JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 6, 1992 Mary Ann Liebert, Inc., Publishers
Technical
Report
Laparoscopic Appendectomy:
A
Simplified Technique
THOMAS L. BRYANT, M.D., F.A.C.S.
ABSTRACT
Laparoscopic appendectomy can easily be performed by a surgeon familiar with laparoscopic cholecystectomy. The technique described employs the same spatial relationships which are used in laparoscopic cholecystectomy. By maximizing the similarities between the two operations, surgeon and assistants can rapidly become comfortable with laparoscopic appendectomy. Of the laparoscopic appendectomies attempted 88% were successfully completed. The technique and results are presented and discussed.
INTRODUCTION the widespread use of
Despiteacceptance.however, wide
laparoscopic cholecystectomy, laparoscopic appendectomy has not gained appendectomy is one of the first major operations learned by a new laparoscopic appendectomy is now a frequent offering in courses for
Conventional
surgeon. Ironically, "advanced" laparoscopic surgery. The surgeon who is comfortable with laparoscopic cholecystectomy possesses nearly all of the skills needed for laparoscopic appendectomy. Unfortunately, the surgical literature presents the surgeon with a sometimes confusing array of techniques. Multiple positioning techniques have been described including trocar placement and the position of the surgeon and assistant. Retaining the now familiar spatial relationships used in laparoscopic cholecystectomy facilitates the coordination of the surgeon and crew.
TECHNIQUE All
procedures were performed by a single surgeon in a 150 bed community hospital over a 27 month period. During the first 18 months, the procedure was used only on patients older than 11 years. Subsequently, laparoscopic appendectomy was attempted, regardless of age.
Marietta Memorial
Hospital, Marietta, OH. 343
BRYANT After induction of general endotracheal anesthesia, the patient is placed in a supine position. A Foley catheter and nasogastric tube are placed. The patient is prepped and draped. The first laparoscopy port is placed in the umbilical position (Fig. 1). The umbilical skin is everted with Adson forceps as completely as possible. A 2 cm transverse skin incision is made, passing through the center of the umbilicus. The umbilical skin is then dissected away from the midline fascia for 1-2 cm both inferiorly and superiorly. This fascia exposure will later facilitate the delivery of a large specimen. The midline fascia is opened vertically for about 1.5 cm. The peritoneum is incised under direct vision and a 12 mm laparoscopy port is inserted. The everted umbilical skin is then closed against the port to prevent gas leakage. Sharp towel clips applied to umbilical skin edges are effective for this purpose. Pneumoperitoneum with C02 is established to a pressure of 15 mmHg. With the laparoscope (10 mm 0°) in the umbilical port, a 5 mm port is placed in the right upper quadrant. A second 5 mm port is placed in the right lower quadrant. A 10 mm port is placed in the midline 2 cm superior to the symphysis pubis, avoiding the urachal fold as well as the urinary bladder. All secondary ports are placed under laparoscopic control. Diagnostic laparoscopy can be performed at any stage of the port placement. This can include evaluation of the female reproductive organs and running the small bowel. After all four ports are placed, the laparoscope and camera are transferred to the suprapubic port. The surgeon, assistant, and camera operator have now occupied the same relative positions used in the laparoscopic cholecystectomy technique of Reddick' (Fig. 2). The patient is placed in the Trendelenburg position with the table tilted to the left. This facilitates reflection of the viscera away from the cecum. The same blunt grasping instruments used in cholecystectomy are employed in laparoscopic appendectomy. However, they are applied to the bowel with only the minimum amount of force necessary. If the appendix is retrocecal, the cecum is grasped and reflected medially. The suprapubic camera position greatly facilitates identification and division of the lateral peritoneal reflection. The appendix is gently grasped with an instrument. Countertraction is applied to the cecum with a second grasping instrument and the mesoappendix is identified. Division of the mesoappendix is then accomplished. A Kleppinger bipolar electrocautery forceps (Fig. 3) (Richard Wolf, Rosemont, II) is inserted via the umbilical port. One paddle of the cautery device is placed on each side of the leading edge of the mesoappendix. The mesoappendix is then serially cauterized and sharply divided. Bipolar cauterization prevents the need to specifically identify friable vessels in an edematous mesoappendix. If bleeding occurs
\
K
I
placement. (1)12 mm-umbilicus; (2) 5 mm-right upper quadrant; (3) 5 mm-right lower quadrant; (4) mm-suprapubic. FIG. 1.
