]

24 o Surglcol

Procedures lnctuding.Minimol Access procedures

Gostrointesflnot Surgery

r l!$

Discussion

ists,trowever, as to the propriety ofperforming laparoscopic appendectomy in that the standard open procedure can often, by a small incision, be accomplished in less time with niinimal postoperative morbldity and less.operating room anesthesia cost. When the preoperative diagnosis is in doubt, the laparoscopic approach iq very useful especially in the female patient to exclude gynecologic and other entities, some of which can then be treated laparoscopically (e.g., ovarian torsion or cyst). Some authorities suggest that laparoscopic visualization is superior to the traditional small incision approach in instances ofobesity and to expose a retrocecal appendix. However, when an abscess or significant adhesions are encountered and the definitive operative area cannot be defined expeditiously or if a mucoc-ele or neoplasm is found, conversion to an open procedure is _necessary. Incidental appendectomy may be performed in conjunction with other laparoicopic
procedures.

Indications for .laparoscopic append.ectomy are the same as for the traditional procedure. Contioversy ex-

placed just distal to the same, the appendix is ampu_

p_loyed,

electrocautery or scissors. The appendicJutrr-p *ry be cauterized. During the procedur" tt;;;; functions can be a.lternated. The specimen is withdrawn into the trocar slbeve (ofthe selecied port). Ifthe.pp""ai* i".._ verely inflamed or edematoui, .r, specimen pouch can be employed. Hemostasis is assure^d. "ndoscopic Local rrrgatron and suction may be done and a drain placed as indicated. Pneumoperitoneum is released th" sounds closed in the usual manner. "rrd

tated..Altern-atively, additional suture^ loop can be em_ and the appendix divided by endo laser fiber or

Preporotion of potient

'Ihq patient is_ supine; both arms may be padded and iucked in at the p-atient's sides. Apply eleitrosurgical
fispersive pad. Foley catheter is not routinely plaied.
Skin Preporotion

Begin at the midline extending from the nipples to the qrper thighs and down to the lable at the siies.

Procedure Pneumoperitoneum is established. Abdominal exploration is performed through a 10/11 mm or 12 mm port. If appendicitis is confirmed, additional ports in ttre suprapubic area (5 mm) a.nd right subcostal at the anterior axillary line (12 mm) are established. Additional right or left lower quadrant ports may be required. The cecu-m rs retracted superiorly via a right subcostal port employing an atraumatic instrument (e.g., end.oscbpic Babcock). After appropriate dissection the appendiceal tip is-distractg4 by grasping forceps (or by endoscopic loop ligature if edematous). The mesoappendix is exposed and a "window" made in a.t arrasculir site. Using an endoscopic gastrointestinal stapler or between serial clips, the mesoappendix (includlng the appendiceal artery) is divided. An endoscopic loop ligature of chromic catgut may be secured about the appendiceal base, and with an endoscopic gastrointestinal stapler

Droping
{Gamera cable cover

Folded towels and a laparoscopy sheet

Equipment

-Tlleo monitor

ilcB

hsufflation device (CO2) fiberoptic light source (e.g., Xenon 800 W)

I unit

tray
needles

(5 mm, 10 mm, 12 mm, or Hasson)