Fig. 29.1.
Recommended port placement for laparoscopic surgery. A port is first placed at position 1 to accommodate the laparoscope. A 5-mm port is initially used. A 12-mm port may be utilized to accommodate the 10-mm laparoscope and, if needed, laparoscopic specimen pouch. All other ports should be 3–5 mm. Ports 1, 2, and 3 may be used to evaluate the length of the small bowel and to perform an appendectomy. Port 4 may be added to perform cholecystectomy, with the option of adding port number 5 to assist in surgery.
Pearls/Pitfalls
It is the policy of some surgeons to always perform an appendectomy during diagnostic laparoscopy, even if the structure appears grossly normal. The clinical significance of a pathologic diagnosis of chronic appendicitis or a fibrotic appendix remains controversial. However, the gold standard for the procedure should be relief of symptoms, regardless of the ultimate diagnosis.
Postoperative Care
Outcomes
The incidence of identifying pathology via diagnostic laparoscopy ranges from 20 to 100 %, depending on the study. An interesting, yet controversial, entity is appendiceal colic. There is debate over whether this chronic right lower quadrant pain is a true disease process. These patients tend to be predominantly female and present with pain at McBurney’s point, and many have associated nausea, vomiting, and postprandial worsening of pain. Laboratory examination is invariably normal, and imaging findings are not consistent with acute appendicitis. Historically, contrast studies may demonstrate irregular filling and/or emptying of the appendix. Some studies show success rates (resolution of symptoms) in up to 89–98 % of cases. Proper patient selection is the key.
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