Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

C H A P T E R 37

LAPAROSCOPIC APPENDECTOMY

Arthur P. Sanford

STEP 1: SURGICAL ANATOMY

Anatomic relationships of the appendix for laparoscopic appendectomy are identical to those for the open appendectomy.

With the limited access and visibility possible through the laparoscope, the serosal landmarks of the colon and appendix become more significant.

STEP 2: PREOPERATIVE CONSIDERATIONS

Early diagnosis and expeditious operative intervention for appendicitis prevents the complications of perforation and spillage of purulence.

Perform laparoscopic appendectomy after careful consideration with the option of open appendectomy and after assessing the patient, habitus, placement of trocars and scars, and likelihood that you can complete the procedure without needing to convert to an open procedure.

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3. CLOSING

Undertake a final inspection for hemostasis before removal of the laparoscope and ports.

Minimize irrigation of the abdomen to a volume that you can completely aspirate to prevent abscess formation.

Remove ports under direct visualization from within the abdomen.

Undertake suture closure for any port greater than 5 mm and the umbilical port.

Apply sterile dressings.

No peritoneal drains are indicated.

STEP 4: POSTOPERATIVE CARE

If placed at operation, nasogastric tube and Foley catheter can be removed immediately postoperatively.

Dietary resumption may begin immediately in the case of acute appendicitis, but if free purulence was found at operation, postoperative ileus mandates awaiting the return of bowel function.

Postoperative antibiotics are not necessary in acute appendicitis but should be continued in the presence of intra-abdominal purulence.

STEP 5: PEARLS AND PITFALLS

Placement of trocars facilitates intra-abdominal manipulation and avoids narrow angles of functional use.

SELECTED REFERENCES

1. Silen W, Cope Z: Cope’s Early Diagnosis of the Acute Abdomen, 21st ed. New York, Oxford University Press, 2005, pp 67-83.

2. Lally KP, Cox CS Jr, Andrassy R: The appendix. In Townsend CM, Beauchamp RD, Evers BM, Mattox KL (eds): Sabiston Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 1381-1399.

C H A P T E R 38

OPEN APPENDECTOMY

Arthur P. Sanford

STEP 1: SURGICAL ANATOMY

The blood supply for the appendix comes from the appendiceal artery, a branch of the ileocolic artery.

The location of the appendix in the right lower quadrant (RLQ) is variable, depending on a possible retrocecal position.

Note: The gravid uterus also displaces the cecum cephalad.

To increase exposure of the peritoneal cavity, extend a muscle-splitting incision, lateral to the arcuate line, medially and laterally.

STEP 2: PREOPERATIVE CONSIDERATIONS

History, physical examination, laboratory tests, and computed tomography (CT) scan as indicated will identify patients with acute appendicitis for appendectomy.

Appropriate preoperative antibiotics should be administered upon confirmation of the diagnosis of appendicitis until operative intervention, with postoperative administration based on operative findings. Coverage should include typical intestinal flora, including gram-negative organisms and anaerobes.

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STEP 3: OPERATIVE STEPS

1. INCISION

Identify the midpoint of a line between the umbilicus and right anterior-superior iliac spine. Appropriate skin incision is made at this level (Figure 38-1).

Electrocautery is used to dissect down to the fascia of the external oblique muscle, lateral to the rectus abdominus muscle.

The external oblique fascia is incised along the length of its fibers and spread.

FIGURE 38–1

4 0 6 S E C T I O N I V • T H E A B D O M E N

Blunt dissection can be used to separate the underlying internal oblique and transversus abdominis muscles along the length of their fibers in layers, as well (Figure 38-2).

The peritoneum can then be cleaned off and incised.

Peritoneal incision is typically done by elevating the peritoneum between two hemostats and making sure no intra-abdominal contents have been trapped in the operative field.

2.DISSECTION

Once the peritoneum has been entered, the RLQ can be explored to identify the location of the appendix and any associated pathologic findings or abscess.

The small intestine can be retracted medially, allowing identification of the cecum.

Transversus

abdominis muscle

Internal oblique muscle split

External oblique muscle

FIGURE 38–2

4 0 8 S E C T I O N I V • T H E A B D O M E N

The cecum and base of the appendix are brought out of the wound.

The mesoappendix containing the appendiceal artery is divided and ligated down to the serosa of the appendix where it joins the cecum (Figure 38-5).

The appendiceal base is crushed at the proposed level of division, and the clamp released and replaced distally. This creates a position to ligate the appendix (Figure 38-6, A).

The appendiceal stump can be doubly ligated with slowly absorbing suture, or the appendix can be singly ligated with rapidly absorbing suture if it is to be imbricated. The ligature is to obliterate the lumen but not strangulate the short segment of appendix between the ligatures

(Figure 38-6, B).

The mucosa of the appendiceal stump should be obliterated with electrocautery to prevent accumulation of a mucocele.

Purse-string suture around the appendiceal base or Z stitch can be used to secure the base of the appendix, as well.

3. CLOSING

Once hemostasis is ensured, the abdomen is closed in layers, starting with the peritoneum (optional); if a muscle-splitting incision has been performed, the internal oblique and transversus abdominis muscles require only loose approximation.

More attention should be given to closure of the fascia of the external oblique muscle, which will be a strength layer.

In more corpulent patients, Scarpa’s fascia can be loosely approximated.

If purulent appendicitis was found at exploration, the skin should be left open, or closed in acute appendicitis.

No intraperitoneal drains are indicated.

Sterile dressings are applied.