Appendectomy, laparoscopic - general and visceral surgery

1. The author demonstrates two possible trocar positions. As demonstrated here, the 12 mm trocar is inserted in the umbilicus, the 5 mm trocar in the midline superior to the pubic symphysis and a pararectal 10 mm trocar in the LLQ.
2. Optionally, the 10 mm and 5 mm trocar may be placed at the pubic hairline in the RLQ and LLQ.

Infraumbilical incision, minilaparotomy and insertion of the camera trocar under camera view after placement of fascial stay sutures.

Establish the pneumoperitoneum. The pressure level should reflect size, age and sex of patient (6–8 mmHg in children, 10–14 mmHg in adults). Limit the CO2 flow rate to 1 mL/min.

Laparoscopy always starts with the abdominal exploration! This case presents with acute suppurative appendicitis with inflammatory adhesions to the anterior abdominal wall. 

In the video, first the right lower quadrant is explored, then the right upper quadrant, left upper quadrant, again the area of the appendix, and finally the lesser pelvis.

The lower abdominal organs are inspected in the numerical order of the sketch: Inspection around the appendix is followed by uterus and bladder (A), Douglas pouch (B), left ovary (C), and deep inguinal orifice (D). This is continued to the right groin area (E).  Then the laparoscope is directed into the right upper quadrant (5) where the gall bladder (F) and right hepatic lobe (G) are inspected. This is followed by inspection of the left upper quadrant: Spleen and gastric corpus (H) as well as left hepatic lobe with falciform ligament, stomach and greater omentum (I).

Under camera view, place a  pararectal 10 mm trocar and a suprasymphyseal 5 mm trocar. Administer local anesthetic to each trocar site prior to its incision.

Mobilize the appendix bluntly with a swab and put the appendix under gentle traction with laparoscopic Babcock forceps or the like.

Transect the mesoappendix with monopolar cautery to its base and close off the appendicular artery with titanium clips.

Insert the Endo GIA™ (30 mm, blue magazine) through the 12 mm trocar and transect the appendix. The use of locking appendix clips is also possible.

Note 1: The current metaanalyses cannot answer which technique should be preferred for laparoscopic transection of the appendix (Röder snare, clips, stapler...), so that cost-effectiveness will also be a factor in the decision-making process. 

Note 2: Only explore for Meckel diverticulum if the appendix appears rather unremarkable. Resect the diverticulum sufficiently far from its base with a linear cutter (e.g., Endo GIA™ blue 30 mm or 45 mm cartridge) (not shown in video), since definite appendicitis as the cause of the complaints has been ruled out.

Place the appendix into the specimen retrieval bag, clean the Douglas pouch with one or more gauze pads inserted via the 12 mm trocar and check for a dry field. Depending on the contamination, also blot the paracolic gutter this way.

Remove the specimen retrieval bag from the abdominal cavity via the umbilical 12 mm trocar; this will require incising the fascia.

After removal of the 12 mm trocar close the infraumbilical fascia (Vicryl 0, UR6 needle). Monitor this suturing of the fascia with the laparoscope. Under camera view remove the 5 mm trocar. Close the skin with subcuticular suture (3/0 or 4/0).

Note: In the case of local peritonitis and a clean field, drainage is not routinely performed!