George Crawford, MD
Laparoscopic Appendectomy
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
Relevant Anatomy
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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.
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.
Operative Steps
Access
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.
Repair
Repair
- The appendix is identified and retracted superiorly.
- 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.
- 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.
- 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.
Closure
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
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.
Additional resources
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