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298
T2
10.1 Appendectomy
T3
ca. 3 mm
Fig. 10.1.15 Appendectomy. Reversed technique: transecting the base
of the appendix.
The emptied base of the appendix is transected between the ligature and
the closed grasper (trocar 3) at a safe distance from the Roeder knot with
scissor introduced through trocar 2. Next pull the appendix into the ap-
pendix retrieval sleeve in a retrograde fashion and extract it from the
abdominal cavity through trocar 3. Now disinfect the stump of the base
with a Betadine swab as shown in Fig. 10.1.17.
Note: Use a new inner tube or sleeve for the swab introduction.
T3
Fig. 10.1.16 Appendectomy. Complication: extraction error.
Here, the surgeon neglected to first pull the entire appendix into the retrieval sleeve while removing the appendix from the abdominal cavity.
The tip of the appendix outside the retrieval sleeve becomes caught in the
flap valve. Once this happens, attempting to pull the appendix out of the
valve will only pull the valve itself shut, rendering extraction impossible.
One can only extract the appendix if you remove the entire upper lock
with the flap valve from the trocar. To prevent a complete loss of CO
sure from the abdomen, the assistant must place a finger over the opening of the trocar.
Prevention:
− Always advance the retrieval sleeve 2−3 mm beyond the end of the
trocar in the abdomen.
− The second assistant places the index finger on the retrieval sleeve to
hold it when the appendix is pulled into the sleeve (see Fig. 4.1.83).
− Only remove the retrieval sleeve from the trocar after the appendix has
been pulled into the sleeve.
Note: Disposable and reusable new generation trocars are equipped with a
mechanism that facilitates specimen retrieval while preserving the
pneumoperitoneal seal.
pres-
2
컅 Fig. 10.1.17 Appendectomy. Disinfecting the stump of the appendix.
The residual ligated stump of the appendix should be as short as possible
to reduce the danger of necrosis or stump appendicitis. Disinfect it with a
Betadine swab inserted through a new uncontaminated retrieval sleeve
(trocar 3). Allow at least five seconds for the disinfectant to act. Swab
handling and possible complications are described in Figs. 4.1.80 and
4.1.81. Do not bury the stump of the appendix. This technique eliminates
the need for a pursestring suture.
Alternative Techniques
T2
T3
T2
T3
T2
T3
Trocar Placement
299
Fig. 10.1.18 Appendectomy. Alternative technique. Preparing for a retro-
grade appendectomy. Incise the peritoneal covering of the mesoappendix
near the base (trocar 2) while applying tension to the appendix. If bleeding occurs, hemostasis can be immediately obtained with bipolar electro-
cautery.
Fig. 10.1.20 Appendectomy. Alternative technique. Stapling across the base of the appendix. After opening the
window in the mesoappendix, move the base of the appendix into the jaws of the stapler, keeping the stapler as
close to the base as possible. By activating the stapler, two double staple lines are placed, one on each side of a
blade separating the appendix from the cecum, while both hollow structures are simultaneously closed by the
staples. Two staple applications are necessary if the mesoappendix is large and is taken separately, as will most
often be the case.
Note: The tissue to be transected must be placed exactly between the markings on the stapler.
After selecting the proper stapler size and separating the appendix from the mesoappendix, place the stapler
close to the base of the appendix. After stapling appendix and mesoappendix (in one or two applications as
needed), remove the stapler and extract the appendix through the T3 trocar using a grasper inserted through the
retrieval sleeve or tube.
Fig. 10.1.19 Appendectomy. Alternative technique. Window of the mesoappendix.
Grasp the appendix approximately 2−3 cm from its base on the cecum
(trocar 3). Insert a grasper through the 5.5-mm trocar sleeve (trocar 2) located in the left lower abdomen. With blunt dissection and spreading of
the grasper blades, open a window in the base of the mesoappendix. If
bleeding occurs, obtain immediate hemostasis with bipolar electrocautery.
Fig. 10.1.21 Appendectomy. Alternative technique. Circumferential ligature applied to the base of the appendix
and secured with an extracorporeally tied knot.
An alternative to the stapler technique shown in Fig. 10.1.20 is to use a ligature with an extracorporeal Roeder
knot. Feed the free end of the ligature through the window in the mesoappendix and back out through the 5.5mm instrument sleeve inserted in the left lower abdomen. Knotting technique is described in chapter 2.3. Use a
90-cm length of absorbable suture (metric 3.5).
T3
T2
300
10.1 Appendectomy
T3
T2
Fig. 10.1.22 Retrograde appendectomy. Alternative technique.
