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Katkhouda2005 PDF
Katkhouda2005 PDF
Katkhouda2005 PDF
hair (Fig. 2B). Other settings (eg, left lower quadrant plus geon’s assistant and camera holder then moves to the pa-
suprapubic midline port or a port right under the right costal tient’s left side, cephalad to the surgeon. The patient is
margin) are not recommended because they have functional brought into the Trendelenburg position with the right side
disadvantages or may be cosmetically inappropriate. elevated to facilitate the exposure of the right lower quadrant.
Exposure of the Appendix The surgeon’s left hand operates a Babcock grasper (Ethi-
After insertion of the ports, a quick diagnostic laparoscopy is con Endosurgery, Cincinnati, OH) to retract the cecum and
performed to either confirm the diagnosis or assess other subsequently to expose the appendix (if the appendix is in its
pathology (eg, female organs, diverticulitis, inguinal hernias, usual paracecal position). Particularly if the appendix is sig-
liver/gallbladder disease, carcinomatosis). The sur- nificantly inflamed and friable, it is advisable not to grasp
the appendix itself but rather to place the Babcock around it sect the appendix. After transsection, the appendiceal stump
or at the level of the mesoappendix (Fig. 3). Occasionally, an mucosa is cauterized carefully (Fig. 5).
endoloop can be placed around the appendix and mesoap-
pendix to create a handle to hold the appendix. The surgeon’s Stapling Technique
right hand operates a Kelly grasper or electrical scissors to In this technique, a 30-mm white vascular endostapler (Ethi-
create a window in the mesoappendix (Fig. 3). If the appen- con Endosurgery) is used to divide the mesoappendix, and a
dix is not clearly identifiable because it is retrocecal, the 30-mm blue endostapler is employed for the appendix as
cecum needs to be mobilized and retracted medially (Fig. 4). close as possible to the cecum, leaving only a very short
stump. A window is created at the base of the mesoappendix
in the avascular plane between the base of the appendix and
Transsection Techniques
the appendiceal artery. The first stapler with appropriate car-
Once the appendix has been completely skeletonized, it is tridge (white for vessel, blue for bowel) is inserted and fired
amputated at the base. In general, there is no need for inver- (Fig. 6), followed by a second stapler for completion of the
sion of the appendiceal stump, but it is of crucial importance transection (Fig. 7). Care should be taken to avoid a “junk
to divide the appendix in healthy appearing tissue, if neces- yard” by losing unused staples into the surgical field. After
sary at the level of the cecum, to avoid a breakdown of the firing, the staplers should therefore be opened very carefully,
ligation or stapler line. just enough to release the tissue, but then they immediately
There are two possibilities to divide the appendix and the should be closed again before dropping the unused staples.
mesoappendix—the endoloop technique and the stapling
technique. The former is cheaper and requires only a 5-mm
port on the left side; however, it requires more skill and may Specimen Retrieval
initially take more time. The stapling technique needs less Care is needed to avoid contamination of the abdomen and
skill and initially saves time, but it is more expensive and it port site wounds; the appendix is therefore placed in a re-
will require a 12-mm port. trieval bag before removing it from the abdomen. Alterna-
tively, if the appendix is not too large, it can be pulled into the
Endoloop Technique
port and withdrawn with the port. Rupture of the retrieval
In this technique, the mesoappendix is first divided by means
bag within the abdominal wall because of an inadequate fas-
of cautery, and the appendix is subsequently divided be-
cial gap should be avoided under any circumstances. If de-
tween two endoloops. The appendix should be clearly visible
livery of the endobag is difficult, it is advisable to widen the
from tip to base. Special bipolar cautery forceps are used to
fascial incision.
cauterize and “crush” the mesoappendix. Care has to be
taken not to touch and burn adjacent loops of bowel with the
hot forceps. Portions of the mesoappendix are cauterized and Irrigation and Drainage
subsequently cut with the scissors until the base of the ap- The purpose of irrigation is to remove all debris, purulent
pendix is identified and completely freed. Two endoloops are fluid collections, and blood from the surgical area. In early
inserted and tied at the base, leaving sufficient space to trans- phlegmonous appendicitis without any pus, there is no ad-
12 N. Katkhouda and A.M. Kaiser
vantage to irrigation but rather risks spreading contaminated essary. However, if residual contaminated fluid is to be left in
fluid throughout the abdomen. Otherwise, with the appen- the peritoneal cavity or if the appendiceal/cecal stump is of
dix removed, a thorough lavage of the area is performed. In suboptimal quality, placement of a small drain may be pru-
particular, the pelvis has to be well exposed and any residual dent. It should be brought in through a separate 4- to 5-mm
contaminated fluid should be aspirated and irrigated by re- incision in the right lower quadrant, that is, not through one
tracting the sigmoid colon and exposing the pouch of Doug- of the trocar sites, and laid along the cecum into the pelvis to
las. drain those dependent areas. The drain can be removed after
In the overwhelming majority of cases, a drain is not nec- a few days once the quality of the fluid is serosanguinous.
