Advances in minimally invasive surgery have transformed the management of multiple abdominal and pelvic conditions in a single operative session. Combining procedures like laparoscopic appendicectomy and total laparoscopic hysterectomy (TLH) allows surgeons to address concurrent pathologies efficiently, reducing anesthesia exposure, hospital stay, and overall recovery time. This approach is particularly beneficial in patients with coexisting gynecological and gastrointestinal conditions, enabling a safe, effective, and patient-friendly solution.

Indications

Performing laparoscopic appendicectomy and TLH in the same patient is indicated when:

Concurrent Pathologies: A patient presents with symptomatic appendicitis or an inflamed appendix along with uterine pathology requiring hysterectomy, such as fibroids, adenomyosis, or abnormal uterine bleeding.

Prophylactic Considerations: During TLH for benign disease, an incidental appendectomy may be considered to prevent future appendicitis.

Diagnostic Uncertainty: When preoperative evaluation is inconclusive, combining procedures allows both diagnosis and definitive management.

Preoperative evaluation is critical to ensure patient safety and includes thorough history, physical examination, laboratory testing, imaging studies (ultrasound, CT, or MRI), and anesthesia assessment.

Preoperative Preparation

Key preoperative steps include:

Patient Counseling: Discussing risks, benefits, and the possibility of combined procedures.

Bowel Preparation: May be advised to reduce intraoperative contamination risk.

Fasting and Anesthesia Planning: Standard fasting protocols and preparation for general anesthesia are followed.

Prophylactic Antibiotics: Administered to reduce postoperative infection risk, particularly when appendectomy is performed.

Surgical Technique

Performing both procedures laparoscopically in a single session requires careful planning and skilled surgical coordination.

Patient Positioning and Port Placement:
The patient is placed in a dorsal lithotomy or supine position with a slight Trendelenburg tilt. Typically, four to five laparoscopic ports are used, including a 10 mm umbilical port for the laparoscope and additional 5 mm ports for instruments. Port placement is optimized to allow access to both the pelvis and right lower quadrant for appendectomy.

Laparoscopic Appendicectomy:

The appendix is identified, and any adhesions are released.

The mesoappendix is divided using bipolar cautery or ultrasonic energy, ensuring hemostasis.

The base of the appendix is ligated securely using intracorporeal or extracorporeal sutures, or techniques like Mishra’s Knot.

The appendix is removed in a retrieval bag to prevent contamination.

Total Laparoscopic Hysterectomy:

The uterus is mobilized by dissecting the round ligaments, broad ligaments, and uterine vessels.

Careful identification of ureters and surrounding structures is essential to prevent injury.

The uterine vessels are coagulated and divided using bipolar energy or advanced sealing devices.

The uterus is detached from the vaginal cuff, and the specimen is retrieved through the vagina or morcellation if necessary.

The vaginal cuff is closed laparoscopically with sutures to ensure hemostasis and structural integrity.

Intraoperative Considerations:

Maintaining clear visualization and avoiding contamination from the appendectomy site is critical.

Continuous monitoring for bleeding or injury to surrounding structures, such as the bladder, ureters, bowel, and major vessels, is mandatory.

Instrument handling must be coordinated to perform two distinct procedures efficiently without prolonging operative time unnecessarily.

Postoperative Care

Postoperative care emphasizes early recovery and prevention of complications:

Pain Management: Multimodal analgesia is administered, typically allowing early ambulation.

Early Oral Intake: Resumption of liquids and soft diet is encouraged within hours of surgery.

Monitoring: Patients are observed for bleeding, infection, bowel function, and urinary output.

Discharge: Most patients can be discharged within 48–72 hours, with follow-up scheduled to assess wound healing, uterine cuff integrity, and recovery from appendectomy.

Outcomes and Advantages

Combined laparoscopic appendicectomy and TLH offer several advantages:

Reduced Hospital Stay: Performing two procedures in a single session avoids a second hospitalization.

Faster Recovery: Patients recover more quickly than if procedures were done separately.

Lower Overall Anesthesia Exposure: Reduces risks associated with multiple general anesthetics.

Minimally Invasive Benefits: Reduced postoperative pain, minimal scarring, and improved patient satisfaction.

Cost-Effectiveness: Combining procedures reduces total healthcare costs related to hospital stay, anesthesia, and recovery.

Potential complications, although uncommon, may include bleeding, infection, injury to adjacent organs, or postoperative adhesions. Careful surgical technique and patient selection minimize these risks.

Conclusion

Performing laparoscopic appendicectomy and total laparoscopic hysterectomy in the same patient is a safe, effective, and efficient strategy for managing coexisting gastrointestinal and gynecological conditions. By leveraging minimally invasive techniques, surgeons can achieve excellent outcomes with reduced pain, faster recovery, and improved patient satisfaction. With meticulous planning, skilled surgical execution, and attentive postoperative care, this combined approach exemplifies the evolving standards of modern laparoscopic surgery.