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288
9.9 Alternative Operative Techniques for Gastro-Jejunal Bypass in Morbid Obesity
Fig. 9.9.12 Introduction of the anvil into the stomach and through the
anterior gastric wall using a right angle dissector and a long silk suture.
Step-by-Step Procedure
Initial Preparation
1. Place the patient in the supine position with a foot board at
the bottom of the table.
2. Lower extremity compression pneumatic compression devices are applied.
3. Insert Veress needle in the left upper quadrant at the level of
the mid-clavicular line.
4. Establish a pneumoperitoneum and remove the Veress
needle once 4 liters of CO
and insert a 12 mm port.
5. Place the remaining ports as illustrated in Figure 1.
6. Retract the left lobe of the liver form the most lateral left port
site.
7. Place the patient in steep reverse Trendelenburg position.
8. Insert a baker tube trans-orally into the stomach and fill the
balloon with 15 cc of air. Pull back the balloon against the
gastroesophageal junction.
9. Use the electro-cautery to “tatoo” the anterior gastric wall
serosa just below the balloon to demarcate the boundary line
of the inferior portion of the future gastric pouch.
10. Remove the baker tube.
has entered the peritoneal cavity
2
Method 1
1. Insert a naso-gastric tube (NGT) trans-orally and advance until
it is visualized in the body of the stomach.
2. Create an anterior transverse gastrotomy, 2.5 cm in length,
over the NGT using the harmonic scalpel.
3. Using a grasper through the 15 mm port site, pull the NGT
out the gastrotomy site and through the 15 mm port.
4. Remove the 15 mm port over the NGT and secure the head of
a 21 mm circular stapler to the NGT as illustrated in Figure 2.
5. Tie a six-inch prolene suture with a needle on the other end to
the tip of the anvil.
6. Dilate the 15 mm port in order to allow passage of the anvil.
7. The NGT is pulled back by the anesthesiologist introducing
the anvil through the dilated 15 mm port into the peritoneal
cavity and through the gastrotomy (Figure 3).
8. The anvil is advanced into the esophagus by pulling back on
the NGT.
9. Grasp the free needle with a needle driver and advance it
through the gastrotomy to the site where the tip of the anvil
should ultimately pass.
10. Pass the needle half way through the anterior gastric wall and
hold in position (Figure 4).
Results
289
11. Apply electrocautery to the anterior gastric wall directly adjacent to the needle.
12. Pull the suture and allow the passage of the shaft of the anvil
through the anterior gastric wall.
13. Cut the suture and remove the needle from the peritoneal
cavity.
14. Close the gastrotomy site with a linear stapler and create the
15 cc gastric pouch by stapling below the shaft of the anvil
(Figure 5).
15. Place patient in the supine position and identify the ligament
of Treitz.
16. Divide the jejunum 35 cm from the ligament of Treitz along
with the mesentery.
17. Suture a Penrose drain to the distal transected jejunal limb.
18. Measure the Roux-limb, starting where the Penrose drain is,
from 100−150 cm in length.
19. Create a side-to-side jejuno-jejunostomy with a linear stapler
using the transected proximal limb and the distal jejunum
measured at 100−150 cm.
20. Close the defect in the mesentery with a few interrupted sutures.
21. A window is created in the transverse mesocolon with the har-
monic scalpel.
22. The Penrose drain on the distal jejunal limb is secured with a
reticulating grasper and inserted through the mesenteric win-
dow behind the distal gastric stump along with the jejunal
limb.
23. Once the jejunal limb is in the appropriate position adjacent
to the gastric pouch, the Penrose drain is removed along with
the staple line that closes the jejunal limb.
24. The left lateral 12 mm port site is dilated to allow insertion of
the 21 mm circular stapler.
25. Advance the circular stapler into the open jejunal limb 10 cm
and deploy the cartridge spike through the antimesenteric
wall. Connect the hollow portion to the anvil shaft that is
through the gastric pouch (Figure 6).
26. The circular stapler is fired and an end-to side gastro-jejunal
anastomosis is created.
27. On withdrawal of the circular stapler, the suture securing the
head of the anvil to the tip of the naso-gastric tube is cut with
the Endoshears (Figure 7).
