 24-year-old female who presented with a history of perforated appendix that occurred 6–8 weeks ago. She was on antibiotic therapy to manage the inflammation while she awaited an interval laparoscopic appendectomy. In addition to the appendicitis, the patient also had an umbilical hernia. Her appendicitis and umbilical hernia were both treated in the same operation, which allowed her to avoid an extra umbilical incision and additional round of anesthesia.
Physical examination revealed an adult female who had seemingly recovered from acute appendicitis with no abdominal tenderness. An umbilical hernia was again noted with no signs of acute incarceration or strangulation, pain on palpation, or skin changes over the hernia. She was otherwise in good health.
A diagnosis can be made with positive clinical symptoms in addition to an elevated white blood cell count and a positive computed tomography (CT) for appendicitis.4
If a patient presents with signs and symptoms of acute appendicitis, CT imaging should be done.5 When a CT is positive for appendicitis, the clinician should decide whether or not the patient requires surgery based on clinical signs such as periumbilical colicky pain that patients often describe as sharp and localized to the right iliac fossa.6
Ultrasound (US) and MRI may also be used, and are especially useful in evaluating children and pregnant patients seeking to avoid CT.6
In patients with an umbilical hernia, either CT or abdominal ultrasound can be utilized to support the diagnosis and provide additional details of the hernia.2 This can be especially effective in determining the size of the hernia in obese patients as advanced imaging offer more insight as to what/ if any structures the hernia may be impinging upon. In addition, imaging studies can assess for strangulation of the hernia, a frequent complication that warrants surgery.2
Acute appendicitis typically presents with severe pain in the right lower quadrant of the abdomen. In addition to abdominal pain, patients with acute appendicitis can have nausea, vomiting, tachycardia, pyrexia, or a dry tongue.7
Patients with appendicitis are typically classified as uncomplicated or complicated based upon preoperative, intraoperative, and/or histopathological findings.6
- Uncomplicated appendicitis - an inflamed appendix without signs of gangrene, perforation, intra-peritoneal purulent fluid, contained phlegmon, or intra-abdominal abscess (IAA).6
- Complicated appendicitis - all patients with either a gangrenous, inflamed appendix with or without perforation, intra-abdominal abscess, peri-appendicular contained phlegmon, or purulent free fluid.6
The average rate of perforation for appendicitis after the first 36 hours from the onset of symptoms is between 16–36%, and for every subsequent 12 hour period, the risk of perforation increases by 5%.7
Untreated appendicitis may progress to sepsis, which can be fatal.7
Patients with an umbilical hernia often present with abdominal tenderness and incarceration, and may also experience pain or GI discomfort.2 A diagnosis is often made by a clinician upon physical exam and can be supported by CT or ultrasound imaging. A positive diagnosis of an umbilical hernia can be made after identifying ventral protrusion or bulging at or above the umbilical region.2
A laparoscopic appendectomy is the standard surgical procedure in treating acute appendicitis.8 Antibiotic therapy has been shown to be sufficient in treating uncomplicated cases of acute appendicitis;8 however, in the majority of cases, laparoscopic appendectomy is required to achieve cessation of symptoms.
Surgery is often required to repair an umbilical hernia to prevent a multitude of health complications. One notable contraindication to surgery to repair an umbilical hernia is when the patient has uncontrolled ascites.2
While this patient recovered from her acute appendicitis, she returned to the clinic feeling very strongly about getting her appendix removed. She decided on an interval appendectomy, which typically takes place 6–12 weeks following recovery.
Primary reasons for an interval appendectomy are concerns for recurrent appendicitis or the presence of malignancy.4 Particularly in cases involving a phlegmon or mass in the appendix, interval appendectomy can be beneficial by providing a definitive diagnosis.4 The value of interval appendectomy after non-operative management of an appendicular mass is still controversial. Patients and surgeons may decide on an interval appendectomy to avoid missing possibly malignancy (incidence 6%) or developing recurrent appendicitis (incidence 5-44%).6
Since the patient was already undergoing surgery, everyone agreed it made sense to repair the asymptomatic umbilical hernia at the same time.
No special considerations for this patient.
