Benefit of laparoscopic approach in an appendicular purulent peritonitis

This video is one of a series of laparoscopic appendicectomies and shows the advantage of the videoscopic approach in accessing the entire peritoneal cavity in cases of diffuse peritonitis. Blood tests revealed an inflammatory syndrome in a young woman with a 3-day history of diffuse abdominal pain and fever. Exploration of the abdominal cavity during emergency laparoscopy confirmed the clinical impressions. The authors performed aspiration and lavage of the peritoneal cavity. Thorough assessment revealed the omentum to be concentrated in the right iliac fossa, and gentle dissection uncovered a necrotic, perforated appendix. Dissection of the cecum and appendix was difficult because the tissues were friable and adherent. The usual tissue planes were not present, but the laparoscopic view allowed for a safe approach.

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Benefit of laparoscopic approach in an appendicular purulent peritonitis

Authors

F Costantino, J Marescaux

Abstract

This video is one of a series of laparoscopic appendicectomies and shows the advantage of the videoscopic approach in accessing the entire peritoneal cavity in cases of diffuse peritonitis.
Blood tests revealed an inflammatory syndrome in a young woman with a 3-day history of diffuse abdominal pain and fever. Exploration of the abdominal cavity during emergency laparoscopy confirmed the clinical impressions. The authors performed aspiration and lavage of the peritoneal cavity. Thorough assessment revealed the omentum to be concentrated in the right iliac fossa, and gentle dissection uncovered a necrotic, perforated appendix. Dissection of the cecum and appendix was difficult because the tissues were friable and adherent. The usual tissue planes were not present, but the laparoscopic view allowed for a safe approach.

Keywords

laparoscopic appendicectomy, videoscopic approach, diffuse peritonitis, exploration, lavage

Media type

Surgical video

Duration

07'15''

Publication

2007-09

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E-publication

WeBSurg.com, Sept 2007;7(09).
URL: http://www.websurg.com/doi-vd01en2192.htm

Benefit of laparoscopic approach in an appendicular purulent peritonitis

1. Exploration and lavage 00'15''

This video shows a case of purulent peritonitis in a young woman who presented with a 3-day history of diffuse abdominal pain and fever. Blood investigations revealed the presence of an inflammatory syndrome. Antibiotics and intra-venous fluids were commenced immediately and the patient was scheduled for emergency laparoscopy. Exploration of the abdominal cavity confirms the clinical impression. Aspiration and lavage of the peritoneal cavity is performed to reduce the bacterial burden. A thorough assessment reveals the omentum to be concentrated in the right iliac fossa, and gentle dissection uncovers a necrotic, perforated appendix. Trocars were placed in the usual positions for laparoscopic appendectomy – a 10-12mm optical trocar in the umbilicus, and two 5mm working trocars, 1 in the left lower quadrant and 1 in the suprapubic position. However, dissection of the caecum and appendix is difficult because the inflammatory process caused the tissues to be friable and adherent. The usual tissue planes are not present, but the excellent view afforded by laparoscopy allows a careful and safe approach.

2. Mobilization of appendix 02'20''

In cases such as this, with extensive peritoneal soilage, it is useful to perform the dissection with a suction catheter. This allows repeated aspiration and irrigation, allowing the field to be cleared and giving good visualisation. Finally, the appendix is exposed entirely up to its base. This is an important step because in such cases when the appendix is necrotic, parts of the appendix may be left behind during the surgery, leading to prolongation of the septic process and post-operative abscess formation. Once the appendix is identified completely, you can see that bipolar cautery and scissors dissection can be applied very effectively as we usually do in order to dissect the meso-appendix. In this case you can see that the inflammation extends almost to the base of the appendix. Another important point is that it is important to identify clearly the base of the appendix where it joins the caecum.

3. Division of appendix 04'47''

Here, you can see the application of a Vicryl loop to secure the base of the appendix. In situations where the base of the appendix is completely necrotic, it may be necessary to resect part of the caecum as well. In this case, it may be useful to use an endoscopic stapler. Once the base of the appendix is secured with the Vicryl loops, the appendix is divided and placed in an extraction bag. The stump is inspected to ensure that closure is secure. The peritoneal cavity is lavaged once more to reduce the sceptic load and the risk of post-operative abscess formation. The lavage performed is a thorough one, including the upper quadrant and subphrenic spaces as well. Another problem in severe inflammation such as this is that the inflammatory tissues bleed rather easily and therefore it is necessary to secure good haemostasis at the end of the surgery. When the surgery is finished, a drain is placed in the pelvis. The patient recovered well, and the drain was removed two days later.