Appendicitis is among the most common surgical emergencies worldwide, and while most cases are managed before perforation, a significant proportion present late with a ruptured appendix. Rupture of the appendix leads to peritonitis, abscess formation, and systemic infection, making it a potentially life-threatening condition. Traditionally, open surgery was the standard of care for complicated appendicitis, but with advancements in minimally invasive surgery, laparoscopic management has become the gold standard, even in cases of rupture.

Pathophysiology of Ruptured Appendix

Acute appendicitis usually begins with luminal obstruction of the appendix due to fecoliths, lymphoid hyperplasia, or rarely tumors. Obstruction leads to bacterial overgrowth, increased intraluminal pressure, ischemia, and necrosis. If untreated, the appendix perforates, releasing pus and fecal material into the peritoneal cavity. This results in:

Localized peritonitis when the omentum walls off infection, leading to an appendicular abscess.

Generalized peritonitis when contamination spreads diffusely across the peritoneal cavity.

The systemic inflammatory response can progress to sepsis, underscoring the urgency of surgical management.

Clinical Presentation

Patients with ruptured appendix usually present with:

Severe, diffuse abdominal pain.

High-grade fever and chills.

Nausea, vomiting, and anorexia.

Signs of dehydration and sepsis.

Abdominal tenderness, guarding, and rigidity on examination.

In many cases, presentation is delayed because patients initially ignore mild appendicitis symptoms or access to medical care is limited.

Diagnosis

Diagnosis is based on a combination of clinical evaluation and imaging.

Laboratory tests: Leukocytosis with neutrophilia, elevated CRP, and sometimes deranged electrolytes due to dehydration.

Ultrasound: Useful in detecting abscesses or peri-appendiceal fluid collections.

CT Scan: Gold standard for confirming perforated appendicitis, showing peri-appendiceal fat stranding, abscess, or free fluid.

Once confirmed, urgent surgical intervention is mandatory.

Role of Laparoscopy in Ruptured Appendix

Laparoscopy has revolutionized the management of ruptured appendix by offering precise visualization, complete peritoneal toilet, and reduced morbidity compared to open surgery. It is especially advantageous in obese patients, young women, and those with uncertain diagnosis.

Laparoscopic Surgical Technique

1. Patient Preparation and Anesthesia

The patient is resuscitated with IV fluids, antibiotics, and analgesics.

Nasogastric tube insertion and urinary catheterization may be required for decompression.

General anesthesia with endotracheal intubation is used.

Port Placement

Typically, a three-port technique is used:

Umbilical port for the camera.

Two working ports in the suprapubic and left iliac fossa regions.

Additional ports may be added in cases of dense adhesions or abscesses.

Exploration
The peritoneal cavity is inspected. In ruptured appendix, findings include purulent fluid, fibrin deposits, and inflammatory adhesions involving the cecum, omentum, and small bowel loops.

Appendectomy

Adhesions are carefully lysed to identify the ruptured appendix.

The base of the appendix is secured using endoloops, staplers, or clips, depending on surgeon preference.

The specimen is placed in an endoscopic retrieval bag to prevent spillage during extraction.

Peritoneal Toilet

One of the most critical steps in managing rupture is thorough irrigation of the peritoneal cavity.

Copious lavage with warm saline is performed until aspirated fluid is clear.

All pus pockets and debris are meticulously cleared.

Drain Placement

Depending on the degree of contamination and presence of abscesses, one or more drains may be placed in the pelvis or paracolic gutter.

Closure
Ports are closed in layers after ensuring hemostasis.

Postoperative Care

Antibiotics: Broad-spectrum antibiotics covering Gram-negative and anaerobic organisms are continued for 5–7 days, or longer if systemic sepsis persists.

Drain management: Drains are monitored and removed once output decreases and becomes serous.

Nutrition: Oral intake is resumed gradually as bowel function returns.

Pain control: Laparoscopy significantly reduces postoperative pain compared to laparotomy.

Mobilization: Early mobilization is encouraged to prevent complications like ileus or deep vein thrombosis.

Advantages of Laparoscopic Approach

Better visualization: Entire peritoneal cavity can be explored, identifying other pathologies or abscesses.

Complete peritoneal lavage: More effective clearance of pus and debris.

Less pain and faster recovery: Patients ambulate earlier and resume oral intake sooner.

Shorter hospital stay: Most patients can be discharged earlier than those undergoing open surgery.

Cosmetic benefit: Minimal scarring compared to laparotomy.

Reduced wound infection rates: Laparoscopy decreases the incidence of wound-related complications, which are common after open appendectomy for ruptured appendix.

Challenges and Considerations

Severe sepsis: Patients with hemodynamic instability may not tolerate pneumoperitoneum and may require initial stabilization.

Dense adhesions: Extensive inflammation can make dissection challenging. Conversion to open surgery is sometimes required.

Recurrence of abscesses: Despite lavage, postoperative intra-abdominal abscesses may occur in some patients. Careful follow-up is essential.

Conclusion

The management of ruptured appendix has evolved significantly with the advent of laparoscopy. Once considered a contraindication, ruptured appendicitis is now best managed laparoscopically in the majority of patients. The technique provides superior diagnostic accuracy, thorough peritoneal toilet, faster recovery, and lower postoperative complications. With proper surgical expertise and perioperative care, laparoscopic management of ruptured appendix has become the gold standard, offering patients the benefits of minimally invasive surgery even in complex surgical emergencies.