If the tip of the appendix is adherent or otherwise inaccessible, perform
the appendectomy in a retrograde fashion. Transect the appendix near its
ligated base and coagulate the mesoappendix first (trocar 2). Grasp the
free end of the transected appendix with a grasper (trocar 3). If a stapler is
used, double staple lines, one each on the base of the appendix and on
the free end of the transected appendix, provide a secure closure (see
Fig. 10.1.20).
T3
5 mm
Fig. 10.1.23 Retrograde appendectomy. Alternative technique: retrieval.
Pull the transected appendix base first into the retrieval tube (trocar 3).
This tube must be advanced approximately 5 mm beyond the end of the
trocar in the abdomen.
Caution: Avoid contaminating the end of the trocar.
T3
T2
Fig. 10.1.24 Appendectomy. Alternative technique. Double-loop technique. Transecting the appendix.
The double-loop technique is another alternate method of performing la-
paroscopic appendectomy without coagulating the base of the appendix.
After placing a ligature around the base of the appendix and squeezing
the lumen from the base to the tip, place a second Roeder loop and knot
approximately 5−7 mm above the initial ligature. Now one can transect
the appendix (scissors, trocar 2) between these two ligatures without
having to coagulate it. Extract the transected appendix from the abdominal cavity through a sleeve (trocar 3), and disinfect the stump (see
Fig. 10.1.17,p.).
T1
T3
T2
Fig. 10.1.25 Appendectomy. Alternative technique. Stapled appendectomy: trocar placement.
The 12-mm trocar (trocar 2) inserted in the left lower abdomen is used for
introducing the stapler and removing the appendix.
The grasper for applying tension to the appendix is inserted through the
15-mm instrument sleeve in the right lower abdomen. The forward-viewing laparoscope is introduced through a 10-mm sleeve inserted in the inferior umbilical rim (trocar 1).
T2
T3
T2
Trocar Placement
301
T3
Fig. 10.1.26 Appendectomy. Alternative technique. Stapled append-
ectomy.
While elevating the appendix with a grasper, insert the mesoappendix
near the base of the appendix into the open jaws of the stapler. Determine
the proper stapler size, adapted to tissue thickness. Two applications of
the stapling instrument may be necessary if the mesoappendix is too
large. Note that the tissue to be transected must be placed exactly be-
tween the markings on the stapler.
Fig. 10.1.27 Appendectomy. Alternative technique. Stapled appendectomy.
After selecting the proper stapler size and cleaning the appendiceal base,
place the stapler close to the cecum.
After stapling, remove the stapler and retrieve the appendix through the
same trocar sleeve (12 mm) using a grasper inserted through the 5-mm
converter.
Fig. 10.1.28 Appendectomy. Alternative technique. Stapler append-
ectomy: the surgical site.
Inspect the surgical site to ensure that hemostasis has been obtained. Remove any superfluous staples from the abdominal cavity under laparo-
scopic control.
Disinfect the stump of the appendix with a Betadine swab inserted
through the left 12-mm trocar. This completes the procedure.
Fig. 10.1.29 Appendectomy. Alternative technique. Closure of the appendiceal artery.
The vessels of the mesoappendix can be managed securely by intra- or extracorporeally knotted ligatures. This technique is particularly useful for a
fat-rich mesoappendix. Suture: resorbable polyglycolic acid 0; metris 3.5;
length 90 cm.
302
10.1 Appendectomy
T3
T2
Fig. 10.1.30 Appendectomy. Alternative technique. Bipolar coagulation.
Pull the distal end of the appendix into the T3 trocar inner sleeve and
begin coagulation of the appendiceal artery close to the appendix using
bipolar electrocautery. Apply power only in short bursts of 1−2 seconds at
a medium-range power setting (see Fig. 10.1.7 for key to instrument num-
bers).
Drainage and Lavage
Placement of a peritoneal drain exiting through a separate stab
wound is indicated in localized and generalized peritonitis. Irrigate the abscess cavities with isotonic saline solution at body
temperature with the patient placed in the reverse Trendelenburg position.
Note: In the presence of generalized peritonitis, immediate conversion to conventional laparotomy is indicated.
Antibiotic Therapy
Perioperative parenteral antibiotic therapy (with medications
such as cefotam dihydrochloride and metronidazole) is recom-
mended for colon surgery. Antibiotic therapy is indicated following intestinal perforation, peritonitis, periappendiceal infiltration, and appendiceal abscess. Continue therapy for three to
five days. Obtaining a culture is indicated.
Palliative Surgery
In the presence of an appendiceal abscess, exposing the appendix can be difficult and may lead to complications.