The surgical procedure started by draping the patient in accordance with standard surgical protocol. Once the patient was prepped in a sterile environment, an infraumbilical incision was made to access the abdomen. A camera port was inserted through the incision, and a pressure of 15 mmHg was set. This level of inflation allows for better visualization of the abdomen without compromising perfusion and minimizes CO2 absorption throughout the surgery. Two additional ports were placed: one in the left lower abdominal quadrant and one above the pubic symphysis. A small hole was cut through the mesentery, creating a window to allow access to the blood supply of the appendix. The junction of the cecum and appendix was identified. A window was created between the base of the appendix and the mesoappendix with division of both with staplers. The appendix was then placed into a bag and removed through the umbilical incision.
The umbilical hernia was repaired after the laparoscopic appendectomy was completed. Dissection was performed around the stalk of the umbilical hernia, and the hernia was lifted superiorly once it was isolated. The incarcerated fat was separated from the stalk, and the hernia sac was removed. The incision was then closed using figure-of-eight sutures.
Possible abdominal postoperative complications include, but are not limited to: hematomas, seromas, pain, and infection.3 When compared to open repair surgery, laparoscopic groups have had a statistically significant reductions in postoperative pain, length of stay, morbidity, and rates of discharge in the hospital after surgery.3 There is, however, evidence that suggest that laparoscopic appendectomy has a higher rate of infection when compared with open surgery.9 One theory is that a lack of standardization among laparoscopic techniques is the cause of the infectivity rates, another theory is that increased use of irrigation fluid increases the susceptibility to infection.9 Laparoscopic surgery still is considered the gold standard approach to appendectomies.
In this surgical case, two procedures were able to be performed in the same operation. This is beneficial to patients as they undergo fewer rounds of induction anesthesia and spend less time in postoperative recovery. When patients have multiple conditions that can be surgically treated, it is important to consider a treatment plan that would address all problems at once. In this case, the umbilical hernia was repaired directly following the appendectomy, using the same umbilical incision.
No specialized equipment was used in this case.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Jones MW, Lopez RA, Deppen JG. Appendicitis. [Updated 2020 Apr 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493193/.
- Coste AH, Jaafar S, Parmely JD. Umbilical Hernia. [Updated 2020 Jun 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459312/.
- Korukonda S, Amaranathan A, Ramakrishnaiah VPN. Laparoscopic versus open repair of para-umbilical hernia- a prospective comparative study of short term outcomes. J Clin Diagn Res. 2017;11(8):PC22-PC24. doi:10.7860/JCDR/2017/28905.10512.
- Hori T, Machimoto T, Kadokawa Y, et al. Laparoscopic appendectomy for acute appendicitis: how to discourage surgeons using inadequate therapy. World J Gastroenterol. 2017;23(32):5849-5859. doi:10.3748/wjg.v23.i32.5849.
- Kirshenbaum M, Mishra V, Kuo D, Kaplan G. Resolving appendicitis: role of CT. Abdom Imaging. 2003;28(2):276-279. doi:10.1007/s00261-002-0025-3.
- Gorter, Ramon R, et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surgical endoscopy. 2016;30(11):4668-4690. doi:10.1007/s00464-016-5245-7.
- Humes DJ, Simpson J. Acute appendicitis. BMJ. 2006;333(7567):530-534. doi:10.1136/bmj.38940.664363.AE.
- Becker P, Fichtner-Feigl S, Schilling D. Clinical management of appendicitis. Visc Med. 2018;34(6):453-458. doi:10.1159/000494883.
- Kotaluoto S, Pauniaho SL, Helminen MT, Sand JA, Rantanen TK. Severe complications of laparoscopic and conventional appendectomy reported to the Finnish Patient Insurance Centre. World J Surg. 2016 Feb;40(2):277-83. doi:10.1007/s00268-015-3282-3.
Cite this article
Grove J, Sell N, O'Donnell T, Saillant NN. Laparoscopic interval appendectomy and open umbilical hernia repair. J Med Insight. 2023;2023(270). doi:10.24296/jomi/270.