Port
344
10
LAPAROSCOPIC APPENDECTOMY ANESTHESIA
VIDEO
MONITOR
ASSISTANT
INSTRUMENT NURSE
FIG. 2.
FIG. 3.
Operating room setup.
Kleppinger bipolar electrocautery forceps. 345
BRYANT
FIG. 4.
The cauterized
mesoappendix is divided.
Division is
moving toward the tip.
after tissue division, bipolar cautery is applied directly to the bleeding point. Endoscopie clips may be applied directly to vessels but are rarely necessary. If the tip of the appendix is hard to mobilize, division of the mesoappendix may proceed outward from a window created adjacent to the appendix (Fig. 4). A pressure irrigation device is very useful in maintaining a clear field. In the first 10 cases, the appendiceal base was controlled with pre-tied loop ligatures of size zero polydioxanone. The ligatures are introduced via the umbilical port. Two ligatures are placed on the appendix near the cecum. A third loop is placed approximately 1 cm distally on the appendix, to prevent spillage from the specimen. The appendix is divided between the second and third ligatures. Exposed mucosa may be cauterized with bipolar current (Fig. 5).
FIG. 5.
Bipolar current cauterizes the mucosa of the appendiceal stump. 346
LAPAROSCOPIC APPENDECTOMY
FIG. 6.
The Endo-GIA divides the
appendix.
Rather than using loop ligatures, it is now preferred that the appendix be controlled with an Endo-GIA Autosuture (U.S. Surgical, Norwalk, CT). The Endo-GIA can divide the appendix and secure both ends with a single step. It is introduced via the 12 mm umbilical port, placed across the base of the appendix, and fired (Fig. 6). Each end of the severed appendix is securely closed with staples (Fig. 7). If necessary, the Endo-GIA can be used to divide the appendix prior to division of the mesoappendix. The divided appendix is then removed. It may be grasped and drawn into the umbilical port. The port and appendix are then simultaneously withdrawn from the patient. If the specimen is bulky, scissors may be used to extend the incision in the previously exposed midline umbilical fascia.
FIG. 7.
Each end of the divided
appendix has been sealed by the Endo-GIA. 347
BRYANT
FIG. 8.
The
appendix is placed within the sterilized condom.
A sterilized impermeable bag may be used to prevent wound contamination during specimen extraction. A steam-sterilized condom may be used for this purpose." The condom is rolled like a cigarette and inserted via the umbilical port with a dissecting instrument. The rim of the condom is stabilized with the two grasping instruments as the condom is unrolled. The specimen is then placed within the condom (Fig. 8). Axial rotation of a grasping forcep closes the opening of the condom (Fig. 9). The condom is then grasped, pulled partially into the umbilical port, and withdrawn through the umbilical incision. The umbilical fascia is closed with size zero poly-glycolic sutures; 3-0 plain gut suture is used for subcuticular skin closure. The first umbilical skin suture is placed first through the umbilical fascia and then through the subcuticular layers of the superior and inferior skin flaps. Tying this suture restores the umbilical inversion. The incision becomes almost invisible.
FIG. 9.
Axial rotation of the grasper closes the condom.
348
LAPAROSCOPIC APPENDECTOMY Table 1. Complicated Appendectomy
Complicated appendectomy
15 cases 6 total 5 1
Perforated antececal
Completed laparoscopically Converted to open operation Retrocecal non-perforated
5 total 4 I
Completed laparoscopically Converted to open operation Perforated and retrocecal
4 total 2 2
Completed laparoscopically Converted to open appendectomy All patients uncomplicated
treated with antibiotics. Cefotetan was used in adults and cefoxitin in children. In of appendicitis, a single dose was used. In cases with perforation, antibiotics were continued until the patient became afebrile. Laparoscopy was performed by a single surgeon in 35 patients with a preoperative diagnosis of acute appendicitis. Two patients were found to have primary cecal lesions and were converted to open operation. Laparoscopic appendectomy was attempted in the remaining 33 patients and completed in 29 (88% completion). Four patients were converted to open appendectomy; one of these was retrocecal, one perforated, and two were both perforated and retrocecal. Of the 29 appendectomies completed laparoscopically, two were both perforated and retrocecal. Five were perforated and antececal and four were non-perforated and retrocecal (Table 1). Four histologically normal appendices were removed (Table 2). All of these patients recovered uneventfully. In one patient, a normal appendix was removed along with an infarcted corner of omentum. In those cases where laparoscopic appendectomy was successful, "skin to skin" operative time averaged 72 min (range 42-130 min). The average patient age was 31 years (range 6-76 years). Patient weights ranged from 41-278 lbs. Postoperative hospitalizations averaged 2.4 days (11 h-7 days). None of these patients developed wound infections or intraabdominal abscesses. were
cases
DISCUSSION
appendices.3
Laparoscopic appendectomy was described by Semm in 1983 for the removal of non-inflamed He placed the patient in the lithotomy position and employed ports in the umbilicus, right upper quadrant, and
two
suprapubic ports.