Corrective action:
− Laparoscopy: Debride and irrigate the abscess cavity, leaving
the appendix in place. Place a peritoneal drain. Remove the
appendix during a second procedure after a safe clinical interval.
− Laparotomy: Chances for safe appendectomy are better
using conventional techniques. Otherwise, proceed as described above.
T2
Fig. 10.1.31 Appendectomy. Alternative technique. Transecting the
coagulation zone.
Transect the mesoappendix in the coagulation zone with curved laparoscopic scissors. The coagulation zone extends close to the base of the appendix (see Fig. 10.1.7 for key to instrument numbers).
Complications
Improper use of electrocautery in laparoscopic appendectomy
can cause serious complications. These can be reduced by not
using monopolar electrocautery. Every surgeon must be familiar with the characteristics of the respective coagulation device
used (i. e., laser, monopolar or bipolar electrocautery, etc.). The
surgeon must appreciate that any application of these techniques results in thermal tissue destruction and that the various
techniques require different practice methods and specific
timing.
To reduce complications involving the stump of the appendix,
observe the following precautions:
1. Only experienced laparoscopic surgeons should perform
the procedure.
2. The retrograde technique will reduce the use of electrocautery (see p. 291). Use a stapler at the base; do not use
clips.
3. Precisely expose the base of the appendix.
4. Be familiar with anatomic variants (see Fig. 10.1.3 and
10.1.13).
5. Use synthetic absorbable sutures but not catgut.
6. Use the proper specimen retrieval technique.
7. Disinfect the stump of the appendix.
8. Leave only a short appendiceal stump in place to avoid
necrosis (3−5 mm maximum).
9. When in doubt, convert to open procedure.
10. Convert to open procedure in the presence of a proximally
ruptured appendix.
Fig. 10.1.32 Appendectomy. Complication: coagulation of the mesoappendix.
The heat produced by electrocautery is an important factor in complications. The following errors can produce thermal necrosis of the appendiceal base on the cecum:
− Coagulation time too long.
− Coagulation too close to the base of the cecum.
− Power setting too high.
− Use of monopolar electrocautery.
Prevention:
The surgeon can observe thermal tissue changes:
− Tissue shrinkage occurs (the tissue is dehydrated).
− Blistering occurs (the tissue “cooks” and edema forms).
− Discoloration occurs (proteins are destroyed and the tissue is coagulated).
When using electrocautery, always ensure proper
− duration,
− power setting,
− type of application (monopolar or bipolar).
T3
Complications
3–5 mm
303
Corrective action:
If intraoperative thermal tissue damage is observed, conversion to laparotomy may be indicated depending on the extent of the damage.
Intraoperative Complications
Generalized peritonitis.
Corrective action: Convert to open procedure.
Specific laparoscopic complications can occur which necessi-
tate conversion to a conventional open procedure.
Injury to a Hollow or Parenchymal Organ
(See Fig. 10.1.6 and Fig. 10.1.13).
Corrective action: Intestinal punctures can be laparoscopically
sutured. If difficulties are encountered or in case of doubt, con-
version to laparotomy is indicated. The same applies to major
injuries of solid organs.
Uncontrollable Bleeding from the Appendiceal Artery
Corrective action: If hemostasis cannot be obtained laparoscopi-
cally, conversion to laparotomy is indicated to control bleeding.
Puncture of the Common Iliac Artery
(See Fig. 10.1.12).
Injury to the common iliac artery is a major complication. This
can occur as a result of improper placement of instrument tro-
cars into the lower abdomen.
Corrective action: Convert to open laparotomy immediately and
repair the puncture.
Puncture of an Epigastric Blood Vessel
(See Fig. 10.1.15).
Corrective action: Place a transabdominal ligature with a
straight or curved needle under laparoscopic visualization.
T2
Thermal Damage to the Small Intestine or Colon
(Figs. 10.1.32 and 10.1.33).
Using electrocautery to coagulate the base of the appendix can
cause direct or indirect thermal necrosis in adjacent parts of the
cecum.
Corrective action: If in doubt or if major lesions are present, conversion to laparotomy is indicated.
Avulsion of the Appendix
In a gangrenous or phlegmonous vermiform appendix, there is
the danger of tearing the appendix, avulsing the tip, or avulsing
the entire organ (Fig. 10.1.34).
Corrective action: Completely remove the fragments laparoscopically, or by laparotomy.
Caution: Place peritoneal drain (see Fig. 4.1.50).
Tears in the Mesoappendix
(Fig. 10.1.35).
Tears in the mesoappendix can damage the appendiceal artery.
Corrective action: Immediate repair. Apply clips to obtain hemostasis. Conversion to laparotomy is indicated if difficulties
occur.
