George Crawford, MD

Laparoscopic Appendectomy

Laparascopic Appendectomy Image

 

 

 

Procedure Overview

Pre-operative Patient Care

Prep & Patient Positioning

Operative Steps

Post-operative Patient Care

 

Procedure Overview

Laparoscopic appendectomy is a minimally invasive surgical procedure to remove the vermiform appendix. 
 

INDICATIONS:
 

  • Appendicitis (Acute, Chronic, Gangrenous, Perforated, Suspected, or Uncomplicated)
  • Incidental (during another procedure often due to injury or abnormal anatomy)
  • Carcinoid tumors (in children and when confined to the tip of the appendix)
  • Adenocarcinoma of the appendix requires a right colectomy

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Pre-operative Patient Care
 

Typical recommendations for pre-operative care may include, but are not limited to, any of the following:

  • CT Scan with PO or IV contrast.
  • Ultrasound in pediatric population.
  • Clinical Exam is often enough with a thorough history to make diagnosis.
  • Cardiopulmonary evaluation as needed.
  • Anesthesiology consultation as needed.
  • Nothing by mouth for 6 hours before surgery.
  • Prophylactic antibiotics for patients with acute appendicitis.

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Prep & Patient Positioning
 

Common patient positioning:

  • The patient is supine with both arms tucked at the sides. The operating surgeon and assistant stand on the patient's left.

  • Placing the patient with the left side down aids gravity in relocating the small bowel away from the appendiceal/cecal field of vision.

     

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Appendectomy Image

 

Common port placement

  • Infraumbilical port
  • Left lower quadrant port
  • Suprapubic port

 

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Port Placement Image

 

Operative Steps
 

1. Access

  • Patient is positioned, prepped, and draped. Access is generally obtained by making an incision in the umbilicus. 
  • Usually, a 12 mm trocar is used to enter the abdomen, and then lower pelvic 5 mm trocars are placed.

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2. Repair

  • The appendix is identified and retracted superiorly.
Repair Image 1

 

  • The mesentery of the appendix is mobilized and transected using an energy device such as ENSEAL™ X1 Straight Jaw Tissue Sealer or HARMONIC™ 1100 shears. 
Repair Step 2 Image

 

 

  • An endoscopic stapler, such as ECHELON™ 3000 Stapler, is fired across the base of the appendix and cecum taking care to not leave an appendiceal stump.
Repair Step 3 Image

 

  • Once completed, the appendix is placed in a specimen retrieval bag and removed through a 12 mm port.
  • A drain is placed in the right lower quadrant if there are signs of perforation.

 

 

  • The appendix is removed in the specimen retrieval bag through the 12 mm trocar site.

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Repair Image 4

 

3. Closure

  • A suture like a size 0 Vicryl™ Plus Antibacterial suture, is used to reapproximate the fascia of the umbilicus.
  • The remaining trocars are removed.  The wounds are closed using synthetic absorbable monofilament, such as Monocryl™ Plus Antibacterial suture, and a topical skin adhesive such as DERMABOND™ Mini Topical Skin Adhesive, or any appropriate dressing. 

  • The patient is extubated, the Foley is removed, and the patient is taken to the recovery room.

     

    Potential complications include but are not limited to:

  • Bleeding requiring reoperation



    Note: If reoperation is necessary then an adjunctive hemostat such as SURGICEL SNoW™ or SURGICEL Powder™ might be a good option to control bleeding where primary methods (energy, staples, sutures, or clips) are ineffective or impractical.
     

    • Surgical site infection (deep or superficial)
    • Fecal fistula
    • Conversion to open appendectomy
    • Need for midline laparotomy
    • Open wound
    • Need for additional tests or procedures

     



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Closure Image 1

 

 

Post-operative Patient Care
 

Typical recommendations for post-operative care may include, but are not limited to, any of the following:

  • After completion of the surgical procedure, the patient is out of bed, ambulating, with appropriate pain control. 
  • Diet is advanced as tolerated, with plans for discharge on postoperative day 1 for uncomplicated appendicitis. 
  • Resumption of normal activity occurs within 1 day following the procedure; adequate analgesia allows safe return to daily duty.
  • Discharge instructions consist of pain management, instructions on the future signs and symptoms indicating potential complications, and a follow-up office appointment.
  • The postoperative outpatient office visit evaluates the patient's improved progression with a detailed history and physical examination, discussion of the final pathology, and evaluation of the surgical wound. 

 

 

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