Appendectomy, whether performed through an open or laparoscopic approach, is one of the most common emergency surgeries worldwide. The removal of the inflamed appendix generally cures the disease, and recurrence is rarely expected. However, a condition known as stump appendicitis—inflammation of the residual appendiceal tissue left behind after appendectomy—can occur. Though rare, stump appendicitis is increasingly recognized due to better diagnostic imaging and heightened clinical awareness.

Laparoscopic management of stump appendicitis has emerged as the treatment of choice in most centers, offering minimally invasive advantages along with definitive cure.

Understanding Stump Appendicitis

Stump appendicitis is defined as acute inflammation of the appendiceal remnant left after an incomplete appendectomy. The incidence is low, reported at about 1 in 50,000 cases, but it is likely underdiagnosed.

Causes

Inadequate initial appendectomy: Leaving a long stump (>0.5 cm).

Difficult anatomy: Retrocecal or subserosal appendix may hinder complete removal.

Severe inflammation: Poor visualization during surgery leading to incomplete dissection.

Laparoscopic limitations: Early experiences with laparoscopy sometimes resulted in longer residual stumps.

Risk Factors

Patients of all ages can be affected, and the time interval between the original appendectomy and stump appendicitis can vary from weeks to decades.

Clinical Presentation

Patients with stump appendicitis present with symptoms similar to acute appendicitis:

Right lower quadrant abdominal pain.

Nausea, vomiting, and anorexia.

Fever and localized tenderness.

Rebound tenderness and guarding in advanced cases.

Because of a history of prior appendectomy, diagnosis is often delayed, leading to complications such as perforation, abscess formation, or peritonitis.

Diagnosis
Clinical Challenge

The prior history of appendectomy often misleads clinicians into ruling out appendicitis, resulting in misdiagnosis as gastroenteritis, urinary tract infection, or Crohn’s disease.

Imaging

Ultrasound: Can sometimes reveal an inflamed tubular structure in the cecal region.

CT Scan: Gold standard for diagnosis. CT typically shows a dilated, inflamed appendiceal stump with surrounding fat stranding and fluid.

Laboratory Tests: Leukocytosis and raised inflammatory markers support the diagnosis but are nonspecific.

Early diagnosis through imaging prevents morbidity by facilitating timely surgical intervention.

Laparoscopic Management

Laparoscopy has become the preferred method for both diagnosis and treatment of stump appendicitis.

Advantages of Laparoscopy

Diagnostic clarity: Provides direct visualization of the inflamed stump and surrounding structures.

Therapeutic efficacy: Allows definitive completion appendectomy.

Minimally invasive: Less postoperative pain, shorter hospital stay, and faster recovery.

Reduced morbidity: Lower wound infection rates compared to open surgery.

Surgical Technique

Port Placement: Standard three-port laparoscopic setup is used.

Umbilical port for camera.

Suprapubic and left lower quadrant working ports.

Exploration: The cecum and ileocecal junction are identified. Adhesions from the previous surgery are carefully released.

Identification of the Stump:

The appendiceal stump is visualized at the base of the cecum.

Care is taken to differentiate it from the terminal ileum and mesenteric fat.

Dissection:

The mesoappendix remnant is dissected and vascular pedicles are secured with clips, bipolar cautery, or vessel-sealing devices.

Completion Appendectomy:

The appendiceal stump is divided flush with the cecum using endoloops, staplers, or intracorporeal sutures.

Ensuring no residual appendiceal tissue remains is critical.

Specimen Retrieval: The excised stump is removed in a retrieval bag to prevent contamination.

Irrigation: If perforation or abscess is present, peritoneal lavage and drainage may be performed.

Postoperative Care

Early ambulation and resumption of oral intake are encouraged.

Intravenous antibiotics may be required in complicated cases.

Patients usually recover quickly, with discharge possible within 24–48 hours for uncomplicated cases.

Outcomes

Laparoscopic completion appendectomy for stump appendicitis has excellent outcomes when performed promptly. Reported recurrence after definitive surgery is extremely rare. Patients enjoy the benefits of minimally invasive surgery, with low rates of postoperative complications and high satisfaction.

Challenges and Considerations

Dense adhesions: Previous surgery can make dissection challenging. Experienced laparoscopic surgeons are best suited for complex cases.

Delayed diagnosis: Leads to advanced disease, abscess formation, and increased operative difficulty.

Resource limitations: In centers without laparoscopic expertise, open completion appendectomy remains a viable option.

Conclusion

Stump appendicitis, though rare, is a clinically significant entity that should be considered in patients presenting with right lower quadrant pain even after appendectomy. Delayed recognition can increase morbidity due to perforation and abscess formation.

Laparoscopic management has proven to be the gold standard for stump appendicitis, offering both diagnostic accuracy and definitive treatment with the advantages of minimal invasiveness. By ensuring complete removal of the appendiceal stump and minimizing surgical trauma, laparoscopy provides patients with quicker recovery and excellent long-term outcomes.

Raising awareness among clinicians about this rare condition, combined with the widespread adoption of laparoscopic techniques, will continue to improve patient care in cases of stump appendicitis worldwide.