performed over 700 laparoscopic appendectomies.4 They also place the patient in the lithotomy position, however, they use the umbilical port for visualization, a 5.5 mm port in the left lower quadrant, and an 11 mm port in the right lower quadrant. The mesoappendix is controlled with bipolar electrocautery. Pier and Götz have
Table 2. Diagnosis When Appendix Was Normal
Diagnosis when appendix was normal Laparoscopic appendectomy completed Salpingitis Ovarian cyst Infarcted corner of omentum Gastroenteritis Converted to open operation (laparoscopic not
6 4 I 1 I I
appendectomy
2
attempted)
Cecal carcinoid tumor Infected peritoneal cyst of cecum
349
1 1
cases
BRYANT
Saye uses an umbilical port for visualization, a 5 mm suprapubic port, a 5 mm port in the midline between the first two ports, and a fourth 5 mm port in the right side of the abdomen.2 Byrne employs a 10 mm umbilical port for laparoscope placement.5 A 12 mm right lower quadrant port is used to exteriorize the appendix. Control of the mesoappendix and appendiceal excision is accomplished
extracorporeally. All of these techniques employ an orientation of the patient, equipment, and personnel which differs significantly from the method used for laparoscopic cholecystectomy. The technique described here eliminates this disadvantage. The efficacy of bipolar electrocautery to control the vessels of the mesoappendix has been previously demonstrated.6 This modality is inexpensive. It minimizes tedious dissection and clip application. Unlike the exclusive use of staples for hemostasis, it can be initiated even when a portion of the mesoappendix remains fixed. Use of the Endo-GIA increases the expense of securing the appendiceal base. It shortens the operating time by approximately 5 min. The Endo-GIA permits the division of the appendix prior to division of the mesoappendix. The greatest advantage of the Endo-GIA is that it permits the excision of a small piece of cecum along with the appendix. This is greatly reassuring if the appendiceal necrosis extends to its base. Placing the 12 mm port via the umbilical cutdown allows suture repair of the largest fascial defect. The worst cases were sometimes converted to open operation. Therefore, these cases did not adversely affect the statistics for completed laparoscopic appendectomies. Nonetheless, the rapid recoveries of the laparoscopic patients was impressive. Perforation need not be a contraindication to laparoscopic appendectomy. As with conventional operations, patients with perforated appendicitis will require additional postoperative recovery time to resolve their peritonitis. Laparoscopic appendectomy may virtually eliminate problematic wound infections. The superior visualization of laparoscopy is a great advantage. It is very useful in women of reproductive age. In older patients, it can determine whether acute diverticulitis is present. If all laparoscopic findings are grossly normal, the appendectomy is completed. This prevents future diagnostic dilemmas. Occasionally, an early mucosal appendicitis may be difficult to detect by gross external examination.
CONCLUSIONS The technique, which is described is "user-friendly" to surgeons and crews who are experienced with laparoscopic cholecystectomy. It can be used in cases of perforated and retrocecal appendicitis.
REFERENCES
Laparoscopic laser cholecystectomy. Surg Endose 1989;3:131-133. Saye WB, Rives DA, Cochran EB, et al: Laparoscopic appendectomy: Three years experience. Surg. Laparosc Endose
1. Reddick EJ, Olsen DO:
2.
1991;1:109-115.
Endoscopie appendectomy. Endoscopy 1989;15:59-64. Pier A, Götz F, Bacher C, et al: Laparoscopic appendectomy in 625 cases: From innovation to routine. Surg Laparosc
3. Semm K: 4.
Endose 1991;1:8-13. 5. 6.
Byrne DS, Bell G, Morrice JJ, OrrG, et al: Technique for laparoscopic appendicectomy. Br J Surg 1992;79:574-575. Götz F, Pier A, Bacher C, et al: Modified laparoscopic appendectomy in surgery. Surg Endose. 1990;4:6-9. Address reprint requests to: Thomas L. Bryant, M.D., F.A.C.S. Marietta Memorial Hospital 400 Matthew Street Marietta, Ohio 45750
350
Technical
Report
Laparoscopic Appendectomy:
A
Simplified Technique
THOMAS L. BRYANT, M.D., F.A.C.S.
