Laparoscopic

Appendicectomy
 EVOLUTION

1982 –Kurt Semm

1991 – Pier and associates – 625 cases with very good
results

Different technique; variable results

“Two hand technique”
 Indications
Same like open surgery
Unless medically contraindicated - all the cases

Stages of learning
Simple cases
Difficult positions
Acute Appendicitis
Appendicular mass, abscess,Prior lower
abdominal surgery and Pregnancy
 CONTRAINDICATIONS

Firm mass in the RIF - More than a week

duration - Interval appendicectomy

Suspicion of Malignancy
Preoperative preparation

Cardiologist evaluation
Pulmonologist opinion
Overnight starvation
Prophylactic Antibiotics
Preoperative preparation

Neotomic enema –avoid in acute cases

Cleaning of the umbilicus
Empty the bladder before surgery
Catheterization in difficult cases
Position of the patients and team

Patient is in supine position

Surgeon and camera assistant on the left side
Monitor on the right side
Staff nurse on the right side
Position of the patients and team
 Pneumoperitoneum
Veress needle at the umbilicus
- Beware of appendicular mass

Alternative site Veress

- Miniscopes

Open technique
- Multiple Scars
- Peritonitis with ileus
 Trocars
Umbilicus – 10mm
Right hand working port

Suprapubic – 10mm / 5mm / 3mm

Camera port -30 degree telescope

RIF – 5mm/ 3mm

Left hand working port

Trocars
 Suprapubic trocar

Use left hand for insertion

Avoid Urinary Bladder and Urachus –
2-3 cm above the pubic symphysis
Change the direction of trocar after peritoneum
is reached
 Suprapubic trocar
Trocar to the right of the medial umbilical ligament

Only the tip of the trocar should be intra-peritoneal

Midline adhesions – trocar entry to the right

of adhesions

Shift the camera to this port, after insertion

 Exposure
Sand bag
Head up / down
Left lateral tilt
Additional trocars
- Distended bowel loops
- Difficult positions
Placement of Sandbag
 RIF Trocar
Left hand working port

At the level or below the base of the appendix

- Pelvic Caecum
- Highly placed appendix
Avoid vessels
Relatively tight incision in thin walled patients
 Subhepatic appendix

Umbilicus – Camera
Epigastric – Right hand working
Right lumbar – Left hand working
Subhepatic appendix
 Identification

Identify the Caecum

Trace the Taenia down

 Difficulty

Abnormal Caecal position

Difficult Appendiceal position
Retrocaecal – Mobilise the caecum
Paracaecal – Retract the caecum
Retroileal – Put the small bowel loops up
 Division of the
Mesoappendix
Cautery
Release of the lateral attachment
Clip to the meso-appendix
Divide the meso-appendix
Skeletonisation
May need multiple clips
Division of the Mesoappendix

Edematous meso-appendix ?
Fatty meso-appendix?

Stay close to the appendix

Use bipolar
 Retrograde technique

Para-caecal appendix with short meso appendix

 Ligation and Division
Confirm the base
Two Endo-loops – adjustment of the loop
Less than 5mm in-between loops
Third loop in purulent cases
Risk of avulsion
Division of the appendix
 Extraction
Under vision
Into the reducer sleeve first
Division of the meso-appendix
Endobag
Risk of loss of specimen
 Care of the Stump and
Completion of the procedure

Povidone Iodine
Electrocautery

Examination of the small bowel – Meckel’s!

Peritoneal lavage and Drainage
 Paediatric cases
Lesser working space
Movement of the trocars
Diathermy injury to the ports
 Acute appendicitis
Difficulty in exposure – omentum
Difficulty in grasping
Edematous mesoappendix
Friable base
Difficulty in extraction
Peritoneal contamination
Drainage
 Perforated appendix

Confined perforation with Abscess

Perforation with generalised peritonitis
Appendicular Abscess
 Appendicular Abscess

Gentle separation of the mass with suction nozzle

Suck out the pus immediately
Perforation at the tip – easy to manage the base
Perforation at the base – Suture or no suture
Additional retractors
Perforation with Peritonitis

Thorough wash – first step

Rest of the steps – similar to the
confined perforation
Drainage is essential
 Mass and abscess
General Principles

Select only the early cases

Gentle separation with nozzle
Drain the pus immediately
Risk of bowel perforation
Identification of the appendix
Unvisualised Appendix

Sloughed appendix

Interval appendicectomy
Submucosal Appendicectomy

Appendix firmly adherant the bowels

Split the muscle layer

Removal of the mucosa

Post operative care
Oral fluids
Clean cases – after 5 hrs
Difficult cases – After flatus

Normal diet
Clean cases – I POD
Difficult cases – 3-4 days
 Conclusion
Appendix is one of the simple procedure to start

Not all the appendicectomies are easy

Convert when there is difficulty

With adequate experience even the most difficult

Cases Can be managed laparoscopically
Thank you