Appendectomy in Pokhara: Recognizing Appendicitis and Surgical Treatment

Appendicitis is one of the most common abdominal emergencies worldwide. In Nepal, delayed presentation due to limited access to diagnostic facilities and distance from hospitals means that perforated appendicitis — a more dangerous complication — is disproportionately common. Recognizing the symptoms early and seeking surgical care promptly can prevent a straightforward operation from becoming a life-threatening emergency.

What Is Appendicitis and Why Does It Need Surgery?

Appendicitis is inflammation of the appendix — a small, finger-shaped pouch attached to the large intestine at the lower right abdomen. When the appendix becomes blocked (by stool, mucus, or infection), bacteria multiply, the appendix swells, its blood supply is compromised, and if untreated, it perforates (bursts), spreading infection throughout the abdomen (peritonitis).

Appendicitis does not resolve on its own. Antibiotics alone can treat uncomplicated appendicitis in selected patients but carry a significant recurrence rate. Surgical removal of the appendix (appendectomy) is the definitive treatment and carries low risk when performed before perforation.

What Are the Classic Symptoms of Appendicitis?

Classic appendicitis follows a recognizable pattern. However, the classic presentation occurs in only about 60% of cases. Atypical presentations — particularly in children, the elderly, pregnant women, and those with a malrotated or retrocaecal (behind the colon) appendix — cause diagnostic delays.

Classic presentation:

• Periumbilical pain starting at or around the navel — typically dull and crampy in nature.
• Migration to the right lower quadrant (RLQ) over 4–12 hours as the inflammation spreads to the peritoneum lining the abdominal wall. McBurney’s point — one-third of the distance from the anterior superior iliac spine to the navel — becomes the point of maximum tenderness.
• Anorexia (loss of appetite) — one of the most consistent features.
• Nausea and vomiting — typically after pain onset (vomiting before pain suggests gastroenteritis rather than appendicitis).
• Low-grade fever (37.5–38.5°C) in simple appendicitis; higher fever suggests perforation.
• Rebound tenderness — pain worse when pressure is suddenly released from the right lower abdomen.

Atypical presentations:

• Children under 5: Diffuse abdominal pain, fever, vomiting, and diarrhea may dominate — mimicking gastroenteritis.
• Elderly: Symptoms blunted, fever may be absent. RLQ pain less localized. Higher perforation rate due to delayed presentation.
• Retrocaecal appendix: Pain may be felt in the right flank or back rather than right lower quadrant.
• Pelvic appendix: Pain in the right lower quadrant with urinary symptoms or dysuria — may be confused with UTI or pelvic inflammatory disease.

How Is Appendicitis Diagnosed?

Appendicitis is primarily a clinical diagnosis — based on history, symptoms, and physical examination. Investigations support but do not replace clinical assessment.

Blood tests:

• White cell count (WBC): Elevated in appendicitis but non-specific. Counts above 18,000/mm³ suggest perforation.
• C-reactive protein (CRP): Rises 12–24 hours after inflammation onset. Elevated CRP with elevated WBC increases diagnostic certainty significantly.

Imaging:

• Ultrasound abdomen: First-line imaging. Visualizes the appendix in approximately 70–80% of cases. A non-compressible tubular structure more than 6 mm in diameter is diagnostic. Also excludes ovarian cyst, kidney stone, and other differential diagnoses.
• CT scan abdomen/pelvis: Highest sensitivity (94–98%) and specificity for appendicitis. Used when ultrasound is inconclusive or when perforation and abscess are suspected. Involves radiation — used selectively.

Alvarado Score: A clinical scoring system (0–10 points) based on symptoms, signs, and blood tests. Scores of 7–10 have a high probability of appendicitis. Scores of 5–6 warrant observation and repeat assessment. Scores below 4 suggest an alternative diagnosis.

What Happens in a Laparoscopic Appendectomy?

Laparoscopic appendectomy is the preferred surgical approach for appendicitis in fit patients without perforation and diffuse peritonitis.

Procedure:

1. General anesthesia is induced.
2. Three port incisions: one at the navel (10–12 mm), one in the left iliac fossa (5 mm), and one in the suprapubic area (5 mm).
3. The abdomen is insufflated with carbon dioxide gas.
4. The laparoscope is introduced and the appendix identified.
5. The mesoappendix (blood supply) is divided using electrocautery or clips.
6. The appendix base is secured with two to three loop ligatures or a stapler.
7. The appendix is divided and removed in a retrieval bag through the navel port.
8. The abdominal cavity is washed out with saline if contamination is present.
9. Port sites are closed.

Duration: 30–45 minutes for uncomplicated appendicitis.

Advantages over open surgery: Less post-operative pain, earlier mobilization, shorter hospital stay (1–2 days vs 3–5 days), lower wound infection rate (particularly important as the appendix is a contaminated organ), better visualization of the pelvic organs in women.

What Happens If the Appendix Perforates — Is It Still Laparoscopic?

Perforated appendicitis with free perforation and diffuse peritonitis is a more complex situation. Laparoscopic approach is still used by experienced surgeons in many centers for perforated appendicitis, with the advantage of thorough abdominal washout under camera visualization.

However, conversion to open surgery may be needed when:

• Dense adhesions from previous surgery prevent safe laparoscopic access
• An appendix abscess (periappendiceal mass) is present — some are managed initially with IV antibiotics and interval appendectomy 6–8 weeks later
• Intraoperative bleeding cannot be controlled laparoscopically
• Extensive bowel damage requiring formal bowel resection

Perforated appendicitis requires longer hospital stay (typically 4–7 days for IV antibiotics), greater analgesia requirements, and a longer recovery period.

What Is the Recovery After Appendectomy?

Laparoscopic appendectomy (uncomplicated):

• Hospital stay: 1–2 days
• Return to sedentary work: 1 week
• Return to physical work: 2–3 weeks
• Driving: Day 5–7 (when off prescription pain relief)
• Exercise: Week 3–4

Open appendectomy (perforated):

• Hospital stay: 4–7 days with IV antibiotics
• Return to sedentary work: 2–3 weeks
• Return to physical work: 4–6 weeks

Diet after appendectomy: No specific dietary restrictions. Start with clear fluids, progress to light foods, and return to normal diet over 2–3 days. The appendix plays no role in digestion.

Can You Live Normally Without an Appendix?

Yes. The appendix is a vestigial structure with limited current function. It contains immune-related lymphoid tissue and may play a role in gut microbiome maintenance, but its absence is not associated with any clinically significant immune deficiency or digestive impairment.

Long-term studies of patients who have undergone appendectomy show no increased rates of serious illness, immune dysfunction, or bowel disease compared to the general population.

What Diet Changes Are Needed After Appendix Surgery?

No specific long-term dietary changes are required after appendectomy. During the 2–3 week recovery:

• Soft, easily digested foods in the first week — khichari, curd, boiled vegetables, dal soup.
• Avoid heavy, spicy, or fried foods until bowel function normalizes.
• Adequate fiber to prevent constipation (straining increases post-surgical abdominal pain).
• Resume normal diet by week 2–3.

Emergency Appendectomy in Pokhara — A&B International Hospital

A&B International Hospital

Pokhara-02, Bindhyaabasini Way to Sarangkot

Phone: +977 061-412512

Website: abinthospital.com

24/7 surgical emergency. Laparoscopic appendectomy. Diagnostic ultrasound and blood tests available at all hours. If you or your child has right lower abdominal pain — do not wait. Come to A&B emergency now.