ABSTRACT
Laparoscopic appendectomy can easily be performed by a surgeon familiar with laparoscopic cholecystectomy. The technique described employs the same spatial relationships which are used in laparoscopic cholecystectomy. By maximizing the similarities between the two operations, surgeon and assistants can rapidly become comfortable with laparoscopic appendectomy. Of the laparoscopic appendectomies attempted 88% were successfully completed. The technique and results are presented and discussed.
INTRODUCTION the widespread use of
Despiteacceptance.however, wide
laparoscopic cholecystectomy, laparoscopic appendectomy has not gained appendectomy is one of the first major operations learned by a new laparoscopic appendectomy is now a frequent offering in courses for
Conventional
surgeon. Ironically, "advanced" laparoscopic surgery. The surgeon who is comfortable with laparoscopic cholecystectomy possesses nearly all of the skills needed for laparoscopic appendectomy. Unfortunately, the surgical literature presents the surgeon with a sometimes confusing array of techniques. Multiple positioning techniques have been described including trocar placement and the position of the surgeon and assistant. Retaining the now familiar spatial relationships used in laparoscopic cholecystectomy facilitates the coordination of the surgeon and crew.
TECHNIQUE All
procedures were performed by a single surgeon in a 150 bed community hospital over a 27 month period. During the first 18 months, the procedure was used only on patients older than 11 years. Subsequently, laparoscopic appendectomy was attempted, regardless of age.
Marietta Memorial
Hospital, Marietta, OH. 343
BRYANT After induction of general endotracheal anesthesia, the patient is placed in a supine position. A Foley catheter and nasogastric tube are placed. The patient is prepped and draped. The first laparoscopy port is placed in the umbilical position (Fig. 1). The umbilical skin is everted with Adson forceps as completely as possible. A 2 cm transverse skin incision is made, passing through the center of the umbilicus. The umbilical skin is then dissected away from the midline fascia for 1-2 cm both inferiorly and superiorly. This fascia exposure will later facilitate the delivery of a large specimen. The midline fascia is opened vertically for about 1.5 cm. The peritoneum is incised under direct vision and a 12 mm laparoscopy port is inserted. The everted umbilical skin is then closed against the port to prevent gas leakage. Sharp towel clips applied to umbilical skin edges are effective for this purpose. Pneumoperitoneum with C02 is established to a pressure of 15 mmHg. With the laparoscope (10 mm 0°) in the umbilical port, a 5 mm port is placed in the right upper quadrant. A second 5 mm port is placed in the right lower quadrant. A 10 mm port is placed in the midline 2 cm superior to the symphysis pubis, avoiding the urachal fold as well as the urinary bladder. All secondary ports are placed under laparoscopic control. Diagnostic laparoscopy can be performed at any stage of the port placement. This can include evaluation of the female reproductive organs and running the small bowel. After all four ports are placed, the laparoscope and camera are transferred to the suprapubic port. The surgeon, assistant, and camera operator have now occupied the same relative positions used in the laparoscopic cholecystectomy technique of Reddick' (Fig. 2). The patient is placed in the Trendelenburg position with the table tilted to the left. This facilitates reflection of the viscera away from the cecum. The same blunt grasping instruments used in cholecystectomy are employed in laparoscopic appendectomy. However, they are applied to the bowel with only the minimum amount of force necessary. If the appendix is retrocecal, the cecum is grasped and reflected medially. The suprapubic camera position greatly facilitates identification and division of the lateral peritoneal reflection. The appendix is gently grasped with an instrument. Countertraction is applied to the cecum with a second grasping instrument and the mesoappendix is identified. Division of the mesoappendix is then accomplished. A Kleppinger bipolar electrocautery forceps (Fig. 3) (Richard Wolf, Rosemont, II) is inserted via the umbilical port. One paddle of the cautery device is placed on each side of the leading edge of the mesoappendix. The mesoappendix is then serially cauterized and sharply divided. Bipolar cauterization prevents the need to specifically identify friable vessels in an edematous mesoappendix. If bleeding occurs
\
K
I
placement. (1)12 mm-umbilicus; (2) 5 mm-right upper quadrant; (3) 5 mm-right lower quadrant; (4) mm-suprapubic. FIG. 1.