28. The naso-gastric tube is removed by the anesthesiologist and
the stapler is removed out of the peritoneal cavity.
29. The open end of the Roux-limb is closed with a linear stapler
and the gastro-jejunal anastomosis is reinforced with a run-
ning suture.
30. Test the anastomosis for leaks using air insufflation.
31. Close the mesenteric defect in the transverse mesocolon with
a few simple interrupted sutures.
32. A JP drain is placed by the gastro-jejunal anastomosis and all
fascial port sites greater then 5 mm are closed (Figure 8).
Method 2
1. Follow steps 1−10 in the initial preparation section.
2. Create an anterior transverse gastrotomy, 2.5 cm in length,
with the harmonic scalpel.
3. A red rubber catheter is cut 10 cm proximal to the tip and is
placed over the shaft of the 21 mm anvil outside of the peri-
toneal cavity.
4. Introduce the anvil and catheter into the peritoneal cavity
through the 15 mm port site.
5. Advance the head of the anvil through the gastrotomy into
the esophagus using a grasper (Figure 9).
6. Position the tip of the rubber catheter in the area where the
anvil shaft should ultimately pass through the anterior gastric
wall. Electro-cautery is then applied directly to the gastric wall
overlying the catheter tip to make a small opening (Figure
10).
7. The catheter tip is now advanced through the opening and
pulled from the other end with a grasper (Figure 11).
8. The red rubber catheter is removed from the shaft of the
anvil.
9. Continue with steps 14−32 from method one for completing
the operation.
Method 3
1. Follow steps 1−10 in the initial preparation section.
2. Create an anterior transverse gastrotomy, 2.5 cm in length,
with the harmonic scalpel.
3. Secure a long silk suture to the tip of the 21 mm anvil shaft
and introduce it into the peritoneal cavity through the 15 mm
port site.
4. With a right angle dissector, carry the end of the silk suture
through the gastrotomy site to the future site of the gastro-jejunal anastomosis.
5. The anterior gastric wall is incised over the tip of the right
angle clamp using the harmonic scalpel.
6. The suture is grasped and pulled with a dissector from the left
lateral port site (Figure 12).
7. Continue with steps 14−32 from method one for completing
the operation.
Results
Laparoscopic Roux-en-Y gastric bypass is a technically demanding and challenging operation requiring appropriate laparoscopic skills. Established complications related to RYGB include
pulmonary embolism, deep venous thrombosis, hernia forma-
tion, respiratory compromise, anastomotic leaks, intraoperative
splenic injury and wound infections (Yale, 1989; Manson et al.,
1992). The benefits of the laparoscopic approach include
shorter hospital stay and quicker recovery time (Wittgrove et
al., 1994; Wittgrove et a., 1996). Other benefits include gratify-
ing cosmetic results and reduced incisional hernia rates and
wound complications.
In order to provide safe and appropriate care, the laparoscopic
procedure should be identical to the open procedure except in
the approach. The surgeon should not alter the procedure because a particular step may be technically difficult or time consuming. For example, some authors report performing laparoscopic antecolic loop gastric bypass although that operation is
no longer an accepted open procedure (Lonroth et al., 1996). In
the late 1960’s Manson performed loop gastric bypass but this
was modified to a Roux-en-Y gastro-jejunostomy because of the
high incidence of postoperative esophagitis and bile gastritis
(Manson and Ito, 1969; McCarthy et al., 1985). It is imperative
that we do not compromise a patient’s health by performing an
operation that is laparoscopically easier to perform but not ac-
290
9.9 Alternative Operative Techniques for Gastro-Jejunal Bypass in Morbid Obesity
cepted worldwide in the open approach. We realize that the
skill and learning curve required to perform a laparoscopic
Roux-en-Y gastric bypass is extensive. The creation of a small
(15-ml) gastric pouch with anvil placement is the most challenging portion of the operation and potentially the limiting
factor. Emphasis must be place d on how crucial a small gastric
pouch is in determining a good future outcome.
We described three alternative techniques for introduction of
the 21-mm circular stapler anvil and creation of the 15-ml gastric pouch. These techniques utilize a gastrotomy prior to divi-
sion of the stomach and avoid upper endoluminal endoscopy for
anvil placement. The risk of injuring the esophagus or phar ynx
with manipulation of the anvil is totally avoided.