Table of Contents
- Identify Cecum and Appendix
- Make Window into Mesentery at Junction with Cecum
- Mobilize Appendix
- Divide Mesentery and Blood Supply with Vascular Load Stapler
- Inspect for Hemostasis Along Staple Lines
- Place in Specimen Bag and Remove from Abdomen
- Remove Ports and Desufflate Abdomen
- Identify Hernia Defect
- Amputate Stalk Completely
- Remove Hernia Sac
- Repair Opening in Fascia
- Reattach Umbilical Stalk to Fascia
So this is a healthy 24-year-old female who initially presented with perforated appendicitis. Since it was somewhat delayed when she presented, she was managed conservatively with antibiotics and then subsequently came back to clinic and felt very strongly about getting her appendix out. She was therefore booked for what we call an interval appendectomy - we usually like to wait about 6-8 weeks for the inflammation to settle down from the perforation, and then we go in and actually remove the appendix. The key steps for any appendectomy are number 1, prepping the abdomen and draping in accordance with the usual surgical standard. We then turn our attention to gaining access to the abdomen. So we usually make an infraumbilical incision. This is to permit the camera port. This is then dissected down to level of the fascia. We then place our camera port in and insufflate to about 15 mmHg. We like that insufflation level just because it still allows good perfusion to the abdomen and minimizes any risk of CO2 absorption by the patient. And then, under direct visualization, we then place 2 additional ports that are 5 mm. One is actually on the opposite side of the appendix, on the left side in the left lower quadrant, and then an additional one above the pubic symphysis with care not to injure the bladder. Find the cecum and where it joins with the appendix. Lift and elevate that. We then make a small hole into the mesentery, which is the blood supply of the appendix, and then that allows us to place a special surgical instrument that is a stapler with appropriately-sized staples for the the intestinal width. After that's done, we then use a vascular load stapler that's actually a little bit smaller in terms of the staple. The appendix is then delivered into a bag and removed from the umbilicus. She had an umbilical hernia, so we will be doing a couple additional steps. Number 1, we're going to be dissecting around the stalk of the umbilical hernia, then isolating that off of the fascia, and just kind of lifting it right up. We'll reduce the contents, and then after that we will then repair the area where there's an opening in the fascia in a primary fashion. Anything under 2 cm usually can be done primarily with just some sutures. After that we basically will tack down the stalk and then we will close the skin of the 5-mm ports and the umbilical port, and just place - I like to use skin glue because I think this makes patients realize their incisions are quite small.
So to begin our procedure, we're going to have a little local. We're going to gain access to the abdomen at the umbilicus - you can see the patient has a small umbilical hernia that we'll eventually incorporate into the repair at our umbilical access site. Yep. Perfect. And you can make it semi-large because we're going to have to deal with that umbilical hernia at the end. Yeah, good. The bovie is used to separate the soft tissues down to the level of the fascia. And then using blunt separation, we expose the fascia. Snap and cut, please. I'll take another snap and another cut. Needle back. I'll take the gas on please. Okay. The camera port is inserted in the umbilicus, and the abdomen is insufflated to 15 mmHg. Opening pressure is 5. Good, pull that back just a little bit, perfect. Okay.
The cecum is identified in the right lower quadrant. The omentum is retracted away from the cecum. The terminal ileum is seen coming in to the cecum. The appendix is identified.
And some adhesions are gently dissected. This patient had perforated appendicitis 6 weeks ago, was treated with antibiotics, and is here for interval appendectomy.
Probably make your window. Yeah. Can I get the Maryland? The junction of the appendix and the cecum is identified. And a window is made into the mesentery. Beautiful. Yep. We're going to need a - the purple and the tan load. Good. Now, back out. Yep.
I need a little more. Yep, you do. Good. Okay. You can take that.
The adhesive bands are sharply divided. Just foreshorten the mesentery a little bit, which is... Yep. Yep. That stuff right there.
Yep. Good, now lift off the RP. Good. Okay. Yep, okay, I'm okay with that. So like right there? And just lift a little bit away. Okay. Great.
We inspect for hemostasis along the staple lines.
Can we level her out, please? And removed. Good.
Okay, we can take that out.
So, right there. Yep. Good.
That's fine. Good. A little fat. Incarcerated umbilical fat is separated from the stalk. And the hernia sac removed.
Okay. Figure-of-eights are utilized. Okay, snap and a cut. Snap and a cut, thanks. I think it's back further, yeah. Like this? Like that, yep. And can I get the skin glue for closing? Sure.
Okay, and - yep, suture scissors - and you guys can feel free to count. We're just going to need the Monocryl.
I think the case overall went well, as we mobilized, the appendix came down and made a hairpin turn, and when it does that, it actually kind of crinkles the mesentery for the stapler loads across it, so we have to spend some time taking down those adhesions to straighten it, so that we can come across the bottom and get the blood supply clearly without, you know, encroaching upon the retroperitoneum where important structures like the ureter are, and without coming across the appendix itself as well. Other than that, I think everything went pretty straightforwardly. I was very happy. Also, we did an additional umbilical hernia repair that went quite well, and we got good closure and no complications, and I think she'll do well and be able to be discharged from the postanesthesia care unit.