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Stepwise approach for laparoscopic treatment of retrocaecal appendicitis

Authors

Abstract

The vermiform appendix has no constant position and the data on the variations in its position are limited. This video shows a stepwise approach to explore the abdominal cavity and correctly offer the treatment of a retrocaecal appendicitis.

Classification

basic techniques

Keywords

Stepwise approach, laparoscopic treatment, retrocaecal appendicitis

Media type

Duration

04'00''

Publication

2009-03

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E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2559.htm

Stepwise approach for laparoscopic treatment of retrocaecal appendicitis

1. Clinical case presentation 00'07''

The objective of this video is to show the different steps of a standard laparoscopic appendectomy. This is the case of an 18-year-old female patient who has had a pain for 2 days in the right iliac fossa associated with a hyperleukocytosis as shown with her biological findings. A positive McBurney’s point is also found. Ultrasonography shows a thickening of the appendix.

2. Trocar and patient positioning 00'28''

The 1st umbilical trocar is introduced using an open coelioscopic approach. A 2nd 5mm trocar is placed at the junction between the umbilical line and the left anterior axillary line. This 5mm trocar is placed suprapubically. The patient is placed in a Trendelenburg position with a 15 degree left tilt.

3. Abdominal cavity exploration 00'47''

The first step consists in exploring the abdominal cavity. The laparoscopic exploration always starts at pelvic level and goes through the whole abdominal quadrant. The greater omentum is retracted and positioned supramesocolically.

4. Small bowel exploration 01'02''

The 2nd step is to explore the small bowel starting from its distal extremity until the last 60cm segments proximal to the duodenojejunal flexure. This exploration is achieved using the atraumatic grasper. The small bowel is positioned so as to not impair the visualization of the ileocaecal region. The pelvic exploration is undertaken. Traction of the round ligament is carried out alternatively to the right and then to the left in order to visualize the Douglas’ pouch and the ovaries. Once the last ileal loop and the taenia coli have been identified, we search for the insertion of the caecal appendix.

5. Retrocaecal appendix identification 01'57''

In the present case, we can observe the presence of a retrocaecal appendix with signs of acute inflammation.

6. Appendix exposure and vascular control 02'05''

Exposure of the inflammation is achieved using cephalad traction on the appendicular mesentery in order to completely expose it and prevent any perforation. The appendicular artery is then controlled progressively using bipolar coagulation to ensure a safe hemostasis. The adhesions are further freed using scissors.

7. Resection of appendix 02'47''

The procedure is continued with the resection of the appendix. At the base of the appendix, a Vicryl 2/0 suture with an extracorporeal knot is applied. The first suture is positioned at the base of the appendix. The second one is placed 1cm above in order to avoid any fecal contamination once the appendix has been divided. An extraction bag is introduced through the umbilical trocar. It will be positioned just above the appendix. Division of the appendix is achieved with cold scissors and the appendix is placed into the extraction bag.

8. Control of appendicular stump 03'48''

The appendicular stump is coagulated. The procedure ends with the patient being placed in a supine position. The appendicular stump is routinely covered with the omentum.

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