A 17-year-old young lady complained of worsening abdominal pain of several days’ duration. Her pain was initially peri-umbilical but gradually migrated to the right lower quadrant. It was exacerbated by movements, especially extension of her right hip; and it was associated with anorexia but no nausea or vomiting. She was otherwise healthy. Her menses were regular, and she was mid-cycle.
Appendicitis Scoring (A score of 4 or more is significant.)
| Clinical Variable | Response | Value |
| Anorexia | Yes | 1 |
| Nausea or Vomiting | No | 0 |
| Migration of Pain | Yes | 1 |
| Fever > 100.4F/38C | No | 0 |
| Pain with Cough/Percussion | Yes | 1 |
| RLQ Tenderness | Yes | 1 |
| Leukocytosis | Yes | 1 |
Her vital signs were normal. Blood work included a basic metabolic panel and a complete blood count. Abnormal values were a leukocytosis of 13,300/cm and an elevation of C-reactive protein 1.6 (normal < 1). Physical examination was unremarkable, except that her abdomen was mildly distended and tympanitic. Bowel sounds were diminished, and she was tender in the right lower quadrant with guarding. Psoas sign was positive on the right side. No hernia or organomegaly was appreciated.
The appendix was not visualized by Ultrasound. A CT scan demonstrated an acutely inflamed, retrocecal appendix with fat stranding but no abscess (Figs. 1, 2).
It is noteworthy that appendicitis with phlegmon is sometimes, but not always, apparent on CT scan [7].
Parenteral fluids and antibiotics, as well as an analgesic and antiemetic were given.
Consent for laparoscopic appendectomy was obtained. A retrocecal appendicitis with phlegmon was identified and excised, as described below. The young lady’s recovery was prompt; and she was discharged the next day. Analgesics, but no antibiotics, were prescribed.
The pathology report describes acute and chronic inflammation with peri-appendicitis, which accords with our clinical supposition that an extended period of time is required to create fibrous encasement of the appendix.
Operative Procedure
The usual arrangement of the ports for laparoscopic appendectomy places the camera in the left lower quadrant, and the two working ports in the midline: one supra-pubic and the other at the umbilicus.
Because a child’s abdomen is smaller than an adult’s, the ports are arranged differently: the camera is placed at the umbilicus, and the working ports are situated in the left lower and right upper quadrants respectively. This creates an equilateral triangle, which facilitates dissection and tying intracorporeal knots.
If the appendix is retrocecal, the inferior and lateral peritoneal attachments of the cecum are divided to facilitate its medial rotation. In this case, the appendix was adherent to the posterolateral aspect of the cecum, buried in a trough and covered by a thick veil of fibrovascular tissue (Fig. 3).
In simple appendicitis, the appendix derives its blood supply from a well-defined vascular pedicle that can be divided en mass with a stapler or stepwise with cautery (Fig. 4). An appendix that is adherent to the cecum shares its blood supply, which consists of multiple small vessels that must be individually coagulated and divided.
Excising the appendix, without injuring the cecum, is dauntingly hazardous. The appendix is least inflamed at its base, proximal to the fecalith. A space is created beneath the appendix by gentle dissection, dividing the small blood vessels as they penetrate the wall of the appendix (Fig. 4).
The appendix is doubly ligated and divided (Figs. 5, 6). If a surgeon prefers to divide the appendix with a stapler, the encircling ties will assist in creating an adequate space for the stapler and situating it correctly.
The ports’ equilateral arrangement facilitates intra-corporeal knot tying. By pulling the short end of a square knot up and the long end down, a sliding knot is created [10]. The distal end of the appendix is elevated away from the cecum, and nutrient blood vessels are cauterized and divided.
Dissection proceeds in an antegrade direction (towards the tip) along the appendiceal wall, dividing the overlying fibrovascular tissue and underlying blood vessels (Figs. 6–8).
Laparoscopy in Uncomplicated Appendicitis
“Follow the omentum!” An acutely inflamed appendix stands out like a sore thumb (Fig. 4). The vascular pedicle is a distinct structure that is readily coagulated and divided. Retrograde dissection proceeds towards the cecum; the appendiceal base is secured by stapler or Endo-Loops and transected (Fig. 9, 10)