Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 280 - файл

The patient is placed in the supine position on the operating table with the left arm or both arms tucked. A Foley catheter should be considered if the patient was not confirmed to have voided before the case. The patient is prepped from the xiphoid process to the pubis. The abdomen is accessed through the umbilicus either with an open technique using a Hasson trocar or closed technique with a Veress needle. For placement of the Veress needle, the umbilicus is elevated with two towel clips, and an incision is made through the skin. The Veress needle is inserted perpendicular to the skin and advanced until two audible clicks as the spring-loaded needle retracts are appreciated. The first click occurs as the needle transverses the fascia, and the second click occurs as the needle transverses the peritoneum. A saline drop test is then performed to confirm entry into the peritoneal cavity. The abdomen is insufflated with carbon dioxide until intraabdominal pressure is 12 to 15 mm Hg. The Veress needle is retracted, followed by either a blind entry with a 12-mm closed conventional trocar or radially expanding trocar ver­sus visual entry with an optical trocar (Optiview, Visiport). For the Hasson open technique, an incision is made into the infraumbilical or supraumbilical fold and carried through the subcutaneous tissue. Dissection is then performed through the subcutaneous tissue with S-retractors or a Kelly clamp until the rectus fascia is visualized. Two retention sutures are placed into the fascia on either side of the midline. With a knife, scissors, or electrocautery, a vertical incision is made through the fascia elevated with the retention sutures. The peritoneal cavity is entered bluntly with a Kelly clamp. The Hasson port is inserted under direct visualization and anchored in place with the stay sutures. The abdomen is insufflated and inspected to ensure that no injury occurred during entrance. The placement of subsequent trocars can be variable, depending on patient size, age, and pregnancy (Fig. 4). However, our preference is the use of an umbilical camera port and the working 5-mm ports at the right upper quadrant and LLQ (see Fig. 4A). A four-quadrant exploration is first done to quickly rule out other intraabdominal abnormalities before the patient is placed in reverse Trendelenburg with the right side up. Atraumatic graspers are used to follow the cecum to the con­vergence of the taenia coli. The cecum is lifted toward the left upper quadrant to better expose the base of the appendix. The mesoappen­dix is grasped/elevated, and peritoneal and/or omental attachments are lysed to expose the entirety of the appendix. For the retrocecal appendix, the white line of Toldt must be divided to mobilize the cecum and expose the appendix. A window is created through the mesoappendix. A linear gastrointestinal endoscopic stapler with a white load or an electrosurgical device (cautery or LigaSure) is intro­duced through the umbilical port, and the mesoappendix is divided, leaving the base of the appendix exposed (Fig. 5A). A blue load on the stapler is then used to divide the appendix (Fig. 5B; Fig. 6). Of note, an Endoloop may also be used to control the appendiceal base. The appendix is placed in a retrieval bag and withdrawn through the umbilical port. The staple line is then inspected, and hemostasis is achieved, as necessary. If murky, turbid fluid is observed in the pelvis, consideration should be given to obtaining a sample for Gram stain, culture, and sensitivities. Information gained may influence the choice of postoperative antibiotics. Recent data discourage peri­toneal irrigation as it shows no benefit and may lead to an increased incidence of postoperative abscess formation. The working ports are removed under direct visualization, followed by desufflation through the umbilical port and closure of the trocar sites.