Keywords

Preference Card

  • 15-blade scalpel

  • Adson forceps

  • Rat tooth grasping forceps

  • DeBakey forceps

  • Kocher clamps

  • Kelly Clamps

  • Mayo scissors

  • Electrocautery (35/35)/grounding pad

  • Suction

  • Army-Navy retractors

  • 2-0 Vicryl on UR-6 needle

  • 4-0 Vicryl PS-1 needle

  • Needle driver

  • Two ratcheted bowel graspers

  • Maryland dissector

  • Stapler with vascular 45 mm and medium thickness 45 cartridges

  • Ultrasonic dissector (optional)

  • Hassan blunt port, 5 mm ports ×2

  • General endoscopic drape

  • 10 mm scopes and 5 mm scope

  • Camera/light cord

  • Insufflation cord

  • Endocatch

  • Suction/irrigation and saline 1000 ml

  • Bupivacaine

  • 10 mm syringe, 25 G hypo

  • Steri-Strips 0.5 inch

  • Anti-fog

  • Ligaclip applier 5 mm

Patient Positioning/Operating Room Setup (Fig. 31.1)

  • Patient position supine, operating table rotated 15–30 degrees left.

  • Left arm is tucked in at the patient’s side. Right arm may be extended.

  • Surgeon position on patient’s left.

  • Assistant position to the right of the surgeon initially and then move to the left.

  • Nurse on patient’s right.

  • Anesthesiologist at patients head.

  • Monitor position patient’s right.

  • Trocars (Fig. 31.2)

    • 12 mm camera port location at umbilical port.

    • Two 5 mm trocars, one suprapubic and one left lower quadrant lateral to rectus muscle. As an alternative an additional 12 mm trocar can be used in the left lower quadrant instead.

Fig. 31.1
figure 1

Positioning the patient and the team. Patient in supine position. Anesthesiologist (ANS), surgeon (S), assistant (A1), nurse (N), monitor (M)

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Fig. 31.2
figure 2

Port placement for laparoscopic appendectomy

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Nodal Points

Localization and Exposure of the Appendix (Fig. 31.3)

  • Introduce left-hand ratcheted grasper through suprapubic port.

  • Right-hand soft bowel clamp through left lower quadrant port.

  • Identify terminal ileum and cecum.

  • Retract the ileocecal fold of Treves cephalad.

  • Hold appendix up with left-hand ratcheted grasper.

  • Swipe small bowel and expose base of appendix with closed soft bowel clamp.

  • If needed, introduce an additional 5 mm trocar at right upper abdominal wall.

Fig. 31.3
figure 3

Localization and exposure of the appendix

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Take Down of Mesoappendix and Appendix Base (Figs. 31.4 and 31.5)

  • Switch to a 5 mm camera and put it into left lower quadrant port.

  • If another 12 mm trocar in the right lower quadrant is available, keep the camera at the umbilical port.

  • Introduce a vascular or medium cartridge linear stapler through umbilical port depending on which will be taken down first (vascular load for mesentery and medium load for appendix base).

  • Alternatively, the mesentery can be taken down by Harmonic scalpel, or dissect a window in the mesoappendix near the base of the appendix (Fig. 31.4).

  • The mesoappendix can be transected after applying clips and then electrocautery. The appendix can be transected by applying the stapler (Fig. 31.5). When clips are used, make sure they are not caught between the jaws of the stapler.

Fig. 31.4
figure 4

Create window at mesoappendix near the base of appendix

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Fig. 31.5
figure 5

Transect appendix at its base with stapler

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Irrigation, Hemostasis, and Specimen Removal (Fig. 31.6)

  • Hold the appendix stump with a grasper through suprapubic port.

  • Introduce clip applier through umbilical port, and clip staple line as needed for hemostasis.

  • Introduce endo bag through umbilical port.

  • Place appendix in the bag with a grasper.

  • Remove bag.

  • Irrigation and hemostasis of pelvis and appendix stump area.

  • Close fascia at umbilical port site using 2-0 Vicryl on a UR-6 needle.

  • If desired, infiltrate each port with local anesthetic.

  • Close port site with subcuticular sutures using a 4-0 Monocryl or Vicryl suture.

Fig. 31.6
figure 6

Specimen removal

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Pearls and Pitfalls

  • A Foley catheter should be placed to decompress the bladder and avoid injuries during trocar placement.

  • In females if appendix is normal in appearance, explore the peritoneum, ovaries, tubes, and uterus to rule out endometriosis.

  • In males if appendix is normal, explore the stomach, duodenum, and colon.

  • If appendix is normal, explore the last 2 feet of small bowel to rule out Meckel’s diverticulum.