Bibliography
Belachew M, Legrad M, Vincent V, Lismonde M, LeDocte N, Deschamps V.
Laparoscopic adjustable gastric banding. World J Surg 1998; 22: 955−63
Committee on standards for reporting results. American Society for Bariatric
Surgery guidelines for reporting results in bariatric surgery. Obes Surg
1997; 7: 521-2
Dargent J. Laparoscopic adjustable gastric banding: lessons in the first 500
patients in a single institution. Obes Surg 1999; 9: 446−452
De la Torre RA, Scott JS. Laparoscopic Roux-en-Y Gastric Bypass: A Totally
Intra-abdominal Approach-Technique and Preliminary Report. Obes Surg
1999; 9: 492−498
Frantzides CT, Carlson MA, Schulte WJ. Laparoscopic Gastric Bypass in a Por-
cine Model. JSLS 1995;5:97−100.
Gastrointestinal surgery for severe obesity. NIH Consensus Statement 199,
March 25−27;9(1):1−20.
Holeczy P, Payer J Jr, Kralova A. Laparoscopic adjustable gastric banding: first
experience in Slovakia. Obes Surg 1999; 9: 198−201
Lonroth H, Dalenback J, Haglind E, Lundell L. Laparoscopic gastric bypass.
Another option in bariatric surgery. Surg Endosc 1996; 10: 636−38
Lonroth H, Dalenback J, Haglind E, Josefsson K, Olbe L, Fagevik Olsen M, Lun-
dell L. Vertical banded gastroplasty by laparoscopic technique in the treat-
ment of morbid obesity. Surg Laparosc Endosc. 1996; 6: 102−107
Manson EE, Ito C. Gastric Bypass. Ann Surg 1969; 170: 329−39
Manson EE, Renquist KE, Jiang D. Perioperative risks and safety of surgery for
severe obesity. Am J Clin Nutr 1992; 55: 573S-6S
McCarthy HB, Rucker RD, Chan EK, et al. Gastritis after gastric bypass
surgery. Surgery 1985; 98: 68−71
Metropolitan Life Insurance Company. New weight standards for men and
women. Stat Bull Metrop Ins Co 1959; 40: 1
Nguyen NT, Ho HS, Mayer KL, Palmer L, Wolfe BM. Laparoscopic Roux-en-Y
Gastric Bypass for Morbid Obesity. JSLS 1999; 3: 193−196
Nguyen NT, Wolfe BM. Hypopharyngeal Perforation During Laparoscopic
Roux-en-Y Gastric Bypass. Obes Surg. 2000 Feb;10(1):64−7.
Potvin M, Gagner M, Pomp A. Laparoscopic Roux-en-Y gastric bypass for
morbid obesity: a feasibility study in pigs. Surg Laparosc Endosc 1997; 7:
284−297
Schauer PR, Ikramuddin S, Gourash WF. Laparoscopic Roux-en-Y gastric by-
pass: a case report at one-year follow-up. J Laparoendosc Adv Surg Tech A
1999; 9: 101−106
Serra C, Baltaser A, Bou R, Miro J, Cipagauta LA. Internal Hernias and Gastric
Perforation After a Laparoscopic Gastric Bypass. Obes Surg 1999; 9: 546−
549
Teixeira J, Borao FJ, et al. An Alternative Technique in Laparoscopic Roux-en-
Y Gastric Bypass for Morbid Obesity: Experience with twenty-eight con-
secutive patients. Obes Surg 2000; in press
Wittgrove AC, Clark WG, Schubert KR. Laparoscopic Gastric Bypass, Roux-
en-Y: Technique and Results in 75 Patients With a 3−30 Months Follow up.
