Appendectomy
Laparoscopic appendectomy is the most frequently performed endoscopic surgery procedure worldwide. This chapter deals with the operation room setup, patient positioning, special instruments and port placement sites for laparoscopic appendectomy. The indic
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35 Appendectomy Amulya K. Saxena
35.1
Operation Room Setup
Surgical Team Position
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Chapter 35 Appendectomy
35.2
Patient Positioning
Supine position with arms tucked to the side.
35.4
Location of Access Points
Port Placement Sites
35.3
• • •
Special Instruments
Endoscopic loop sutures Bipolar forceps Specimen retrieval bag
Amulya K. Saxena
35.5 1. 2. 3. 4.
Indications
Acute appendicitis. Perforated appendicitis. Appendicitis with coprolith. Retrocecal appendicitis.
35.7
Preoperative Considerations
35.6
Contraindications
Appendicitis complicated by bowel obstruction with abdominal distension (mesoceliac appendicitis).
35.8
Technical Notes
1. Leave a povidone iodine gauge in the umbilicus until the patient enters the operating room. 2. Place a Foley catheter before the procedure. 3. Preoperative resuscitation should be done if there are signs of peritonitis. 4. In case of suspected perforation, antibiotics should be administered before general anesthesia is induced.
1. Manipulate the fragile appendix with care. In this case, manipulation using the mesoappendix is recommended. 2. In cases of localized abscess, care should be taken not to burst the abscess. Pus should be aspirated using a large needle inserted through the abdominal wall under laparoscopic guidance. 3. A preperforative or perforated appendix must be removed from the abdomen in an specimen retrieval bag.
35.9
35.10 Laparoscopic Appendectomy
Procedure Variations
1. Extra-abdominal (laparoscopic-assisted), singleport method (see Chap. 36). 2. Mixed technique (mesoappendix hemostasis performed intra-abdominally and the appendix is ligated extra-abdominally), three-port method. 3. Intra-abdominal techniques with: a. Endoscopic stapler. b. Intra-/extracorporeal suturing.
Please see Figs. 1–6.
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Chapter 35 Appendectomy
Figure 35.1
The bowel loops are mobilized and the appendix is lifted using an atraumatic grasper
Figure 35.3
The cauterized mesoappendix is cut using a pair of hooked scissors
Figure 35.2
The vessels of the mesoappendix are coagulated using bipolar forceps
Figure 35.4
Three endoscopic loop sutures are used and the appendix is ligated toward the base
Amulya K. Saxena
Figure 35.5
The distal endoscopic loop suture is left uncut and the appendix is cut between it and the two proximal sutures
Recommended Literature 1. Gauderer MW (2007) An individualized approach to appendectomy in children based on anatomico-laparoscopic findings. Am Surg 73:814–817 2. Saxena AK, Springer A, Tsokas J, Willital GH (2004) Laparoscopic appendectomy in children with Enterobius vermicularis. Surg Laparosc Endosc Percutan Tech 11:284–286 3. Schmelzer TM, Rana AR, Walters KC, Norton HJ, Bambini DA, Heniford BT (2007) Improved outcomes for laparoscopic appendectomy compared with open appendectomy in the pediatric population. J Laparoendosc Adv Surg Tech A 17:693–697
Figure 35.6
The distal endoscopic loop suture is used to extract the dissected appendix through the (5-/10-mm) port. Postoperative v
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