Ultrasound-Determined Appendix Position and Anatomical Variation as Predictors of Operative Difficulty and Anesthetic Duration in Laparoscopic Appendectomy

Abstract

Background: Appendicitis is one of the most frequently encountered surgical emergencies and laparoscopy is a well-established surgical approach for appendicitis. The procedure is basically easy to perform, but the position of the appendix and the grade of local inflammation may affect the intra-operative visualization, dissection and operative difficulty, as well as the total anesthetic exposure. Ultrasonography, performed before the surgery, may be helpful in giving anatomical information that can help anticipate these challenges.

Objective: To determine the association of ultrasound-determined appendix position and anatomical variation with operative difficulty and anesthetic duration in patients undergoing laparoscopic appendectomy.

Methodology: This prospective observational study was conducted at Mercy Teaching Hospital, Peshawar, from January 2026 to June 2026. Fifty-seven patients with acute appendicitis were included who underwent laparoscopic appendectomy. The position of the appendix and inflammatory findings were determined by ultrasonography before surgery. The position of the appendix was classified as retrocecal, pelvic, subcecal, pre-ileal, or post-ileal. Intraoperative findings, operative difficulty, operative duration and total anesthetic duration were recorded. Comparative tests were used for the statistical analysis and multivariable logistic regression, p<0.05 was considered statistically significant.

Results: The appendix was visualized preoperatively in 52 (91.2%) patients. Retrocecal position was the most common, occurring in 20 (35.1%) cases, followed by pelvic position in 16 (28.1%). Operative difficulty was classified as difficult in 11 (19.3%) patients. Difficult procedures were most frequent among patients with a post-ileal appendix, 4/5 (80.0%), followed by retrocecal position, 5/20 (25.0%), with a significant association between appendix position and operative difficulty (p=0.006). Post-ileal appendices were also associated with the longest mean operative duration (78.6 ± 18.2 minutes) and anesthetic duration (103.8 ± 21.6 minutes). Periappendiceal fluid and sonographic evidence of perforation were also significantly associated with increased operative difficulty.

Conclusion: Ultrasound-determined appendix position and associated inflammatory changes may help predict the technical difficulty and anesthetic duration of laparoscopic appendectomy. Post-ileal and retrocecal positions were associated with more challenging procedures and longer operative and anesthetic times. Detailed preoperative ultrasonographic assessment may therefore improve perioperative planning.