Appendectomy, laparoscopic - general and visceral surgery
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Trocar positioning
- 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.
- Optionally, the 10 mm and 5 mm trocar may be placed at the pubic hairline in the RLQ and LLQ.
Instruments, minilaparotomy
Pneumoperitoneum, exploration
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).
Working trocars, mobilizing the appendix
Transecting the mesoappendix
Transecting the appendix
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.
Retrieving the appendix
Removing the specimen retrieval bag
Fascial suture, removing the trocars, skin suture
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!
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