Corrective action: See Fig. 10.1.36.
Injury to the Ureter
Dissection of an adherent retrocecal appendix involves the risk
of damaging the right ureter (Fig. 10.1.37).
Corrective action: Anastomose or suture the ureter using a
splint; consult a urologist.
304
10.1 Appendectomy
T3
T2
Fig. 10.1.33 Appendectomy. Complication: coagulation of the base of
the appendix.
In addition to limiting the duration of the current pulse and using a low
power setting with electrocautery, maintaining a safe distance between the
instrument and the ligature at the base of the appendix is important in
achieving satisfactory results.
The risk of thermal damage to the ligature increases as the distance between the instrument and the ligature decreases. Maintain a distance of
3−5 mm.
Corrective action: Resect the necrotic or damaged tissue, including the
cecum if necessary. Close the lesion over with a double layer of sutures
(absorbable suture material, metric 2/3 × 0).
T3
T2
Fig. 10.1.34 Appendectomy. Complication: necrosis of the cecum near
the base of the appendix.
The illustration shows the surgeon attempting to place a Roeder loop and
knot near the base of the appendix in the presence of a gangrenous appendicitis or necrosis extending into the cecum. Here there is a risk of
tearing the base of the appendix when tightening the ligature.
Prevention: In the presence of appendicitis with necrosis near its base, we
recommend conversion to open appendectomy.
Invert the stump of the appendix, and close the cecum with a pursestring
suture (and an additional Z suture if necessary). This operation should be
decided and/or guided by an expert surgeon.
Immediate Postoperative Complications
Generalized peritonitis: Conventional surgical treatment with laparotomy.
Studies have reported 0.8−15% morbidity following laparo-
scopic appendectomy. Abscesses with and without concurrent
or subsequent peritonitis are a leading complication. Using the
proper suture material for the Roeder loop and knot (absorbable
suture 0; metric 3.5) and proper knot-tying technique an
healthy stumps helps ensure reliable closure.
Serious complications due to adhesions appear to be rare in laparoscopic surgery. The risk of impaired wound healing can be
reduced by thorough preoperative disinfection, particularly in
the umbilical region.
Note: Use a retrieval bag to protect the abdominal wall against
contamination (Fig. 10.1.38).
Bleeding
Generally insufficient coagulation of the appendiceal artery or
an epigastric vessel is the source of the bleeding.
Caution: Sharp pyramidal-tip stylets can cause injury to vascular structures.
Corrective action: Repeat laparoscopy to expose the source of
bleeding and achieve hemostasis. If this is unsuccessful, immediate laparotomy is indicated. To control bleeding from a vessel
in the abdominal wall, place a transabdominal ligature under
laparoscopic visualization.
Note: Corrective laparoscopy requires the highest level of surgical skill.
Impaired Wound Healing and Infection
This is a rare complication.
Intraabdominal abscess: Abscesses can occur as a result of contamination, necrosis of an overly long appendiceal stump, or
thermal damage to tissue or suture material due to improper
use of electrocautery.
Corrective action: Expose the surgical site and perform a culture
under laparoscopic approach. Revise the stump and place a new
suture (pursestring suture or Z suture). Treat with intravenous
antibiotics (2 g of cefotam dihydrochloride and 0.5 g of
metronidazole) until culture and sensitivity results are available. With the patient positioned head up, irrigate and debride.
Place an extraperitoneal drain.
If the ligature of an appendiceal stump slips or fails immediately
postoperatively, you can place a second Roeder loop and knot by
Complications
305
T3
Fig. 10.1.35 Appendectomy. Complication: tear in the mesoappendix
and appendix.
A tear in the appendix when tension is applied is a rare complication. Use
atraumatic graspers. Never apply excessive force to the tip of the appendix nor use sharp-jawed graspers for pulling the appendix into the retrieval
tube. If the appendix is distended, you may have to use a larger size re-
trieval trocar and tube (15 or 20 mm) to permit pulling the transected appendix into the retrieval tube without encountering resistance. A plastic
bag can be used to extract extremely distended appendixes as can occur
in the presence of gangrenous appendicitis or mucoceles (see
Fig. 10.1.38).
T3
T2
Fig. 10.1.36 Appendectomy. Complication: bleeding from the appendiceal artery in a retrograde appendectomy.
The illustration shows bleeding from the appendiceal artery occurring as
the surgeon attempts to create a window in the mesoappendix.
Prevention:
− Blunt dissection with a grasper.
− Always remain close to the appendix in your dissection.
Corrective action: This bleeding can be controlled with bipolar electrocautery. As mentioned previously, coagulate in brief bursts of one or two
seconds at a medium power setting. You can also obtain hemostasis with
a Roeder loop and knot. If this fails, conversion to open appendectomy is
indicated.
