Laparoscopic treatment of disseminated appendicular peritonitis

This video shows the case of a laparoscopic appendicectomy in a male patient with disseminated peritonitis.

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Laparoscopic treatment of disseminated appendicular peritonitis

Authors

F Costantino, J Marescaux

Abstract

This video shows the case of a laparoscopic appendicectomy in a male patient with disseminated peritonitis.

Classification

basic techniques

Keywords

laparoscopy, treatment of disseminated appendicular peritonitis, appendix

Media type

Surgical video

Duration

08'00''

Publication

2008-10

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E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2425.htm

Laparoscopic treatment of disseminated appendicular peritonitis

1. Clinical case presentation 00'21''

This video shows the laparoscopic treatment of a disseminated appendicular peritonitis. It is the case of a 70-year-old patient presenting with pains localised at the level of the right iliac fossa that has been intensifying over the past 48 hours. Clinical signs are fever, hyperleukocytosis and a positive MacBurney’s sign.

2. Trocar positions 00'48''

A 10mm trocar is introduced at the level of the umbilicus, along with one 5mm suprapubic trocar and another 5mm one in the left iliac fossa. The exploration of the abdominal cavity clearly shows the presence of a disseminated peritonitis. As can be seen here, the small bowel shows signs of peritoneal irritation and there is a lot of purulent fluid. Following the removal of a few samples for bacteriological analysis, we aspirate part of the fluid and introduce the last operating trocar: a 5mm in the suprapubic region. The patient is then placed in a Trendelenburg position with a slight tilt to the left; gravity will help us obtain a better exposure of the small bowel. We begin the exploration of the small bowel and we can observe the presence of the inflammatory process. We can observe the cecal appendix, and traction on the last ileal loop highlights its necrotic aspect. We apply traction to the appendix via its own mesentery, allowing us to observe a small perforation around its base. We decide to check the appendix’s base as it is inflammatory, a condition that will not stop us from applying a stitch. We decide to perform an appendicectomy.

3. Appendicectomy – dissection of appendiceal base 02'47''

The dissection of the appendicular mesentery is performed above the insertion at the level of the cecum. This dissection is performed by staying close to the appendix using scissors, and we create a window in a blunt fashion at the level of the appendix. The dissection is continued close to the appendix and in these cases, we use monopolar cautery to perform the dissection. Our objective is now to separate the cecal appendix from the last ileal loop. We modify the traction at the level of the appendix in order to obtain a new dissection plane, and we can now see the origin of the appendicular artery; this one is controlled by using bipolar coagulation. We finish freeing all the appendicular adhesions before checking on the state of the appendix’s base.

4. Base ligation and division 04'52''

We then place two extracorporeal Vicryl 2/0 sutures to control the stump of the appendix.

5. Extraction 05'19''

We dissect the appendix and place it in an extraction bag, then perform the extraction at the level of the umbilicus. This external view allows us to see the appendix’s size and necrotic state. We then go to the level of the abdominal cavity and perform the second most important step of this surgery:

6. Lavage 05'39''

an extensive lavage of the abdominal cavity with 6 litres of physiological saline. This lavage is made easier by the use of an abdominal gauze that will allow us to aspirate and irrigate without injuring the bowel, which as you can see here is inflammatory due to the disseminated peritonitis. The gauze also allows us to retract the tissues in an atraumatic fashion. We begin the lavage of the abdominal cavity at the level of the Douglas’ pouch. At this moment, the patient is in a reverse Trendelenburg position, allowing us to collect all of the saline. We then go to the operative field upon which we also perform a lavage; then to the supramesocolic region where we will begin its lavage by starting at the level of the right hypochondrium. Here you can see the way we perform a lavage, with the use of a gauze, that allows a safe and extensive lavage of the abdominal cavity. This is demonstrated by the deep lavage of the right and left hypochondriums while keeping the spleen under visual control during exposure. We then perform the control of the appendiceal mucosa by applying a little bipolar coagulation at the level of the appendicular stump. The stump is then covered with the omentum during an omentoplasty.

7. Drains 07'04''

We introduce two 5mm drains, one at the level of the pelvic cavity, the other at the level of the appendicular stump.