Obes Surg 1996; 6: 500−504
Wittgrove AC, Clark WG, Tremblay LJ. Laparoscopic Gastric Bypass, Roux-en-
Y: Preliminary Report of Five Cases. Obes Surg 1994; 4: 353−7
Yale CE. Gastric surgery for morbid obesity. Complications and long-term
weight control. Arch Surg 1989; 124: 941−46
10. Appendectomy and Small Bo w el Procedures
291
10.1 Appendectomy
F. Götz, A. Pier, R. Eichen
Goals and Methods
Appendicitis is the most frequent major disorder of the ver-
miform process. There are five basic pathologic-anatomic varia-
tions, each with characteristic gross and histological features
(Table 10.1.1). Generally the diagnosis is based on clinical examination, but can be confirmed with ultrasound.
Note: Appendicitis can be difficult to diagnose; delay and complications involving serious morbidity can occur.
For special anatomy, see Figs. 10.1.1 to 10.1.4.
Less frequent disorders of the vermiform appendix include mu-
coceles, carcinoid tumors, and carcinomas.
A mucocele occurs when the organ becomes distended with
mucus. There are four basic forms: “simple mucoceles” with
stenosis of the appendiceal ostium into the cecum, mucoceles
with hyperplastic polyps, neoplastic mucoceles, and mucoceles
associated with cystic fibrosis. Both benign and malignant mu-
coceles can produce implants throughout the peritoneum following a ruptured appendix (peritoneal and appendiceal pseu-
domyxoma).
The carcinoid tumor develops from the submucosa and possibly
has a neuroendocrine origin. Carcinoids are usually smaller
than 1 cm and are found at the tip of the appendix. The car-
cinoid tumor frequently invades the mesoappendix and the
perineural lymphatic sheaths. Metastases are rare, but may
occur if the carcinoid exceeds 2 cm. Mucoceles, carcinoid
tumors, and carcinomas, e. g., neoplastic tissue changes should
be managed through an adequate incision and an appropriately
careful (mucoceles) and sufficiently radical (carcinoid, carcinoma) excision, as warranted by the findings in each case.
Inflammatory and infectious disorders are treated by append-
ectomy with removal of the mesoappendix. If the cecal cul-desac is also involved (e. g., phlegmon, mucocele, carcinoid), ex-
tended resection (in applicable cases ileocecal resection) is indi-
cated. Tumors require prompt right hemicolectomy and lymphadenectomy.
Table 10.1.1 Stages of acute appendicitis (according to Merkel 1956 and
Remmele 1984).
Stage Elapsed time since
onset of clinical
picture
Early
appendicitis
Phlegmonous
appendicitis
Ulcerous/phlegmonous appendicitis
Intramural abscess-forming
appendicitis
Gangrenous
appendicitis
6 hours Significantly increased serosal
12 hours Generalized surface redden-
24 hours Multiple mucosal ulcerations,
48 hours Yellow purulent foci in the
72 hours Reddish black to grayish green
Macroscopic symptoms
vascularization, especially
distally.
ing. Serosa is often
darkened and with a fibrinous pus covering. Syrupy
yellow fluid in the lumen,
often mixed with blood and
liquid fecal material.
The entire appendix is
thickened and rigid.
especially distally. Phlegmonous infiltration of the
walls.
wall of the appendix.
discoloration of the appen-
dix. Wall of the appendix is
brittle. Fetid contents. Gener-
ally a wide perforation is present, accompanied by
purulent peritonitis with free
feces and contamination.
.
1
Indications
− Acute appendicitis.
− Ruptured appendicitis.
− Suspected ruptured appendicitis.
− Phlegmonous appendicitis.
− Chronic appendicitis.
Fig. 10.1.1 Appendectomy. Regional anatomy. 컄
Peritoneal adhesions.
1 Jackson’s membrane
2 Lane’s band
3 Cecum
4 Vermiform appendix
.
.
.
2
3
4
292
10.1 Appendectomy
.
1
9
.
.
2
.
3
.
8
7
Fig. 10.1.2 Appendectomy. Regional anatomy.
Topographic overview of the lower cecal region. The cul-de-sac of the
cecum and appendix are raised.
1 Vermiform appendix
2 Ileocolic artery
3 Appendiceal artery and mesoappendix
4 Terminal ileum
5 Terminal branch of the posterior
cecal artery
Fig. 10.1.4 Appendectomy. Regional anatomy.