Port
344
10
LAPAROSCOPIC APPENDECTOMY ANESTHESIA
VIDEO
MONITOR
ASSISTANT
INSTRUMENT NURSE
FIG. 2.
FIG. 3.
Operating room setup.
Kleppinger bipolar electrocautery forceps. 345
BRYANT
FIG. 4.
The cauterized
mesoappendix is divided.
Division is
moving toward the tip.
after tissue division, bipolar cautery is applied directly to the bleeding point. Endoscopie clips may be applied directly to vessels but are rarely necessary. If the tip of the appendix is hard to mobilize, division of the mesoappendix may proceed outward from a window created adjacent to the appendix (Fig. 4). A pressure irrigation device is very useful in maintaining a clear field. In the first 10 cases, the appendiceal base was controlled with pre-tied loop ligatures of size zero polydioxanone. The ligatures are introduced via the umbilical port. Two ligatures are placed on the appendix near the cecum. A third loop is placed approximately 1 cm distally on the appendix, to prevent spillage from the specimen. The appendix is divided between the second and third ligatures. Exposed mucosa may be cauterized with bipolar current (Fig. 5).
FIG. 5.
Bipolar current cauterizes the mucosa of the appendiceal stump. 346
LAPAROSCOPIC APPENDECTOMY
FIG. 6.
The Endo-GIA divides the
appendix.
Rather than using loop ligatures, it is now preferred that the appendix be controlled with an Endo-GIA Autosuture (U.S. Surgical, Norwalk, CT). The Endo-GIA can divide the appendix and secure both ends with a single step. It is introduced via the 12 mm umbilical port, placed across the base of the appendix, and fired (Fig. 6). Each end of the severed appendix is securely closed with staples (Fig. 7). If necessary, the Endo-GIA can be used to divide the appendix prior to division of the mesoappendix. The divided appendix is then removed. It may be grasped and drawn into the umbilical port. The port and appendix are then simultaneously withdrawn from the patient. If the specimen is bulky, scissors may be used to extend the incision in the previously exposed midline umbilical fascia.
FIG. 7.
Each end of the divided
appendix has been sealed by the Endo-GIA. 347
BRYANT
FIG. 8.
The
appendix is placed within the sterilized condom.
A sterilized impermeable bag may be used to prevent wound contamination during specimen extraction. A steam-sterilized condom may be used for this purpose." The condom is rolled like a cigarette and inserted via the umbilical port with a dissecting instrument. The rim of the condom is stabilized with the two grasping instruments as the condom is unrolled. The specimen is then placed within the condom (Fig. 8). Axial rotation of a grasping forcep closes the opening of the condom (Fig. 9). The condom is then grasped, pulled partially into the umbilical port, and withdrawn through the umbilical incision. The umbilical fascia is closed with size zero poly-glycolic sutures; 3-0 plain gut suture is used for subcuticular skin closure. The first umbilical skin suture is placed first through the umbilical fascia and then through the subcuticular layers of the superior and inferior skin flaps. Tying this suture restores the umbilical inversion. The incision becomes almost invisible.
FIG. 9.
Axial rotation of the grasper closes the condom.
348
LAPAROSCOPIC APPENDECTOMY Table 1. Complicated Appendectomy
Complicated appendectomy
15 cases 6 total 5 1
Perforated antececal
Completed laparoscopically Converted to open operation Retrocecal non-perforated
5 total 4 I
Completed laparoscopically Converted to open operation Perforated and retrocecal
4 total 2 2
Completed laparoscopically Converted to open appendectomy All patients uncomplicated
treated with antibiotics. Cefotetan was used in adults and cefoxitin in children. In of appendicitis, a single dose was used. In cases with perforation, antibiotics were continued until the patient became afebrile. Laparoscopy was performed by a single surgeon in 35 patients with a preoperative diagnosis of acute appendicitis. Two patients were found to have primary cecal lesions and were converted to open operation. Laparoscopic appendectomy was attempted in the remaining 33 patients and completed in 29 (88% completion). Four patients were converted to open appendectomy; one of these was retrocecal, one perforated, and two were both perforated and retrocecal. Of the 29 appendectomies completed laparoscopically, two were both perforated and retrocecal. Five were perforated and antececal and four were non-perforated and retrocecal (Table 1). Four histologically normal appendices were removed (Table 2). All of these patients recovered uneventfully. In one patient, a normal appendix was removed along with an infarcted corner of omentum. In those cases where laparoscopic appendectomy was successful, "skin to skin" operative time averaged 72 min (range 42-130 min). The average patient age was 31 years (range 6-76 years). Patient weights ranged from 41-278 lbs. Postoperative hospitalizations averaged 2.4 days (11 h-7 days). None of these patients developed wound infections or intraabdominal abscesses. were
cases
DISCUSSION
appendices.3
Laparoscopic appendectomy was described by Semm in 1983 for the removal of non-inflamed He placed the patient in the lithotomy position and employed ports in the umbilicus, right upper quadrant, and
two
suprapubic ports.