Technical Variations to the tip. This is performed as in open surgery and does not
Retrograde Appendectomy require specific skills.
When the tip of the appendix is not clearly visible, a retro-
grade appendectomy can be performed with the stapler (Fig. Difficult Appendicitis
8). The visible base of the appendix is transected after cre- When the surgeon encounters a gangrenous or perforated
ation of an appropriate window, followed by the mesoappen- appendicitis or an appendiceal phlegmon, it can be difficult
dix, and finally the whole appendix is dissected from the base initially to recognize the appendix. In these circumstances, it
Figure 9 Fingeroscopy.
14 N. Katkhouda and A.M. Kaiser
may be necessary to mobilize the cecum first. This mobiliza- though pregnancy in and of itself is not necessarily a contra-
tion should be as conservative as possible to avoid opening indication for the laparoscopic approach,7 the following re-
and contaminating retroperitoneal spaces. The cecum can quirements have to be respected. The surgeon ought to be an
then be flipped over and the appendix visualized. If this is experienced laparoscopist, the operation should under no
still not possible, “fingeroscopy” or conversion to an open circumstances be prolonged, and the trocars should always
procedure has to be considered (Fig. 9). The former tech- be placed via an open access technique.
nique involves removal of the port from the right lower quad-
Control of Intraoperative Bleeding
rant and insertion of the index finger to restore the tactile
Although bleeding complications are relatively rare, they
sensation and to perform blunt, atraumatic mobilization sim-
most commonly arise from the appendiceal artery. Bleeding
ilar to the open procedure but under laparoscopic guidance.6
related to trocar placement (eg, epigastric or iliac vessels)
This will speed up the procedure and should be considered as
should be avoided by careful and visually controlled inser-
the last step in situations where conversion seems inevitable.
tion of the ports. Prompt reaction in a controlled fashion aims
Fingeroscopy can only be performed if the right lower quad-
at localizing the bleeder and stopping it without delay. Dif-
rant incision is close enough to the surgical area (see section
fuse and uncontrolled cautery use to arrest bleeding should
on port placement).
be avoided. It may be helpful to bring in a 2 ⫻ 2 cm ra-
If still no satisfactory progress is made, the only way for-
diopaque-labeled gauze to temporarily compress the area.
ward is to convert to an open operation. The projection of the
With a suction tip in one hand and a fine grasping instrument
cecum is marked on the abdominal wall via transillumination
in the other, the surgeon must identify and grasp the vessel
of the laparoscope, and an incision is then made appropriate
on which a clip or figure-eight stitch may be placed. If the
to the operation to be performed.
bleeding cannot be stopped in a timely fashion, the proce-
Laparoscopically Assisted Appendectomy dure has to be converted to an open operation.
In some cases, especially in children where the appendix is
extremely long and the working space is small, the “assisted”
technique is an easy way of performing an appendectomy.
Postoperative Care
The mesoappendix is first controlled by means of bipolar The postsurgical management depends on both the intraop-
electrocautery. The right lower quadrant port is then re- erative findings and the patient’s symptoms. Duration of an-
moved with the appendix inside. The whole appendix is tibiotics is determined by the extent of the inflammation and
exteriorized and ligated outside the abdomen before the ce- the presence of perforation, rather than by the surgical ap-
cum is pushed back inside the abdomen. proach. Early ambulation and resumption of an oral diet are
encouraged; the latter should be advanced as tolerated.
Special Problems
Diagnostic Uncertainty and Normal Appendix References
Encountering a normal appendix occurs in patients in whom 1. Semm K: Endoscopic appendectomy. Endoscopy 15:59-64, 1983
2. Kaiser AM, Corman ML: History of laparoscopy. Surg Oncol Clin N Am
either preoperative studies and assessment were inconclusive
10:483-492, 2001
or proved to be falsely positive. A careful assessment has to be 3. Guller U, Hervey S, Purves H, et al: Laparoscopic versus open appen-
performed of the whole peritoneal cavity, including running dectomy: outcomes comparison based on a large administrative data-
the small bowel. If a different intraabdominal pathology is base. Ann Surg 239:43-52, 2004
found, that disease process should be appropriately treated 4. McKinlay R, Mastrangelo MJ Jr: Current status of laparoscopic appen-
dectomy. Curr Surg 60:506-512, 2003
and the appendix should be left in place. If no other pathol-
5. Guller U, Jain N, Peterson ED, et al: Laparoscopic appendectomy in the
ogy is found, we recommend removing the appendix and elderly. Surgery 135:479-488, 2004
having it assessed by the pathologist. 6. Katkhouda N, Mason RJ, Mavor E, et al: Laparoscopic finger-assisted
technique (fingeroscopy) for treatment of complicated appendicitis.
Pregnancy J Am Coll Surg 189:131-133, 1999
Acute appendicitis with any type of appendectomy carries a 7. de Perrot M, Jenny A, Morales M, et al: Laparoscopic appendectomy
risk for the pregnant patient and for her unborn fetus. Al- during pregnancy. Surg Lap Endosc Perc Techn 10:368-371, 2000