Frequent variations of the appendiceal artery (according to Lippert). a)
Appendiceal artery originates at an “ileac branch” of the ileocolic artery.
b) Appendiceal artery originates at the ileocolic artery just before it splits
into its terminal branches. c) Appendiceal artery originates at the anterior
cecal artery (according to Platzer).
1 Ileocolic artery
2 Ascending branch
3 Anterior cecal artery
왓
.
.
.
.
6
6 Mesocolic tenia
7 Free tenia
8 Anterior cecal artery with
9 Ascending colon
4 Posterior cecal artery
5 “Ileac branch” of the ileocolic artery
6 Appendiceal artery
5
appendiceal branch
blubb
.
4
1
2
3
5
Fig. 10.1.3 Appendectomy. Regional anatomy.
Various possible positions of the vermiform appendix.
1 Subhepatic position.
2 Resting in the abdominal cavity attached to a mobile cecum or with
incomplete intestinal rotation.
3 Resting in the pelvis between the rectum and bladder or between
the uterus and rectum.
4 Seen as an extension of the free tenia.
5 Retrocecal position.
6 Laterocecal position.
7 Mediocecal position posterior to the terminal ileus.
67
4
.
2
3
.
.
.
4
.
6
.
1
5
abc
Trocar Placement
293
If clinical findings are inconclusive and the patient’s condition
does not require urgent operation, he or she may be hospitalized for observation, intravenous antibiotics and fluids until the
symptoms and pelvic ultrasonography lead to a definitive diagnosis or indicate a resolution of the original presenting signs
and symptoms. A semi-urgent operation or nonoperative treatment will be the response to either eventuality. A diagnostic laparoscopy may help in solving a persistent diagnostic dilemma.
Note: If operation reveals a normal vermiform appendix, the
surgeon must explore the entire abdominal cavity, particularly
the colon (to exclude a sigmoid tumor or diverticulitis) and the
small intestine (to exclude Meckel’s diverticulum). An append-
ectomy requiring resection of an involved cecum is performed
by laparotomy.
Contraindications
General Contraindications to Laparoscopy
− Cardiopulmonary pathology, coagulation disorders that do
not respond to treatment, infection of the abdominal wall.
− Pregnancy after the twenty-fourth week.
− Acute regional enteritis of the terminal ileum.
Specific Contraindications
− Ruptured proximal appendix (closure of the appendiceal
stump via laparoscopy may not be possible). Corrective action: conversion to laparotomy.
− Appendicitis with necrosis or phlegmon of the wall of the
cecum.
− Carcinoid tumor of the base of the appendix.
− Appendiceal carcinoma.
− Treat ruptured appendicitis with peritonitis by conventional
open operation.
In our study group, morbidity ranged from 0.8 to 15% with no
fatalities. Corrective reoperation was required in 0.5% of all
cases, the primary indication being development of a postoperative abscess.
Note: The decision to convert to an open procedure does not
represent a complication. In case of doubt, immediate conversion is indicated.
Several study groups cite an incidence of “cecal distension syndrome” or “fifth day syndrome” of 1.5−3.0%. The incidence of
wound infection appears to be less than in conventional appendectomy. Use of closed suction drains and antibiotic therapy
are indicated in patients with advanced and phlegmonous appendicitis.
Approximately 60% of patients complain of postoperative
shoulder pain following laparoscopy, in most cases beginning
on postoperative day three and spontaneously subsiding thereafter.
Special Preparations
Place a nasogastric tube and indwelling urinary catheter. Fluid
resuscitation and antibiotic treatment of one to two hours are
generally sufficient to prepare for operation on a suspected ruptured appendicitis and/or peritonitis. Although a prompt surgical response is indicated, we caution against a hasty operation
in patients with cardiovascular problems or noncompensated
electrolyte shifts, fluid and acid/base disequilibrium, oliguria, or
anuria. Fluid balance managment can markedly improve the
patient’s initial preoperative situation. In the presence of acute
appendicitis, we administer 2g of cefotam dihydrochloride and
500 mg of metronidazole.
Anesthesia
Surgical Risks and Patient Information
Laparoscopic appendectomy can involve complications due to
the disease and others that are specific to the technique. These
may require conversion to an open procedure.
