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Importance of small bowel inspection during acute appendicitis

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Abstract

This video is one of a series of laparoscopic appendicectomies. Additional pathologies are sometimes discovered during an appendectomy. One should be equally skilled to perform the necessary exploration and intervention by laparoscopy.

Keywords

laparoscopic appendicectomies

Media type

Duration

08'06''

Publication

2007-09

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E-publication

WeBSurg.com, Sept 2007;7(09).
URL: http://www.websurg.com/doi-vd01en2194.htm

Importance of small bowel inspection during acute appendicitis

1. Exploration 00'17''

This video shows the discovery of a Meckel’s diverticulum during a routine laparoscopic appendectomy. Trocars are placed in the usual positions for laparoscopic appendectomy – a 10-12mm optical trocar in the umbilicus, and two 5mm working trocars, one in the left lower quadrant and one in the suprapubic position. The procedure starts with exploration of the peritoneal cavity. The appendix shows signs of acute inflammation, confirming the diagnosis. The small bowel is then run gently. This is an important manoeuvre as sometimes, there may be small abscesses walled off by a portion of the small bowel or contained within the mesentery.

2. Meckel\'s diverticulectomy 01'32''

In this case, 40 cm from the ileo-caecal junction, we discovered a Meckel’s diverticulum. It is clear that there had been some episodes of inflammation in the past as it is quite adherent to the mesentery. The dissection is carried out with bipolar coagulation and scissors. Once again, observe how sequential use of bipolar cautery and scissors a rapid and effective means of controlling the mesenteric vessels. Once the mesentery is completely dissected off the diverticulum, it is then resected using an endoscopic stapler. Before firing the stapler, the ileum is checked to ensure that we do not inadvertently cause a stenosis on the remaining bowel. Once resected, the Meckel’s diverticulum is placed in an extraction bag. We then turn our attention to the appendix.

3. Appendicectomy 05'29''

Using the same technique as observed before for dissecting the mesentery of the diverticulum, vascular control in this case is rapidly achieved with bipolar coagulation and scissors. The dissection proceeds sequentially down to the base of the appendix. Double ligation of the appendicular stump is then performed with Vicryl loops. The appendix is subsequently divided at the base with scissors and extracted in an extraction bag. The appendicular stump is sterilised with the bipolar cautery.

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