performed over 700 laparoscopic appendectomies.4 They also place the patient in the lithotomy position, however, they use the umbilical port for visualization, a 5.5 mm port in the left lower quadrant, and an 11 mm port in the right lower quadrant. The mesoappendix is controlled with bipolar electrocautery. Pier and Götz have
Table 2. Diagnosis When Appendix Was Normal
Diagnosis when appendix was normal Laparoscopic appendectomy completed Salpingitis Ovarian cyst Infarcted corner of omentum Gastroenteritis Converted to open operation (laparoscopic not
6 4 I 1 I I
appendectomy
2
attempted)
Cecal carcinoid tumor Infected peritoneal cyst of cecum
349
1 1
cases
BRYANT
Saye uses an umbilical port for visualization, a 5 mm suprapubic port, a 5 mm port in the midline between the first two ports, and a fourth 5 mm port in the right side of the abdomen.2 Byrne employs a 10 mm umbilical port for laparoscope placement.5 A 12 mm right lower quadrant port is used to exteriorize the appendix. Control of the mesoappendix and appendiceal excision is accomplished
extracorporeally. All of these techniques employ an orientation of the patient, equipment, and personnel which differs significantly from the method used for laparoscopic cholecystectomy. The technique described here eliminates this disadvantage. The efficacy of bipolar electrocautery to control the vessels of the mesoappendix has been previously demonstrated.6 This modality is inexpensive. It minimizes tedious dissection and clip application. Unlike the exclusive use of staples for hemostasis, it can be initiated even when a portion of the mesoappendix remains fixed. Use of the Endo-GIA increases the expense of securing the appendiceal base. It shortens the operating time by approximately 5 min. The Endo-GIA permits the division of the appendix prior to division of the mesoappendix. The greatest advantage of the Endo-GIA is that it permits the excision of a small piece of cecum along with the appendix. This is greatly reassuring if the appendiceal necrosis extends to its base. Placing the 12 mm port via the umbilical cutdown allows suture repair of the largest fascial defect. The worst cases were sometimes converted to open operation. Therefore, these cases did not adversely affect the statistics for completed laparoscopic appendectomies. Nonetheless, the rapid recoveries of the laparoscopic patients was impressive. Perforation need not be a contraindication to laparoscopic appendectomy. As with conventional operations, patients with perforated appendicitis will require additional postoperative recovery time to resolve their peritonitis. Laparoscopic appendectomy may virtually eliminate problematic wound infections. The superior visualization of laparoscopy is a great advantage. It is very useful in women of reproductive age. In older patients, it can determine whether acute diverticulitis is present. If all laparoscopic findings are grossly normal, the appendectomy is completed. This prevents future diagnostic dilemmas. Occasionally, an early mucosal appendicitis may be difficult to detect by gross external examination.
CONCLUSIONS The technique, which is described is "user-friendly" to surgeons and crews who are experienced with laparoscopic cholecystectomy. It can be used in cases of perforated and retrocecal appendicitis.
REFERENCES
Laparoscopic laser cholecystectomy. Surg Endose 1989;3:131-133. Saye WB, Rives DA, Cochran EB, et al: Laparoscopic appendectomy: Three years experience. Surg. Laparosc Endose
1. Reddick EJ, Olsen DO:
2.
1991;1:109-115.
Endoscopie appendectomy. Endoscopy 1989;15:59-64. Pier A, Götz F, Bacher C, et al: Laparoscopic appendectomy in 625 cases: From innovation to routine. Surg Laparosc
3. Semm K: 4.
Endose 1991;1:8-13. 5. 6.
Byrne DS, Bell G, Morrice JJ, OrrG, et al: Technique for laparoscopic appendicectomy. Br J Surg 1992;79:574-575. Götz F, Pier A, Bacher C, et al: Modified laparoscopic appendectomy in surgery. Surg Endose. 1990;4:6-9. Address reprint requests to: Thomas L. Bryant, M.D., F.A.C.S. Marietta Memorial Hospital 400 Matthew Street Marietta, Ohio 45750
350