In the early phase, the rate of conversion to open procedures is
about 10%. Complications include difficulties in closing the
stump of the appendix, bleeding from the appendicular artery
that cannot be laparoscopically controlled, thermal damage to
the small intestine or colon during coagulation of the vermiform
appendix with electrocautery, and failure to locate a retrocecal
appendix. The risksof hollow organ puncture associated with es-
tablishing the pneumoperitoneum also apply here.
The risk of injury to epigastric vascular structures when inserting instrument trocars into the lower abdomen is about 0.05%.
Our study group diagnoses abscesses in 0.3% of all cases. These
were due in part to overly long appendiceal stumps and to improper use of electrocautery. A residual appendiceal stump
which is not buried below a pursestring suture should be no
longer than 3−4 mm.
Note: When using electrocautery to coagulate the stump of the
appendix, select a medium-range power setting and apply
power only in short bursts of 1−2 seconds. To avoid thermal
necrosis, we recommend the retrograde technique described in
Figs. 10.1.18 and 10.1.23, p. 292−293.
An automatic stapler may be helpful in laparoscopic append-
ectomy (Figs. 10.1.26 to 10.1.28, p. 293).
General anesthesia.
Positioning
(Fig. 10.1.5).
Position of Operating Team
(Fig. 10.1.6).
Trocar Placement
(Fig. 10.1.7).
Visual Exploration of the Peritoneal Cavity
If inspection reveals only minimal changes of the appendix or
none at all, exploration of the peritoneal cavity to exclude or
treat other possible causes for the clinical symptoms (such as
endometriosis, adnexitis, diverticulitis, or ovarian cysts) will result in only minimal trauma to the abdominal organs. Meckel’s
diverticulum must be regularly excluded in laparoscopic appendectomy. In the absence of any other serious pathological
conditions, laparoscopic appendectomy is indicated. Appendicitis begins in the mucosa and may cause clinical symptoms
before the occurrence of any serosal changes that would be detectable under direct laparoscopic inspection.
294
10.1 Appendectomy
15–20°
Monitor
컅 Fig. 10.1.5 Appendectomy. Positioning of the patient.
Establish the pneumoperitoneum with patient in a horizontal position.
Perform the appendectomy in a slight Trendelenburg position (15−20°)
with the table inclined to the left.
Fig. 10.1.6 Appendectomy. Equipment and position of the operating
team.
The surgeon stands to the left of the patient, holding the laparoscope
with the right hand and the instrument for the left 5.5-mm trocar sleeve
(probe, grasper, bipolar electrocautery, curved scissors, Roeder knot applicator, etc.) with the left hand.
The bipolar electrocautery unit, aspirator/irrigator set, and insufflator are
on the same side as the surgeon. The first assistant stands to the right of
the patient and holds the instruments for the right trocar sleeve (grasper,
appendix extractor, swab with disinfectant, etc.). The monitor and light
source are on the same side as the first assistant. The operating room
nurse stands behind the instrument table at the patient’s feet.
왓
st
assistant
1
Electrocautery unit
Surgeon
Insufflator
1
Aspirator/irrigator set
OR nurse
Step-by-Step Procedure
Technical preparations
1. Adjust the electrocautery unit to a medium setting.
2. Connect the aspirator/irrigator set.
3. Start the recording unit.
Establishing the pneumoperitoneum
1. Select pressure plateau according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Make a periumbilical skin incision (approx. 1 cm).
3. Insert the Veress needle.
4. Perform safety tests: rotation, injection, aspiration, suction,
and manometer tests.
5. Perform insufflation procedure as usual.
Caution: insufflate children at 1 l/min maximum.
Laparoscopy
1. Insert the laparoscope/camera trocar using Semm’s tech-
nique.
2. Explore the peritoneal cavity visually (see Fig. 2.3.2,p.).
3. Insert the instrument trocars in the left and right lower abdo-
men under laparoscopic visualization.
4. In women, expose the reproductive organs with a probe (see
Fig. 2.3.2,p.).
5. Locate the appendix.
6. Make diagnosis and determine operative plan.
7. Grasp the tip of the appendix and pull it to the T3 trocar.
8. Coagulate the immobilized mesoappendix with bipolar electrocautery and scissors and transect the zone of mesoappendix coagulation stepwise.
