Acute Appendicitis
The appendix is a small tubular structure attached to the caecum (junction of small and large bowel). Acute appendicitis - inflammation of the appendix - is the most common acute surgical abdominal condition, affecting approximately 7% of people in their lifetime. Peak incidence: 10-30 years.
Presentation:
- Initial periumbilical pain migrating to the right iliac fossa (McBurney’s point)
- Fever (typically 37.5-38.5-C in uncomplicated; higher in perforated)
- Nausea, anorexia
- Rebound tenderness, guarding; Rovsing’s sign; psoas/obturator sign in atypical positions
Diagnosis:
- Clinical: Alvarado score; APPENDIX score
- Blood: WCC elevated; CRP elevated
- Ultrasound: often first-line - visualises appendix, free fluid; operator-dependent
- CT abdomen/pelvis: gold standard sensitivity (>94%) - identifies appendicitis, perforation, appendix abscess, alternative diagnoses
Severity classification:
- Simple appendicitis: Inflamed, non-perforated - immediate laparoscopic appendicectomy
- Appendix phlegmon: Inflammatory mass around the appendix - antibiotic treatment initially; interval appendicectomy at 6-12 weeks
- Appendiceal abscess: CT-guided drainage + antibiotics; interval appendicectomy
- Perforated appenditis with diffuse peritonitis: Emergency laparoscopic or open appendicectomy + lavage
Elective (interval) appendicectomy: After non-operative management of complicated appendicitis (phlegmon, abscess), interval appendicectomy at 6-12 weeks prevents recurrence (recurrence risk 20-30% without surgery). Also indicated for: recurrent right iliac fossa pain with appendix thickening on imaging; incidental appendix mucocele; carcinoid tumour on histology requiring completion right hemicolectomy if G2 or large (>2 cm).
The Laparoscopic Appendicectomy Procedure
Laparoscopic appendicectomy - technique: Under general anaesthesia; 3-port approach (10/12 mm umbilical camera port; two 5 mm suprapubic working ports). CO- insufflation and 30- laparoscope.
- Systematic inspection of peritoneal cavity - identify appendix; assess for perforation, free fluid, peritonitis
- Appendix tip grasped; mesoappendix dissected and divided with energy device (LigaSure or vessel-sealer)
- Appendix base stapled with laparoscopic linear stapler (endo-GIA 30/45 mm) or ligated with Endoloops -2; appendix divided
- Appendix retrieved in specimen retrieval bag via umbilical port (prevents wound contamination in perforated cases)
- Peritoneal lavage if perforation or free pus
- Drain left in pelvis if perforated - removed next day if output minimal
Advantages of laparoscopic vs. open:
- Lower wound infection rate (especially important in perforated appendicitis)
- Diagnostic laparoscopy simultaneously examines entire abdomen (rules out Crohn’s, ovarian pathology, Meckel’s diverticulum)
- Faster recovery; earlier mobilisation; shorter hospital stay
- Better cosmesis (3 small sclerotomies)
Histopathology: The removed appendix is always sent for histopathological examination. Important findings: acute appendicitis confirmed; appendiceal carcinoid; appendiceal mucinous neoplasm (LAMN/HAMN); Crohn’s disease. Patient is informed of all results.
Post-operative antibiotics: Simple appendicitis: single intraoperative antibiotic prophylaxis sufficient. Perforated appendicitis: IV antibiotics for 24-48 hours; conversion to oral on discharge; total 5-7 day course.
Recovery and Cost
Recovery after laparoscopic appendicectomy:
- Hospital: 1 night (simple); 2-3 nights (perforated/complicated)
- Return to hotel: Day 2
- Diet: clear fluids Day 0; light diet Day 1-2; normal diet from Day 3
- Pain: mild incisional; controlled with paracetamol - ibuprofen; opiate rarely required after laparoscopic
- Physical activity: light walking from Day 1; unrestricted activities from 2 weeks
- Driving: 5-7 days
- Strenuous exercise/sport: 2-3 weeks
- Return to work (desk): 5-7 days; manual work: 2-3 weeks
Flying after appendicectomy:
- Simple laparoscopic: safe to fly from Day 5-7 (CO- absorbed, no gas restriction)
- Perforated/complicated: Day 7-10 minimum; ensure oral antibiotics completed; no DVT concerns beyond standard compression stockings
- We provide a discharge letter documenting fitness-to-fly date
Interval/elective appendicectomy: Recovery identical or slightly shorter - less inflammatory response; often day case or 1-night; return to hotel same day.
Cost comparison Turkey vs. UK:
| Procedure | Turkey | UK Private |
|---|---|---|
| Laparoscopic appendicectomy (elective) | -2,000-3,000 | -3,500-6,000 |
| Emergency appendicectomy + admission | -3,000-5,000 | -6,000-10,000 |
| Complicated/perforated | -4,000-7,000 | -8,000-14,000 |
For emergencies: immediate surgical care is initiated without pre-authorisation delay. All-inclusive billing clarified before discharge.