Laparoscopic appendicectomy: basic principles

This video demonstrates the basic principles of laparoscopic appendectomy in a case of acute appendicitis with limited inflammatory process. The appendicular mesentery is divided using electrocautery and the appendix base is closed with endoloop. This video is enhanced by use of graphic demonstration of key landmarks using artist sketches. It provides for an excellent introduction to laparoscopic appendectomy for beginners.

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Laparoscopic appendicectomy: basic principles

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates the basic principles of laparoscopic appendectomy in a case of acute appendicitis with limited inflammatory process. The appendicular mesentery is divided using electrocautery and the appendix base is closed with endoloop.
This video is enhanced by use of graphic demonstration of key landmarks using artist sketches. It provides for an excellent introduction to laparoscopic appendectomy for beginners.

Classification

basic techniques

Keywords

emergency,operation,appendectomy,laparoscopy, female patient, mesoappendix

Media type

Surgical video

Duration

06'00''

Publication

2002-10

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E-publication

WeBSurg.com, Oct 2002;2(10).
URL: http://www.websurg.com/doi-vd01en1354e.htm

Laparoscopic appendicectomy: basic principles

1. Case presentation 00'15''

The patient presented with symptoms compatible with acute appendicitis. He is placed supine with the left arm tucked along the body, the surgical team is located at the left of the patient, the monitor at the right.

2. First trocar and exposure 00'30''

Access to the peritoneum is done under direct vision using a modified Hasson’s technique. She was brought to the operating room for exploration of the abdominal and pelvic cavities and possible appendectomy. The peritoneum is now opened and the first trocar introduced under direct vision. The pneumoperitoneum is done for a pressure of 12 mm Hg. The abdominal pelvic cavity is explored and there are no gross anomalies.

3. 2nd and 3rd trocars 01'19''

The other trocars are placed as such. A 5 mm trocar is inserted just medial to the left interior-superior iliac spine. We can see here the epigastric vessels and the second 5 mm trocar is placed 4 to 5 cm above the pubis at the midline and to avoid injury of the organs, a counter-pressure is made with a grasper while introducing trocar B before pushing this trocar in completely. An alternative is to push the trocar inside of the optical trocar, as is often done in pediatric surgery.

4. Exposure 02'19''

The patient is placed in Trendelenburg position and the small bowel is retracted cephalad loop by loop. While doing so, the last ileal loop is explored to eliminate the presence of a Meckel’s diverticulum. The pelvic cavity is explored as well, here is the uterus, the right adnexa, which is normal, and the left adnexa as well. The appendix is found here, it is slightly subserosal and seems to be very long. It is followed until its tip, the caecum is very mobile, here is the tip of the appendix, which looks slightly inflammatory.

5. Division of the mesoappendix 03'32''

We begin with the division of the meso-appendix. The meso-appendix can be divided with monopolar or bipolar coagulation or with clips. Here, the Marilyn grasper with monopolar coagulation is used to divide the meso-appendix bluntly. This is performed bit by bit and close to the appendiceal wall. The serosal attachments are divided at the same time and the last ileal loop is slowly detaching. Care is taken to achieve perfect hemostasis. To achieve good counter traction, the appendix is rolled around the left hand grasper. We are now slowly reaching the base of the appendix and now scissors with monopolar coagulation are used.

6. Ligation and retraction 05'13''

The appendix will now be ligated with the endoloop. The endoloop is introduced through the supra-pubic port and is closed at the base of the appendix. The base of the appendix is then milked, the left hand grasper closes the lumen. The appendix will now be divided partly after cutting the endoloop. And now the mucosa of the appendiceal stump is coagulated. The rest of the appendiceal wall is cut.

7. Extraction 06'22''

The appendix is exteriorised through the optic port under direct vision. The peritoneum is explored one last time and hemostasis is checked.