Insertion of laparoscope and grasper through umbilical trocar.
Grab the appendix using the grasper. Aiming just below the tip ensures the appendix doesn’t bend during removal and also allows for identification of the distal end of the appendix during extrication from the umbilicus (Fig. 34.2). Divide the abdominal wall fascial bridge between the 3-mm instrument and the 5-mm trocar. Extend this incision in larger patients (sometimes up to 15–20 mm is necessary). Bring the appendix to the abdominal wall surface through the fascial opening (Fig. 34.3). Divide the appendix and mesoappendix extracorporeally (Fig. 34.4). Ligate the appendix with two 3-0 Vicryl sutures and cauterize the mucosa (Figs. 34.5 and 34.6).
Use grasper to grab distal end of appendix.
Extracorporealization of appendix through umbilical incision.
Extracorporeal division of mesoappendix.
Extracorporeal division of appendix.
Cauterization of appendix stump after division.
Because of the plastic anchor on the AnchorPort, the port can be reinserted into the new, larger fascial opening and still maintain insufflation. This allows for a brief insertion of the scope to assure no bleeding and ensures the presence of an adequately short appendiceal stump.
Intracorporeal, Single-Incision, Multiport Technique
Make a 2-cm infraumbilical or transumbilical incision.
If multiple, individual ports are utilized, insufflate with a Veress needle and then insert three AnchorPorts. Alternatively, one could insert 3-mm instruments through the fascia in the same skin incision as the trocar.
The use of a 2-cm Hasson incision and one multi-port trocar can alternatively be inserted in the umbilicus. The technique for intracorporeal appendectomy is discussed below in the three-port laparoscopic appendectomy section.
Traditional Three-Port Laparoscopic Appendectomy
Patient Position and Room Setup
Position the patient supine.
Although not mandatory, an orogastric tube can be placed to decompress the stomach and similarly a Foley catheter can be placed to decompress the bladder. If the patient urinates prior to surgery, a Foley catheter is rarely required. If placed, both catheters should be removed at the end of the case.
The surgeon and assistant stand on the patient’s left side. The Mayo stand and scrub nurse are on the patient’s right.
Place the monitor at the patient’s hip on the right or directly below the feet (Fig. 34.7).
Surgical team position. The surgeon and assistant stand on the left side. The scrub nurse is on the right side.
Trocar Position and Choice of Laparoscope
Prep the abdominal wall from pubis to lower costal margin.
Place the initial 10–12 mm port at the umbilicus through open cutdown technique or Veress needle. Carbon dioxide pneumoperitoneum is established at a maximum pressure of 15 mmHg. Insert a 5-mm 30-degree telescope for visualization.
Place the second 3- or 5-mm port in the left lower quadrant.
The third 3 or 5-mm port is placed in the midline immediately over the pubis. Care is taken to avoid injury to the bladder (Fig. 34.8).
Performing the Appendectomy
Place the patient in Trendelenburg position and left side down to allow the intestines to slide out of the pelvis.
Perform a thorough exploration to confirm the diagnosis. If the appendix is normal, seek other sources for abdominal pain; run the small bowel to evaluate for a Meckel’s diverticulum and in females, examine the ovary for torsion or cyst. If no other source is found, proceed with appendectomy.
Utilize two 5-mm atraumatic graspers through the midline suprapubic and left lower quadrant ports.
Follow the taenia coli down to their confluence at the base of the cecum and use the grasper through suprapubic port to grab the appendix 1 cm from the base, holding it up and toward the left upper quadrant. Prestige atraumatic graspers (Aesculap, Inc., Center Valley, PA) are an example of blunt graspers that are still sharp enough to get a strong, yet safe, hold of the appendix.
If the appendix is adherent to other bowel or abdominal wall, use of the suction as a dissection tool can gently break the adhesions. If the adhesions are not located close to the bowel, hook cautery can be used for dissection. Free the appendix from tip to base, progressing in the opposite direction, if necessary.
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