TECHNICAL NOTES
John A. Coller, M.D., Editor
Technical Modification t o Laparoscopic Appendectomy Peter Goh, F.R.C.S., Yaman Tekant, M.D., Cheng K. Kum, F.R.C.S., Louis Chow, F.R.C.S., Sing S. Ngoi, F.R.C.S. From the Department of Surgery, National University Hospital, National University of Singapore, Singapore, Singapore An alternative technique for laparoscopic appendectomy is described. The isolated appendix is exteriorized through the trocar wound, ligated, and resected. The cecum is then returned to the abdomen. [Key words: Appendectomy; Laparoscopy; Laparoscopic appendectomy] Goh P, Tekant Y, Kum CK, Chow L, Ngoi SS. Technical modification to laparoscopic appendectomy. Dis Colon Rectum 1992;35:999-1000.
Pneumoperitoneum is achieved using a Veress needle placed in the subumbilical position, and the intra-abdominal pressure is maintained at 14 mmHg using an electronic insufflator. A 10-mm trocar is inserted subumbilically for the videolaparoscope and camera attachment. Diagnosis of appendicitis is confirmed visually. This may be facilitated by an atraumatic forceps inserted through a 10-mm trocar placed on the left lower abdomen. Once the diagnosis of appendicitis is confirmed, another 10-mm trocar is placed on the right iliac fossa directly over the appendix. The appendicular tip is grasped with forceps from the right-sided port, and traction is maintained to allow subsequent coagulation, clipping, and cutting of the mesoappendix containing the appendicular artery. The isolated appendix is pulled completely into the trocar, which is then slowly withdrawn through the abdominal puncture wound (Fig. 1). At the same time, the pneumoperitoneum is evacuated to allow approximation of the cecal wall to the anterior abdominal wall. The trocar is removed, and slight traction is applied on the appendix, which is now exposed, to clearly see its base on the cecum. The appendix is then ligated and resected (Fig. 2). The cecum is returned to the abdomen, which is then reinspected for hemostasis. The area is irrigated if necessary. Finally, the working trocar at the left lower abdomen and the videolaparoscope are removed, and the pneumoperitoneum is evacuated before the subcutaneous sutures and steel skin staples are applied (Fig. 3).
ith the development of laparoscopic cholecystectomy and the advent of a whole new range of sophisticated laparoscopic equipment, laparoscopic appendectomy has evolved from a novelty to a viable alternative to the traditional open appendectomy. The operation can be done in almost all stages of inflammation and, in experienced hands, is quick, safe, and convenient. 1 Several methods have been described to secure the appendicular base (using a preknotted Roeder loop, specially designed clips, rubber banding, or stapling), >3 but all these methods require special equipment or disposable items that increase the cost of the operation. This report describes an alternative technique of securing the appendix base using an ordinary surgical suture. This is achieved by exteriorizing the entire appendix through the trocar wound and doing an extracorporeal ligature on the appendix base.
W
TECHNIQUE Laparoscopy is carried out under general anesthesia with endotracheal intubation and with the urinary catheter in place. The surgeon stands on the left of the patient and operates while watching the video monitor at the foot of the table.
DISCUSSION We have utilized this technique in 12 patients without complications. The main advantage of this method is that it obviates the need for ligating
Address reprint requests to Dr. Ngoi: ConsultantSurgeon, Department of Surgery, National UniversityHospital, LowerKent Ridge Road, Singapore0511, Singapore. 999
1000
GOH E T AL
Figure 1. The appendix-trocar complex being pulled through the lO-mm puncture wound.
Dis Colon Rectum, October 1992
Figure 3. The cecum is returned to the abdomen, and subcutaneous and skin sutures are placed.
devices. It can be p e r f o r m e d in most cases e x c e p t in obese patients, in w h o m it may be difficult to pull the entire a p p e n d i x through the thick abdominal wall adequately e n o u g h to e x p o s e its base. A friable appendix or inflamed and e d e m a t o u s cecal base is also a contraindication. The possibility of infection at the trocar port because of direct contact with the inflamed appendix is the theoretic drawback of the technique. To avoid such a complication, we retract the a p p e n d i x c o m p l e t e l y into the trocar before it is pulled out of the wound, thus minimizing its contact with tissue. Antibiotic prophylaxis is routinely used. ACKNOWLEDGMENT The authors thank Mr. Peter Lim Lian Peng for drawing the figures. REFERENCES
Figure 2. The pneumoperitoneum is evacuated, the trocar is removed, and slight traction is applied on the appendix, which is then ligated and resected.
1. Pier A, Gotz F, Bacher C. Laparoscopic appendectomy in 625 cases: from innovation to routine. Surg Laparosc Endosc 1991;1:8-13. 2. Gangal HT, Gangal MH. Laparoscopic appendicectomy. Endoscopy 1987;19:127-9. 3. Reddick EJ, Saye WB. Laparoscopic appendectomy. In: Zucker KA, Bailey RW, Reddick EJ, eds. Surgical laparoscopy. St. Louis: Quality Medical Publishing, 1991:227-39.
