Acute appendicitis is one of the most common surgical emergencies worldwide. When the diagnosis is delayed, the appendix may perforate, leading to a ruptured appendix with contamination of the peritoneal cavity. This condition is associated with higher morbidity, increased risk of intra-abdominal abscesses, and longer hospital stays if not managed promptly. The evolution of minimally invasive surgery has made laparoscopic appendectomy the gold standard even in complicated cases like rupture, provided it is performed by experienced surgeons.

Understanding Ruptured Appendix

A ruptured appendix occurs when an inflamed appendix perforates, spilling pus and fecal material into the abdominal cavity. This leads to localized or generalized peritonitis.

Risk factors for rupture include:

Delayed presentation (>48 hours after symptom onset)

Atypical symptoms causing misdiagnosis

Very young or elderly patients

Immunocompromised individuals

Clinical features:

Severe abdominal pain, initially periumbilical, then localized to the right lower quadrant

High-grade fever and tachycardia

Guarding and rebound tenderness

Signs of generalized peritonitis in advanced cases

Elevated white blood cell count and raised inflammatory markers

Why Laparoscopic Surgery?

Traditionally, open surgery was preferred for perforated appendicitis due to concerns of contamination and abscess formation. However, laparoscopic surgery now offers clear advantages:

Enhanced Visualization – High-definition cameras allow detailed inspection of the abdominal cavity, ensuring all pus pockets are drained.

Thorough Irrigation – Easy and complete peritoneal lavage reduces postoperative infections.

Reduced Wound Complications – Smaller incisions lower the risk of wound infection and dehiscence.

Shorter Hospital Stay – Faster recovery compared to open surgery.

Better Cosmetic Outcome – Minimal scarring, particularly important for young patients.

Diagnostic Benefit – Allows evaluation of the entire abdomen to rule out other causes of peritonitis.

Surgical Technique
Patient Preparation

General anesthesia is administered.

Intravenous fluids and broad-spectrum antibiotics are started.

A urinary catheter may be inserted in complicated cases to monitor fluid balance.

Port Placement

A standard three-port technique is used: one umbilical port for the camera and two working ports in the left lower and suprapubic regions.

In difficult cases, a fourth port may be added for retraction.

Identification of the Appendix

The cecum is traced to locate the appendix.

In ruptured cases, the appendix may be surrounded by pus, adhesions, or abscesses.

Appendiceal Dissection

Careful adhesiolysis is performed using blunt dissection and energy devices.

The mesoappendix is divided with bipolar cautery or vessel-sealing devices.

Control of the Base

The appendiceal base is secured with endoloops or staplers.

The appendix is then removed in an endobag to prevent contamination.

Peritoneal Toilet

Thorough suction and irrigation are performed to remove pus and debris.

All quadrants of the abdomen are inspected, especially the pelvis and subhepatic region.

Drain Placement

In cases with significant contamination or abscess, a pelvic drain may be placed for 24–48 hours.

Postoperative Care

Antibiotics: Broad-spectrum intravenous antibiotics are continued until sepsis resolves, then shifted to oral therapy.

Pain Control: Managed with non-opioid analgesics, usually requiring minimal medication due to smaller incisions.

Mobilization: Patients are encouraged to ambulate early to reduce risks of thrombosis and ileus.

Diet: Oral intake is resumed once bowel function returns.

Hospital Stay: Typically 3–5 days, depending on infection control and patient recovery.

Outcomes of Laparoscopic Approach

Studies have consistently demonstrated that laparoscopic surgery for ruptured appendix offers:

Lower wound infection rates compared to open appendectomy

Reduced intra-abdominal abscesses when proper lavage is performed

Shorter recovery time and quicker return to normal activities

Comparable or better overall morbidity and mortality outcomes

However, in patients with severe peritonitis or unstable hemodynamic status, open surgery may still be considered.

Challenges and Considerations

Technical Difficulty: Dense adhesions and inflamed tissues increase the risk of bowel injury.

Longer Operative Time: Laparoscopic surgery may take longer in complicated cases.

Resource Intensive: Requires advanced equipment and trained laparoscopic surgeons.

Drain Dependency: Some cases still require drains, prolonging hospital stay.

Despite these, the long-term benefits outweigh the challenges, making laparoscopy the preferred method in most centers of excellence.

Conclusion

Laparoscopic surgery for ruptured appendix has revolutionized the management of complicated appendicitis. By providing superior visualization, effective peritoneal cleaning, and reduced wound complications, it ensures better outcomes compared to open surgery.

At advanced institutions like World Laparoscopy Hospital, under the leadership of Dr. R. K. Mishra, this procedure is performed with precision, safety, and global best practices. For patients, laparoscopic appendectomy not only treats a life-threatening condition but also ensures faster recovery, minimal scars, and a quicker return to normal life.