Acute appendicitis is a common surgical emergency, and one of its frequent underlying causes is the presence of a fecalith, a hardened piece of stool that obstructs the lumen of the appendix. Appendiceal fecaliths can lead to increased intraluminal pressure, bacterial overgrowth, inflammation, and ultimately perforation if untreated. Laparoscopic appendectomy has become the preferred surgical approach for appendicitis caused by fecalith due to its minimally invasive nature, faster recovery, reduced postoperative pain, and excellent cosmetic results.

Pathophysiology of Fecalith-Induced Appendicitis

Fecaliths, also known as appendicoliths, cause obstruction at the appendiceal lumen. This obstruction leads to:

Increased intraluminal pressure: Compression of blood vessels reduces perfusion to the appendiceal wall.

Bacterial proliferation: The stagnant environment allows bacteria to multiply, causing inflammation.

Gangrene and perforation: If left untreated, the appendix can become gangrenous or rupture, leading to peritonitis.

Early surgical intervention is crucial to prevent complications, and laparoscopic appendectomy offers a safe and effective solution.

Indications

Laparoscopic appendectomy is indicated in pediatric and adult patients with:

Acute appendicitis confirmed to be caused by fecalith

Complicated appendicitis with localized abscess

Incidental discovery of appendiceal fecalith during diagnostic laparoscopy

Recurrent right lower quadrant pain with radiologic evidence of fecalith obstruction

Contraindications include severe septicemia, extensive intra-abdominal adhesions, or conditions precluding general anesthesia.

Preoperative Evaluation

Thorough preoperative assessment ensures patient safety and optimal outcomes:

History and Physical Examination: Typical symptoms include right lower quadrant pain, nausea, vomiting, and fever.

Laboratory Investigations: Complete blood count, C-reactive protein, and electrolytes are assessed.

Imaging Studies:

Ultrasound: May show an enlarged, non-compressible appendix with echogenic fecalith.

CT Scan: Highly sensitive and specific for detecting appendiceal fecaliths and assessing complications such as perforation or abscess.

Anesthesia Assessment: Evaluation for general anesthesia safety.

Patients are counseled regarding the procedure, benefits, risks, and recovery expectations. Prophylactic antibiotics are administered to reduce postoperative infections.

Surgical Technique

Laparoscopic appendectomy for fecalith removal is performed under general anesthesia and involves several key steps:

Patient Positioning and Port Placement:
The patient is placed supine with a slight Trendelenburg tilt to move bowel loops away from the operative site. Standard port placement typically includes:

10 mm umbilical port for laparoscope

Two 5 mm working ports in the left lower quadrant and suprapubic region

Exploration and Appendix Identification:

After establishing pneumoperitoneum, the appendix is located, and any adhesions or inflammatory exudates are gently dissected. The presence of a fecalith is confirmed visually or by palpation with laparoscopic instruments.

Mesoappendix Division:

The mesoappendix, containing the appendicular artery, is coagulated and divided using bipolar cautery or ultrasonic devices, ensuring hemostasis.

Appendix Base Ligation:

The base of the appendix is securely ligated using absorbable sutures, endoloops, or techniques like Mishra’s Knot to prevent stump leakage.

Fecalith Removal:

The appendix, containing the fecalith, is carefully divided distal to the ligature. The specimen is placed in a retrieval bag to prevent spillage and contamination within the abdominal cavity.

Cavity Inspection and Irrigation:

The peritoneal cavity is inspected for any signs of contamination, perforation, or abscess. Irrigation with saline may be performed, particularly in cases with fecalith-related perforation.

Port Closure:

Ports are removed, and the fascial and skin layers are closed with absorbable sutures or subcuticular closure for optimal cosmetic results.

Postoperative Care

Postoperative management focuses on pain control, early mobilization, and prevention of complications:

Pain Management: Multimodal analgesics, including acetaminophen and NSAIDs.

Diet: Early oral intake is encouraged, beginning with liquids and advancing as tolerated.

Monitoring: Observation for bleeding, infection, and bowel function.

Discharge and Follow-Up: Most patients are discharged within 24–48 hours, with full recovery expected within 5–7 days.

Outcomes and Advantages

Laparoscopic appendectomy for fecalith offers multiple advantages:

Reduced Postoperative Pain: Smaller incisions result in less tissue trauma.

Faster Recovery: Children and adults resume normal activities sooner than after open surgery.

Low Complication Rates: Secure ligation and careful removal of the appendix minimize stump leakage and intra-abdominal infection.

Better Cosmetic Results: Minimal visible scarring enhances patient satisfaction.

Effective in Complicated Cases: Even perforated appendicitis or localized abscesses secondary to fecalith can be managed laparoscopically.

Conclusion

Laparoscopic appendectomy is the gold standard for managing appendicitis caused by fecaliths. By combining minimally invasive techniques with precise surgical execution, this approach ensures safe removal of the appendix, reduces postoperative pain, accelerates recovery, and provides excellent cosmetic results. Early intervention in fecalith-induced appendicitis prevents complications like perforation and abscess formation, making laparoscopic surgery a reliable and effective solution for both pediatric and adult patients.