John A. Coller, M.D., Editor
Technical Modification t o Laparoscopic Appendectomy Peter Goh, F.R.C.S., Yaman Tekant, M.D., Cheng K. Kum, F.R.C.S., Louis Chow, F.R.C.S., Sing S. Ngoi, F.R.C.S. From the Department of Surgery, National University Hospital, National University of Singapore, Singapore, Singapore An alternative technique for laparoscopic appendectomy is described. The isolated appendix is exteriorized through the trocar wound, ligated, and resected. The cecum is then returned to the abdomen. [Key words: Appendectomy; Laparoscopy; Laparoscopic appendectomy] Goh P, Tekant Y, Kum CK, Chow L, Ngoi SS. Technical modification to laparoscopic appendectomy. Dis Colon Rectum 1992;35:999-1000.
Pneumoperitoneum is achieved using a Veress needle placed in the subumbilical position, and the intra-abdominal pressure is maintained at 14 mmHg using an electronic insufflator. A 10-mm trocar is inserted subumbilically for the videolaparoscope and camera attachment. Diagnosis of appendicitis is confirmed visually. This may be facilitated by an atraumatic forceps inserted through a 10-mm trocar placed on the left lower abdomen. Once the diagnosis of appendicitis is confirmed, another 10-mm trocar is placed on the right iliac fossa directly over the appendix. The appendicular tip is grasped with forceps from the right-sided port, and traction is maintained to allow subsequent coagulation, clipping, and cutting of the mesoappendix containing the appendicular artery. The isolated appendix is pulled completely into the trocar, which is then slowly withdrawn through the abdominal puncture wound (Fig. 1). At the same time, the pneumoperitoneum is evacuated to allow approximation of the cecal wall to the anterior abdominal wall. The trocar is removed, and slight traction is applied on the appendix, which is now exposed, to clearly see its base on the cecum. The appendix is then ligated and resected (Fig. 2). The cecum is returned to the abdomen, which is then reinspected for hemostasis. The area is irrigated if necessary. Finally, the working trocar at the left lower abdomen and the videolaparoscope are removed, and the pneumoperitoneum is evacuated before the subcutaneous sutures and steel skin staples are applied (Fig. 3).
ith the development of laparoscopic cholecystectomy and the advent of a whole new range of sophisticated laparoscopic equipment, laparoscopic appendectomy has evolved from a novelty to a viable alternative to the traditional open appendectomy. The operation can be done in almost all stages of inflammation and, in experienced hands, is quick, safe, and convenient. 1 Several methods have been described to secure the appendicular base (using a preknotted Roeder loop, specially designed clips, rubber banding, or stapling), >3 but all these methods require special equipment or disposable items that increase the cost of the operation. This report describes an alternative technique of securing the appendix base using an ordinary surgical suture. This is achieved by exteriorizing the entire appendix through the trocar wound and doing an extracorporeal ligature on the appendix base.
W
TECHNIQUE Laparoscopy is carried out under general anesthesia with endotracheal intubation and with the urinary catheter in place. The surgeon stands on the left of the patient and operates while watching the video monitor at the foot of the table.
DISCUSSION We have utilized this technique in 12 patients without complications. The main advantage of this method is that it obviates the need for ligating
Address reprint requests to Dr. Ngoi: ConsultantSurgeon, Department of Surgery, National UniversityHospital, LowerKent Ridge Road, Singapore0511, Singapore. 999
1000
GOH E T AL
Figure 1. The appendix-trocar complex being pulled through the lO-mm puncture wound.
Dis Colon Rectum, October 1992
Figure 3. The cecum is returned to the abdomen, and subcutaneous and skin sutures are placed.
devices. It can be p e r f o r m e d in most cases e x c e p t in obese patients, in w h o m it may be difficult to pull the entire a p p e n d i x through the thick abdominal wall adequately e n o u g h to e x p o s e its base. A friable appendix or inflamed and e d e m a t o u s cecal base is also a contraindication. The possibility of infection at the trocar port because of direct contact with the inflamed appendix is the theoretic drawback of the technique. To avoid such a complication, we retract the a p p e n d i x c o m p l e t e l y into the trocar before it is pulled out of the wound, thus minimizing its contact with tissue. Antibiotic prophylaxis is routinely used. ACKNOWLEDGMENT The authors thank Mr. Peter Lim Lian Peng for drawing the figures. REFERENCES
Figure 2. The pneumoperitoneum is evacuated, the trocar is removed, and slight traction is applied on the appendix, which is then ligated and resected.
1. Pier A, Gotz F, Bacher C. Laparoscopic appendectomy in 625 cases: from innovation to routine. Surg Laparosc Endosc 1991;1:8-13. 2. Gangal HT, Gangal MH. Laparoscopic appendicectomy. Endoscopy 1987;19:127-9. 3. Reddick EJ, Saye WB. Laparoscopic appendectomy. In: Zucker KA, Bailey RW, Reddick EJ, eds. Surgical laparoscopy. St. Louis: Quality Medical Publishing, 1991:227-39.
