Laparoscopic submucosal appendectomy for difficult and adherent cases: a novel technique to minimize complications

Recurrent appendicitis with the appendix tip in the subhepatic area and late presentations of perforated appendicitis sometimes test the skills of the surgeon. Because of dense adhesions and distorted anatomy, trying to do retrograde appendectomy or looking for the appendicular artery may lead to troublesome bleeding and injure the adjacent intestine. Submucosal appendectomy could be an answer in these situations.

From October 7, 2005 to July 31, 2011, 1589 laparoscopic appendectomies were performed, of which 239 were recurrent or perforated or formed a mass. In 19 of these cases no plane could be established between the appendix and adjacent structures. So an incision was made on the anti-mesenteric wall of the appendix, and the mucosal sleeve was pulled out, leaving the muscular wall. The base was then ligated flush with the cecum and divided distally, leaving the muscular tube. Postoperative management was similar to usual appendectomies.

Out of 19 cases 13 were male. Ages ranged from 3 to 14 years. Seven cases were perforated, and 12 were recurrent. Submucosal appendectomy was done in all these 19 cases. There was no intraoperative complication. Average operating time was 51 minutes. In 16 cases feeding was tolerated early, and 3 cases suffered from prolonged ileus. Average postoperative hospital stay was 3.47 ± 2.34 days. Follow-up ranged from 3 months to 5 years. Two cases reported occasional abdominal pain, which required re-admission.

Submucosal appendectomy minimizes complications, obviates the need for conversion, and is a safe option for difficult cases during laparoscopy.