Good as Gold: A New Look At One of the Most Commonly Performed Surgeries

by Brie Eteson, Digital Surgery
Laparoscopic Appendectomy: Case Variations and Approaches

Laparoscopic appendectomies are one of the most commonly performed emergency surgical procedures in the world.1 The first laparoscopic appendectomy was performed in 19812, which paved the way for this approach to become the new gold standard treatment, being a safe and effective alternative to open appendectomies. The laparoscopic approach generally boasts a shorter hospital stay, decreased need for postoperative analgesia, early food tolerance, earlier return to work, and a lower rate of wound infection.3 Nonetheless, an open appendectomy may be indicated if the patient had previous abdominal surgery, or cannot tolerate general anesthesia, among other reasons.

In 2005, a survey in the US showed that approximately 58% of appendectomies were performed laparoscopically.4 However, some variation still exists in the way the procedure is performed. This is sometimes due to the hospital’s local practice, or the patient’s case presentation.

This new simulation, free from Touch Surgery™, displays five modules demonstrating case variations for a laparoscopic appendectomy. The first shows a routine procedure, whilst the other four modules describe alternative approaches, and variations for more complex cases and anatomy.

Monofilament loop sutures placed around the base of the appendix

Appendix amputation between the loop sutures

What Is an Appendectomy?

An appendectomy consists of the dissection of the mesoappendix and the resection of the appendix at the base. Although rare, incomplete removal of the appendix can lead to inflammation of the stump.5

Variable Locations of the Appendix

There are multiple locations in which the appendix can lie. The most common location of the appendix is the pelvic position.6 In this simulation,  one module demonstrates an appendectomy with a retrocecal appendix.

Various Appendix Locations.

1: Retrocecal, 2: Subcecal, 3: Postileal, 4: Pelvic, 5: Paracecal, 6: Preileal

Diagnostic laparoscopy

Performing a Routine Appendectomy begins with the patient positioned supine, with their right arm abducted. They are then prepped and draped for surgery. Port insertion is as follows: Using the Hasson technique, an 11 mm trocar is inserted at the umbilicus, and the abdomen is insufflated to establish a pneumoperitoneum at 8-12 mmHg.

The Hasson technique consists of creating a small umbilical incision under direct visualization to enter the abdominal cavity, followed by the introduction of a blunt trocar. Pneumoperitoneum is then rapidly created.7

The patient is then repositioned in Trendelenburg, with tilt on the right side. A laparoscope is inserted through the umbilical port. The right working port (5 mm trocar) is inserted at the left iliac fossa, being cautious of the epigastric vessels, and another 5 mm trocar is inserted into the suprapubic area for the left working port.

Dissection of the mesoappendix

An abdominal laparoscopy is then performed to inspect the abdominal cavity, including the pelvic organs, to exclude other pathologies. The appendix and the base should be located to confirm the diagnosis. The mesoappendix is dissected near the base using diathermy. The appendix is resected by placing monofilament loop sutures around the base and cutting between the sutures.

Following resection, the appendix stump is inspected for contamination and hemostasis. If bleeding or contamination are present, minor irrigation and suction should be performed.

The resected appendix is then placed in a specimen retrieval pouch and removed through the umbilical port. Ports are removed under direct vision, ensuring there is no port site bleeding. The patient is returned to the supine position, the laparoscope is removed, and the abdomen deflated. Finally, the umbilical port is removed. The fascia of the umbilical port site, and all skin incisions, are closed.

Early Appendicitis

Focusing on an alternative method to an uncomplicated appendectomy for an early case of appendicitis, this procedure follows a patient with a three-day history of abdominal pain. One of our authors, Tom Hugh, MD FRACS, prefers the method demonstrated in this module, as it involves looping the mesoappendix rather than having to dissect it out. This technique can result in a shorter operating time.

Retrocecal Appendix

There are multiple possible locations of the appendix. In this case, the appendix lies retrocecal and is adherent to the cecum. This means it is located behind the cecum, making dissection of the mesoappendix more difficult. The procedure requires lateral mobilization of the cecum, and a ‘base first’ technique is shown. When using this technique, the base is dissected before the mesoappendix.

Inflamed Distal Appendix Adherent to Small Bowel

The appendix can become partially stuck to other viscera. In this case, the appendix is adherent to the small bowel and is inflamed distally. The appendix needs to be carefully dissected free prior to the appendectomy, ensuring there is no damage to the surrounding structures.

Gangrenous Appendix with a Localized Perforation

The final module shows an appendectomy for a gangrenous appendix with localized perforation.

This simulation was authored by Isaac Tranter-Entwistle, MD, and Tom Hugh, MD FRACS.

Patient presentation, surgical objectives, instrumentation, and more detailed information can be found in the app. Look for the simulation titled Laparoscopic Appendectomy: Alternative Approaches and Case Variations.

Launch in App

or scan the QR code below.

How to cite this simulation: Tranter-Entwistle I, Hugh T. Laparoscopic Appendectomy: Alternative Approaches and Case Variations. Touch Surgery Simulations. http://dx.doi.org/10.18556/touchsurgery/2021.s0187. Published Jul. 30, 2021.

References

1. Lansdown MR, Gray AJ, Treasure T, Layer GT. Appendicectomy: who performs it, when and how?. Ann R Coll Surg Engl. 2006;88(6):530-534.

2. Meljnikov I, Radojčić B, Grebeldinger S, Radojčić N. History of surgical treatment of appendicitis. Med Pregl. 2009;62(9-10):489-492.

3. Biondi A, Di Stefano C, Ferrara F, Bellia A, Vacante M, Piazza L. Laparoscopic versus open appendectomy: a retrospective cohort study assessing outcomes and cost-effectiveness. World J Emerg Surg. 2016;11(1):1-6.

4. Switzer NJ, Gill RS, Karmali S. The evolution of the appendectomy: from open to laparoscopic to single incision. Scientifica. 2012;2012.

5. Dikicier E, Altintoprak F, Ozdemir K, et al. Stump appendicitis: a retrospective review of 3130 consecutive appendectomy cases. World J Emerg Surg. 2018;13(1):1-4.

6. Ghorbani A, Forouzesh M, Kazemifar AM. Variation in anatomical position of vermiform appendix among iranian population: an old issue which has not lost its importance. Anat Res Int. 2014;2014.

7. Kovachev S, Ganovska A, Atanasova V, Sergeev S, Mutafchiyski V, Vladov N. Open laparoscopy–a modified Hasson technique. Akusherstvo i ginekologiia. 2015;54(4):52-56.

8. SAGES. Guidelines for laparoscopic appendectomy. SAGES Website. https://www.sages.org/publications/guidelines/guidelines-for-laparoscopic-appendectomy/. Published Apr. 2009. Accessed Apr. 22, 2020.

9. Khanna S, Khurana S, Vij S. No clip, no ligature laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech. 2004;14(4):201-203.

10. Mayir B, Ensari CÖ, Bilecik T, Aslaner A, Oruç MT. Methods for closure of appendix stump during laparoscopic appendectomy procedure. Ulus Cerrahi Derg. 2015;31(4):229-231.

11. Yang HR, Wang YC, Chung PK, Jeng LB, Chen RJ. Laparoscopic appendectomy using the LigaSure Vessel Sealing System. J Laparoendosc Adv Surg Tech A. 2005 Aug;15(4):353-356.