Laparoscopic appendectomy for appendicular phlegmon

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Laparoscopic appendectomy for appendicular phlegmon

Authors

J Leroy, J Marescaux

Keywords

emergency,operation,removal,appendix,phlegmon,laparoscopy,appendicectomy

Media type

Surgical video

Duration

09'00''

Publication

2002-10

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E-publication

WeBSurg.com, Oct 2002;2(10).
URL: http://www.websurg.com/doi-vd01en1364e.htm

Laparoscopic appendectomy for appendicular phlegmon

1. Trocar placement 00'16''

The patient is placed in a supine position with the left arm alongside the body. The surgeon and the assistant stand to the left of the patient. Three trocars are placed, the scope is placed immediately next to the umbilicus and two other 5 mm trocars are placed, one just medial to the anterior-superior iliac spine and one in the supra-pubic area on the midline.

2. Exposure of meso-appendix 00'57''

The first step of the procedure is to achieve good exposure of the area. The patient is placed in Trendelenburg position in left lateral tilt and the omentum is retracted cephalad. We complete exposure and then we will focus on the small bowel loop, just right here. This is the last ileal loop and we will explore it first to eliminate any associated pathology. This patient has had in the past a transvaginal hysterectomy. There is presence of some pleural liquid in the pelvis as you can see here. The right adnexa is normal. Some of that liquid is aspirated for microbiological analysis. There are inflammatory adhesions between the caecum and the lateral abdominal wall, these are freed bluntly. We can now visualise the appendix which shows signs of necrosis. The caecum is retracted and this will expose the base of the appendix. The appendix is closely adherent to the structures surrounding it and these adhesions are freed bluntly.

3. Division of meso-appendix 03'23''

This is the necrotised part of the appendix and now we will use bipolar coagulation to dissect and coagulate the meso-appendix. A hook can also be used to achieve this part of the procedure or scissors with monopolar coagulation. The meso-appendix is coagulated next to the base of the appendix. Scissors are then introduced to divide the meso-appendix sharply. Monopolar coagulation is used along with the scissors. We now reach the wall of the appendix and the appendix is held up from its base to retract progressively. Coagulation of the meso-appendix is performed as such, so we end progressively using scissors and mono-polar coagulation until the base of the appendix is reached. Care is taken to achieve perfect anastomosis. Blood present in the paracolic gutter is aspirated and the hemostasis is checked.

4. Ligation and resection 05'43''

A loop is now introduced into the supra-pubic port in order to tie the appendix at its base. We can see that the appendix is being tied, and now a second loop is introduced and is applied approximately 1 cm distal to the first one. After the introduction of a retrieval sac seen on the right of the screen, the appendix is divided sharply. It is then placed in the retrieval sac. The stump of the appendix is now coagulated. We end the procedure by exploration and peritoneal lavage. First the paracolic gutter, then the para-hepatic area, and then the pelvic cavity. Irrigation and aspiration continues until return of clear fluid.

5. Extraction 08'23''

The retrieval bag is extracted under direct vision through the umbilical port. The port is pulled out and the bag with the appendix carefully extracted.