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Laparoscopic Appendicectomy - Operative Technique

Laparoscopic Appendicectomy

Appendicectomy is the commonest operative operation performed which may be done as an emergency or elective procedure. Laparoscopic appendicectomy was described in early 1980s and has gradually gain popularity using the introduction of video laparoscopy. It is well accepted between the laparoscopic surgeons but hasn't gained the wider acceptance between the general surgeons. A UK audit published through the Royal College of Surgeons of England, in 1997 suggested that only 1.2% of patients undergoing appendicectomy had a laparoscopic operation. A Recent analysis in the University Hospitals in the USA suggests a 20% increase in the utilization of lap appendix. The laparoscopic approach has several benefits in comparison with open appendicectomy.

Indications

1. LA is the operation of preference by experienced laparoscopic surgeons for those cases.
2. Acute or chronic right iliac fossa pain with a doubtful diagnosis of acute appendicitis. Rather than laparotomy, a diagnostic laparoscopy, and appendicectomy will avoid unnecessary laparotomies, 4, 5, 6 and allow general visualization of peritoneal cavity.
3. In younger females where it may be hard to differentiate other pelvic pathology from appendicitis.
4. Obese patients who'll require a large incision for open appendicectomy.

Pre Operative Preparation

Pre operative preparation and evaluation overlap with necessary for open appendicectomy and investigations are done according to clinical assessment. The possibility of conversion to spread out operation should be told the individual. Decompression of urinary bladder and stomach to minimise the risk of problems for these organs ought to be done as for other laparoscopic procedures.

Procedure

Laparoscopic appendicectomy is usually performed under GA using the patient in supine and steep Trendelenberg position. The surgeon stands about the left of the patient using the monitors in the foot end. Both upper limbs are placed by the side from the patient. Following the ports are inserted, the table is tilted left, to create the best side up for help in the dissection.

Pneumoperitoneum

Is done through the open or Veress needle method and also the 1st port (10mm), is ntroduced. Transumbilical entry is better and gives a great cosmetic result.

Diagnostic laparoscopy

Through the Umbilical port, a 10mm 300 telescope is introduced and a complete survey from the peritoneal cavity is conducted. The 300 telescope gives more flexibility and wider view. Diagnosing is confirmed and also the extent and severity of the inflammatory process is decided and feasibility of laparoscopic approach is assessed.

Secondary Ports

Two additional 5mm ports are presented under vision. 2nd port, 5mm just above the symphysis pubis in the midline and 3rd port, 5 mm within the left iliac fossa. For better visualization from the operative field Trendelenberg position is maintained with left tilt on the table.

Dissection

A 5mm manipulator is used to assess the appendix, caecum, ileum, pelvic organs and also the remaining abdominal cavity. A non-toothed grasper can be used with the 2nd port for grasping and retracting. The next port is used for the main operation. The appendix is identified and mobilised within the operative field by dissecting the lateral and inferior peritoneal attachments. A retrocaecal appendix with adhesions will require mobilization of caecum and ascending colon. The mesoappendix is grasped at its tip using the non-toothed grasper and also the appendix is raised to visualise the mesoappendix fully (Figure 2). Any adhesions are freed by endoscissors dissection with or without utilization of diathermy.

Mesoappendix

The mesoappendix has become cauterised near to the appendix with the use of bipolar grasper and divided with scissors. By repeating this process a few times the appendix is separated in the mesoappendix and dissected to the base. Bipolar cauterization allows specific tissue cauterisation and coagulates the appendicular vessels. This will make the procedure simple and easy , economical. The appendix has become fully dissected and skeletalised.

Ligation and Division of Appendix

The base of the appendix is doubly ligated with No.1 PDS using a Roeder knot or Mishra's Knot and pushing it having a knot pusher. A third ligature is placed on the appendix about 1cm from the base ligatures which ligature is kept really miss further grasping of the appendix. The appendix is cauterised using bipolar forceps between the ligatures and divided. Utilization of ligatures adds to the affordability of the procedure.

Delivery of the Appendix

The grasper holding the ligature on the appendix is pushed to the umbilical port. By withdrawing the telescope and the port gradually this grasper is presented of the umbilical wound. The appendix is then brought out of the wound. If the appendix is distended and enormous, an endobag is used and also the bag delivered just as. The use of bag prevents contamination from the wound. Irrigation of the area is usually not necessary.

Closing the wound

The linea alba within the umbilical wound is closed without any.1 vicryl. The umbilicus is dressed with a gauze ball dressing without sutures to the skin. Another 2 wounds are closed with 3/0 Subcuticular Monocryl.

Intra Operative Problems & Solutions

Tthere shouldn't be hesitation to convert to spread out operation if there are any difficulties in performing the operation.

The conversion rate mentioned in the literature is 2 to five %, depending upon the expertise of the surgeon. The Methods of solving following specific troubles are described below.

1. Mass Formation: Adhesion round the mass must be dissected gently with blunt or sharp dissection as in open surgery.
2. Retrograde dissection. Initial identification and ligature of appendix base and further dissection.
3. A loop ligature towards the thick and inflamed appendix to hold during dissection. This solves the difficulties of holding the appendix in difficult cases.
4. Mobilisation of the caecum and ascending colon for dissecting retrocaecal appendix.
5. Perforation of the caecum in the base will require suturing the base with 2/0 vicryl.
6. Bleeding - Gentle pressure, bipolar cautery, Harmonic Scalpel or suture the bleeder.
7. Vascular Staplers for that Base of appendix and Mesoappendix is popular within the civilized world. This really is much faster and easier. Might be useful in some selected cases. However it increases the costs and isn't necessary.
8. In current day practice, there appears no need for Lap Assisted appendix operations.

Advantages of Laparoscopic Appendicectomy

1. Complete evaluation of the abdominal cavity and definitive treating other and co-existing abdominal or pelvic pathology is possible without enlarging the incision.
2. Return to normal activity is faster, with almost similar hospitalisation.
3. Reduced post-operative pain.
4. Wound Infection Incidence is nearly nil.
5. Cosmetic answers are better.

Disadvantages of Laparoscopic Appendicectomy

The only real disadvantage is the marginally increased cost. It comes with an initial learning curve, that will boost the duration of surgery. Conversion to open surgery may be needed in difficult cases.

Appendicectomy, being a frequently performed procedure, it gives opportunity to teach surgeons in training with skills in laparoscopy. Laparoscopic Appendicectomy is being used successfully in several centers to train surgical residents and located to become a effective and safe laparoscopy training procedure. The dissection, use of cautery and suturing can be learnt effectively.

Conclusion

Laparoscopic appendicectomy is feasible with experience compares well and better with the open method. It is preferable in ladies with chronic right iliac fossa pain, in obese patients the place where a larger incision is going to be required, when cosmesis is preferred as well as for quick return to normal activities. It has become the option of operation in laparoscopy facilities.

 

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