9. Expose the base of the appendix.
10. Place a loop and ligature of absorbable suture material close
to the base of the appendix (metric 3.5).
11. Coagulate above the base of the appendix with bipolar electrocautery, maintaining a distance of 4−5 cm to the ligature.
12. Transect the vermiform appendix within the coagulation
zone.
13. Remove the transected appendix through the appendix retrieval sleeve of the T3 trocar.
14. Disinfect the remaining stump of the appendix.
15. Expose the distal loops of the small intestine to exclude a
Meckel’s diverticulum.
16. Remove the instrument trocars under laparoscopic visualization.
Caution: Residual bleeding from the trocar incisions may
occur. See Fig. 2.2.33.
17. Close fascia and skin incision.
Trocar Placement
T1
T2
T3
Fig. 10.1.7 Appendectomy. Trocar placement.
T1 10.5-mm laparoscope/camera trocar placed through an inferior umbilical
incision and advanced with the Z technique.
T2 5.5-mm instrument trocar. Locate a poorly vascularized area with transil-
lumination, and insert the trocar into the left lower abdomen under laparoscopic visualization (at the edge of the pubic hair).
T3 10.5-mm or 15-mm trocar; serves also for specimen retrieval. First locate
a poorly vascularized area with transillumination, and insert the trocar
into the right lower abdomen under laparoscopic inspection, using
McBurney’s point as a landmark.
Alternative procedure: open trocar placement.
295
296
10.1 Appendectomy
Operative Technique
T3
Fig. 10.1.8 Appendectomy. Grasping the tip of the appendix.
After exploring the abdominal cavity and excluding other disorders, grasp
the appendix as close to the tip as possible. This spreads the mesoappendix out like a sail (see Fig. 10.1.7 for key to instrument numbers).
Fig. 10.1.9 Appendectomy. Management of vessels with clips.
Pull the distal end into the extractor and make a fenestration near the
base of the appendix. The appendiceal artery is ligated with a suitable
clipping device.
Fig. 10.1.10 Appendectomy. Transecting the mesoappendix.
Transect the mesoappendix with the appendiceal artery in the coagulation zone with curved scissors between the two clips.
Fig. 10.1.11 Appendectomy. Placing the Roeder loop and sliding knot.
Place the Roeder loop around the cleared base of the appendix. It helps to
hold the appendix as close to a vertical position as possible. The ligature
must not constrict the cecum. Use the free tenia as landmark. For ligature
technique, see chapter 2.3.
Trocar Placement
297
T3
Fig. 10.1.12 Appendectomy. Cutting the ligature at the base of the appendix.
After tightening the knot, cut the ligature about 4−5 mm behind the knot
with curved scissors. The blades of curved scissors utilize the same design
principle as a tree pruner and prevent the suture from running along the
cutting edge of the scissor blades as can often happen with straight scissors (see Fig. 10.1.7 for key to instrument numbers).
T3
T2
Fig. 10.1.13 Appendectomy. Reversed technique: milking contents out
of the base of the appendix.
The reversed technique reduces the use of electrocautery. First clip the
vessels as described in Fig. 10.1.9. The retrograde technique shown here
eliminates the need for coagulation of the base of the appendix with electrocautery.
After taking care of the mesoappendix and the appendiceal artery with
clips, pull the tip of the ligated appendix into the inner sleeve of the
T3 trocar. Next squeeze out the appendix with an atraumatic grasper,
beginning at the base of the appendix and moving distally. This presses
the contents of the appendix into its tip (see Fig. 10.1.7 for key to instrument numbers).
Fig. 10.1.14 Appendectomy. Reversed technique: changing graspers. 컄
The grasper inserted through trocar 2 grips the base of the appendix im-
mediately above the ligature. Now insert a second grasper (trocar
sleeve 3) and slide it toward the base of the appendix along the grasper inserted through trocar 2. This helps one find the right position. Both
graspers should now be parallel to each other. Continue to grip the base
of the appendix with the distal grasper (T3) while the other grasper (T2) is
replaced with scissors (see Fig. 10.1.7 for key to instrument numbers).
T3
T2