Fig. 10.1.37 Appendectomy. Complication: injury to the ureter due to an
adherent appendix.
If the appendix lies in a rectocecal position and adheres to the abdominal
wall, there is an increased risk of injuring the ureter during lysis of adhe-
sions.
Prevention: If you cannot satisfactorily expose the interface between the
visceral and parietal peritoneum, we recommend conversion to a open
appendectomy to lyse adhesions. It may become necessary to splint the
ureter.
Corrective action: Convert to laparotomy to repair the injury to the ureter.
T3
T2
306
Fig. 10.1.38 Appendectomy. Using a plastic bag to extract the appendix.
Avoid contamination of the abdominal wall by removing an overly en-
larged appendix in a plastic bag. Tie a knot in the bottom of the bag for
extra strength.
10.1 Appendectomy
laparoscopy after removing the tissue fragments with suction. If
in doubt, suture and bury the stump.
Note: Thermal damage destroys the suture and weakens tissue.
Place the patient in a slight reverse Trendelenburg position to reduce the risk of spreading contamination during irrigation and
debridement.
Subcutaneous or Subfascial Abscess
Corrective action: Generous open debridement and drainage.
Subphrenic Abscess
Corrective action: Repeat laparoscopy and drainage. Alternative:
radiologically guided transparietal deep drain placement or
conventional transperitoneal or extraperitoneal exposure with
opening and drainage of the abscess, depending on the location
(intra- or retroperitoneal), size, and consistency of abscess contents.
Abscess in the Rectouterine Pouch
Corrective action: Drain the bladder. Repeat laparoscopy and
drainage, or conventional transrectal drainage in lithotomy
position.
Note: Place the patient in a slight reverse Trendelenburg position to reduce the risk of spreading contamination during suction and lavage.
Late Complications
Cecal Distension Syndrome (Fifth Day Syndrome)
Acute lower abdominal pain occurs in 1.5−3% of all patients between postoperative days five and nine. Clinical symptoms include leukocytosis between 10,000 and 20,000 without an increase in body temperature. Symptoms persist for two to three
days. The distended non-abscessed cecum typically has a
round-shaped ultrasound image. The syndrome appears to be
the result of thermal tissue damage with subsequent superficial
necrosis.
Corrective action: Nonoperative treatment, intravenous fluids
with attention to electrolyte balance, and antibiotic therapy.
Conventional laparotomy is indicated if peritonitis is present or
suspected.
Postoperative Shoulder Pain Following Laparoscopy
The postoperative shoulder pain syndrome may require treatment.
Corrective action: Treat symptoms with analgesics, ointments,
and heat.
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10.2 Comments on Laparoscopic Appendectomy
K. Rückert
Since the introduction of laparoscopic surgery into daily prac-
tice, laparoscopic cholecystectomy has become an established
routine procedure, whereas laparoscopic appendectomy and
the techniques utilized in this procedure (electrocautery, clips,
and endo-GIA staplers) remain controversial. Conventional
open appendectomy may itself be regarded as a minimally invasive procedure, and the critical surgeon questions whether this
routine operation justifies an expensive and time-consuming
laparoscopic approach under emergency conditions. In many
hospitals, laparoscopic appendectomy has been abandoned as a
routine procedure because of its possible complications, some
of which can be serious. Many surgeons have not even begun to
practice this new method, while other authors report negligible
complications in a broad range of indications. Whether the laparoscopic approach provides measurable benefits to the
patient and whether the new approach is as safe as the open
procedure is open to question. The method is said to have the
following advantages.
1. Avoiding a large incision by opening the abdomen only at
three points: In view of the small incision commonly made
in an appendectomy, this advantage is not as great as, say, in
a cholecystectomy. Laparoscopy is a valuable alternate procedure only in extremely obese patients or in patients with
uncertain abdominal findings, in the presence of an equivocal diagnosis.
2. Prevention of infection of the abdominal wall: Our own experience has shown that the incidence of septic wound complications is the same in both approaches, although the infection is generally less severe following laparoscopic intervention.
3. Excellent visualization: This is an invaluable advantage for
resolving uncertain findings. Experimental studies are required to ascertain whether the wide distension of the peritoneal cavity associated with the pneumoperitoneum can
lead to generalized contamination.
4. The comparatively short recovery period and early discharge
from the hospital: Our experience has shown that patients
feel sick for a longer time after laparoscopic appendectomy
using bipolar electrocautery, by both subjective and objective standards. Patients primarily report annoying flatulence
and postoperative vomiting.