Appendectomy, laparoscopic - general and visceral surgery

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date of publication: 22.04.2009

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  • Instruments, draping, minilaparotomy

    Video
     
    54-4

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

  • Pneumoperitoneum, exploration

    Video
     
    54-5

    Establish the pneumoperitoneum.
    The pressure level should reflect size, age and sex of patient (6–8mmHg in children, 10–14mmHg in adults). Limit the CO2flow rate to 1mL/min.

    Abdominal exploration.

    The video demonstrates acute appendicitis. Laparoscopy always starts with the abominal exploration! 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).

  • Working trocars, freeing the cecum

    Paid content (video)
    Paid content (image)

    Under camera view place a 13.5mm trocar in the left lower quadrant and a 5mm trocar in the right lower quadrant. Put the appendix under gentle traction with laparoscopic Babcock forceps or the like.
    Tip: Suprasymphyseal at midline – in complex situations this may be simpler at times).

  • Dissecting and resecting the appendix

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    Paid content (image)

    Bluntly dissect the mesoappendix close to the base of the appendix with Overholt forceps (in video with scissors).
    Insert the Endo GIA™ (linear stapler, 30 mm, white cartridge) via the 13.5mm trocar and resect the appendix.
    Note: In the video, the"safe” way of resection is taken. Of course, the appendix may also be resected without a linear cutter, e.g., with a Roeder loop.

  • Transecting the mesoappendix, irrigation, suction

    Paid content (video)
    Paid content (image)

    Transecting the mesoappendix (2ndcartridge).
    The mesoappendix may also be transected with diathermy (caution: risk of secondary bleeding).
    Only explore for Meckel diverticulum if the appendix appears rather unremarkable.
    In Meckel diverticulum:
    Resect the diverticulum sufficiently far from its base with a linear cutter (e.g., Endo GIA™ blue 30mm or 45mm cartridge) (not shown in video).
    Check for any bleeding. Irrigate and suction the surgical field, particularly the Douglas pouch (evacuate it!).

  • Retrieving the appendix

    Paid content (video)
    Paid content (image)

    Insert a specimen retrieval bag through the 13mm trocar.
    Place the appendix into the bag (alternatively: use cut-off middle finger of a surgical glove size 8.5).

  • Removing the specimen retrieval bag and trocars

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    Paid content (image)

    Remove the specimen retrieval bag from the abdominal cavity via the 13.5mm trocar.
    Suture (Vicryl 0, UR6 needle) the fascia at the 13.5mm trocar site under camera view (not shown in video).
    Remove the 5mm trocar under camera view.
    No routine drainage in clean surgical fields and localized peritonitis!

  • Fascial suture, skin suture, dressing

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    Paid content (image)

    After removal of the camera trocar close the infraumbilical fascia (Vicryl 0, UR6 needle).
    Skin: Subcuticular suture (absorbable monofilament 4/0).