Laparoscopic Appendectomy

In this article, we will discuss Laparoscopic Appendectomy (Procedure). So, let’s get started.

Procedure

Patient Position and Room Setup

1. Position the patient supine.
2. Some surgeons prefer to use the lithotomy position in women. This allows access to the perineum so that a cervical manipulator may be used to elevate and provide better visualization of the pelvic organs.
3. Tuck the patient’s arms at the sides. This is extremely important to allow sufficient room for the assistant and camera operator to move cephalad as required.
4. The surgeon stands on the patient’s left side.
5. Place the monitor at the patient’s hip on the right or directly below the
feet.
6. Place a Foley catheter to decompress the bladder.

Trocar Position and Choice of Laparoscope

1. Place the initial 10-mm trocar at the umbilicus. Use a 0-degree telescope for visualization.
2. Place the second 5-mm trocar in suprapubic midline to accommodate
a grasping instrument. A 10-mm trocar may be needed to accommodate an endoscopic Babcock clamp. This trocar must be placed far

Figure 1. Trocar placement for laparoscopic appendectomy. The laparoscope is inserted through an umbilical port. A second trocar (5 or 10mm) is placed in the suprapubic region and used to elevate the appendix. The third trocar is the working port and should be placed above trocar #2 or on the left side, beyond the border of the rectus muscle. Placement through the rectus muscle should be avoided because it risks injury to the inferior epigastric vessels with subsequent bleeding.

enough from the appendix to allow sufficient working distance. Occasionally it will need to be placed in the right upper abdomen or even right lower quadrant.
3. The third trocar is usually a 12-mm trocar inserted in the hypogastrium, if the endoscopic linear stapler is to be used or a 5- or 10-mm trocar if clips or ultrasonic scalpel will be employed. Place this trocar in the midline or lateral to the rectus muscle to avoid injury to the inferior epigastric vessels.
4. A fourth trocar may be necessary to assist in grasping or dissecting the appendix (Fig.1).

Performing the Appendectomy

1. Place the patient in steep Trendelenburg position to allow the intestines to slide out of the pelvis, and perform a thorough exploration to confirm the diagnosis.
2. If the appendix is normal, seek other sources for abdominal pain. If no other source is found it is reasonable to proceed with appendectomy. In many cases a fecalith or other evidence of pathology will be found.
3. Identify the appendix by blunt dissection at the base of the cecum.
Elevate the cecum or terminal ileum with an endoscopic Babcock clamp, placed through the right upper quadrant trocar. Generally the base of the appendix will come into view first.
4. Grasp the appendix with an atraumatic grasper or Babcock clamp placed through the suprapubic trocar. An extremely inflamed appendix may be lassoed with a pretied suture ligature, which provides a handy way to elevate it with minimal trauma (Fig.2).
5. Depending upon how the appendix presents, it may be simplest to divide the base before the mesentery. In general, dividing the mesentery first provides the greatest assurance that the dissection of the appendix is carried all the way to the base.

Figure 2. A pretied ligature may be used to elevate a grossly inflamed appendix with minimal trauma
Figure 3. The mesoappendix is divided serially with clips, ligatures, or other hemostatic devices. Both the endoscopic stapler and the ultrasonic scalpel may also be used for this purpose.

6. Divide the mesoappendix serially with clips, cautery, ultrasonic scalpel, or endoscopic stapler (Fig.3).
7. Divide the base of the appendix (Fig.4) Ligatures or the endoscopic stapling device may be used. The endoscopic stapling device saves time but is more costly than using two pretied sutures. If the appendix is normal, the appendiceal base and mesoappendix may be divided by a single application of the stapler.
8. Remove the appendix by pulling it into the 12-mm trocar and removing trocar and appendix together, thus protecting the abdominal wall from contamination. An extremely bulky or contaminated appendix may be placed in a specimen bag to facilitate removal.

Figure 4. A. Division of the appendiceal base using pretied sutures. B. Division of the base using the endoscopic stapling device.

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