Laparoscopic Appendectomy

Laparoscopic Appendectomy

David Ray Velez, MD

Table of Contents

Trocar Placement
Procedure
Complications

See Also:
*See Appendicitis

Trocar Placement

Standard Placement

  • 5-mm Port: Periumbilical
  • 5-mm Port: Suprapubic
  • 12-mm Port: Left Lower Quadrant
  • Variations:
    • *Some Prefer a Periumbilical Port with Two Left Sided Ports Instead to Avoid Bladder Injury without a Suprapubic
    • *Some Place the 12-mm Port Periumbilical Instead

Placement In Pregnancy

  • *Need to Avoid Gravid Uterus in Second and Third Trimesters
  • First Trimester
    • Normal Placement
  • Second Trimester
    • Access: Hasson (May Consider Veress at Subxiphoid or Left Costal Margin)
    • Ports: Supraumbilical, Left Lower Quadrant, and Right Lower Quadrant
    • Avoids Suprapubic Port
  • Third Trimester
    • Access: Hasson (Consider Veress Subxiphoid or Left Costal Margin)
    • Ports: Supraumbilical and Two Along the Right Side
    • Potential Options:
      • Right Lower Quadrant
      • Right Mid-Abdomen
      • Right Upper Quadrant
      • Subxiphoid
    • Avoids Suprapubic and Left Lower Quadrant Ports
  • Also Consider Positioning in Full or Partial Left Lateral Decubitus During the Second/Third Trimesters

Trocar Placement

Procedure

Access the Abdomen

  • Initial Position: Supine with Left-Arm Tucked
  • Prep and Drape in the Standard Sterile Fashion
  • Achieve Pneumoperitoneum by Preferred Method
    • Veress Needle
    • Hasson
    • OptiView Optical Trocar
  • Place Trocars in Appropriate Position (See Above)
  • Complete Patient Positioning with Head Down (Trendelenburg) with Left-Side Down (Left Lateral Decubitus)

Dissection

  • Identify and Expose the Appendix Along its Length from Base to Tip
  • Bluntly Create a Tunnel Through the Mesoappendix at the Base
  • Staple Across the Base of the Appendix
    • Generally Use a Blue Staple Load (3.5 mm)
  • Staple Across the Mesoappendix Near the Appendix
    • A Small Retrospective Study Reported Significantly Less Postoperative Bleeding with a Grey Staple Load (2.0 mm) Compared to a White Staple Load (2.5 mm); However This Finding Has Not Been Definitively Established
  • Variations:
    • Can Staple the Mesoappendix First and the Appendiceal Base Second
    • May Use an Energy Device to Divide the Mesoappendix (LigaSure, Harmonic, EnSeal, etc)
      • No Significant Difference in Postoperative Bleeding Has Been Demonstrated Between Stapler or Energy Device Division of the Mesoappendix

Completion

  • Remove Appendix Through the 12-mm Trocar Site Using an Endoscopic Bag
  • Aspirate Overt Fluid but Avoid Peritoneal Irrigation
    • Routine Irrigation Has Not Been Shown to Reduce Intra-Abdominal Abscess or Surgical-Site Infection Compared with Suction Alone
    • Irrigation May Theoretically Disseminate Contamination and Increases Operative Time – Therefore, Suction Alone is Generally Preferred for Complicated Appendicitis
  • Ensure Hemostasis
  • Close the Fascia of the 12-mm Port Site to Reduce the Risk of Port-Site Hernia
    • Carter-Thomason/PMI Device
    • Suture Passer
    • Direct Closure
  • Release Pneumoperitoneum
  • Close Skin

Laparoscopic Appendectomy 1

Complications

Overall Complication Rate: 10-30%

Surgical Site Infection

  • The Most Common Complication After Appendectomy
  • Laparoscopic Risk:
    • Wound Infection: 1.9-3.7%
    • Intraabdominal Abscess: 2-4% Overall (6-10% if Perforated)
  • Comparison to Open Approach:
    • Laparoscopic Approach Has a Significantly Decreased Risk for Wound Infection (OR 0.30-0.52)
    • Laparoscopic Approach Actually Has a Significantly Increased Risk for Intraabdominal Abscess (OR 1.56-2.29)
  • Management:
    • Antibiotics for Cellulitis, Abscess, or Any Systemic Infection
    • Open/Drain Localized Superficial Infection if Appropriate
    • Consider Percutaneous Drainage for Any Intraabdominal Abscess

Hemorrhage

  • Sources:
    • Mesoappendix/Staple Line
    • Appendiceal Artery Injury
    • Abdominal Wall/Epigastric Vessel Injury
  • Overall Risk: 1%
  • Management:
    • Intraoperative Identification: Achieve Hemostasis with Clips, Sutures, Staplers or Energy Device as Needed
      • Consider Conversion to Open for Uncontrolled Hemorrhage
    • Postoperative Identification: Blood Transfusion as Indicated and Consideration of Angioembolization vs Repeat Surgery

Stump Appendicitis

  • Definition: Recurrent Appendicitis Due to Incomplete Appendectomy Leaving an Excessively Long Stump
  • Clinical Presentation Generally Mimics that of Classic Appendicitis
  • Preventative Measures:
    • Clearly identify the Cecum
    • Complete Appendix Resection
    • Securely Close the Stump with an Endoloop or Stapler
    • Minimal Stump Length (Ideally < 5 mm)
    • Inspect for Anatomical Variations
    • Ensure Hemostasis and Absence of Residual Tissue
  • Management: Completion Appendectomy/Stump Resection
    • May Require Partial Cecectomy for Complete Resection
    • May Require Ileocecectomy vs Right Hemicolectomy if Severe

Other Complications

  • Bowel Injury – From Trocar Placement, Dissection, or Energy Devices
  • Bladder Injury – From Suprapubic Trocar Placement
  • Postoperative Urinary Retention (POUR)
  • Venous Thromboembolism (VTE)
  • Ileus
  • Port-Site Hernia
  • Adhesive Small Bowel Obstruction

References

  1. Strzałka M, Matyja M, Rembiasz K. Comparison of the results of laparoscopic appendectomies with application of different techniques for closure of the appendicular stump. World J Emerg Surg. 2016 Jan 6;11:4. (License: CC BY-4.0)