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    Appendic Ectomy

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    Shashidhara Puttaraj
    1) Laparoscopic appendicectomy was first performed in 1982 by Kurt Semm and has since become a standard procedure with good results. 2) It involves using several small incisions and cameras to visualize and remove the appendix, avoiding the large incision of open surgery. 3) Contraindications include a firm mass that has lasted over a week, suspicion of malignancy, and peritonitis with ileus. Preparation includes evaluation by specialists, overnight fasting, antibiotics, and emptying the bladder.

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    Appendic Ectomy

    Uploaded by

    Shashidhara Puttaraj
    48 views56 pages
    1) Laparoscopic appendicectomy was first performed in 1982 by Kurt Semm and has since become a standard procedure with good results. 2) It involves using several small incisions and cameras to visualize and remove the appendix, avoiding the large incision of open surgery. 3) Contraindications include a firm mass that has lasted over a week, suspicion of malignancy, and peritonitis with ileus. Preparation includes evaluation by specialists, overnight fasting, antibiotics, and emptying the bladder.

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    Appendicitis lap management

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    1) Laparoscopic appendicectomy was first performed in 1982 by Kurt Semm and has since become a standard procedure with good results. 2) It involves using several small incisions and cameras to visualize and remove the appendix, avoiding the large incision of open surgery. 3) Contraindications include a firm mass that has lasted over a week, suspicion of malignancy, and peritonitis with ileus. Preparation includes evaluation by specialists, overnight fasting, antibiotics, and emptying the bladder.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    48 views56 pages

    Appendic Ectomy

    Uploaded by

    Shashidhara Puttaraj
    1) Laparoscopic appendicectomy was first performed in 1982 by Kurt Semm and has since become a standard procedure with good results. 2) It involves using several small incisions and cameras to visualize and remove the appendix, avoiding the large incision of open surgery. 3) Contraindications include a firm mass that has lasted over a week, suspicion of malignancy, and peritonitis with ileus. Preparation includes evaluation by specialists, overnight fasting, antibiotics, and emptying the bladder.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 56

    Laparoscopic

    Appendicectomy
    EVOLUTION

    1982 –Kurt Semm


    1991 – Pier and associates – 625 cases with very good
    results

    Different technique; variable results


    “Two hand technique”
    Indications
    Same like open surgery
    Unless medically contraindicated - all the cases

    Stages of learning
    Simple cases
    Difficult positions
    Acute Appendicitis
    Appendicular mass, abscess,Prior lower
    abdominal surgery and Pregnancy
    CONTRAINDICATIONS

    Firm mass in the RIF - More than a week


    duration - Interval appendicectomy

    Suspicion of Malignancy
    Preoperative preparation

    Cardiologist evaluation
    Pulmonologist opinion
    Overnight starvation
    Prophylactic Antibiotics
    Preoperative preparation

    Neotomic enema –avoid in acute cases


    Cleaning of the umbilicus
    Empty the bladder before surgery
    Catheterization in difficult cases
    Position of the patients and team

    Patient is in supine position


    Surgeon and camera assistant on the left side
    Monitor on the right side
    Staff nurse on the right side
    Position of the patients and team
    Pneumoperitoneum
    Veress needle at the umbilicus
    - Beware of appendicular mass

    Alternative site Veress


    - Miniscopes

    Open technique
    - Multiple Scars
    - Peritonitis with ileus
    Trocars
    Umbilicus – 10mm
    Right hand working port

    Suprapubic – 10mm / 5mm / 3mm


    Camera port -30 degree telescope

    RIF – 5mm/ 3mm

    Left hand working port


    Trocars
    Suprapubic trocar

    Use left hand for insertion


    Avoid Urinary Bladder and Urachus –
    2-3 cm above the pubic symphysis
    Change the direction of trocar after peritoneum
    is reached
    Suprapubic trocar
    Trocar to the right of the medial umbilical ligament

    Only the tip of the trocar should be intra-peritoneal

    Midline adhesions – trocar entry to the right


    of adhesions

    Shift the camera to this port, after insertion


    Exposure
    Sand bag
    Head up / down
    Left lateral tilt
    Additional trocars
    - Distended bowel loops
    - Difficult positions
    Placement of Sandbag
    RIF Trocar
    Left hand working port

    At the level or below the base of the appendix


    - Pelvic Caecum
    - Highly placed appendix
    Avoid vessels
    Relatively tight incision in thin walled patients
    Subhepatic appendix

    Umbilicus – Camera
    Epigastric – Right hand working
    Right lumbar – Left hand working
    Subhepatic appendix
    Identification

    Identify the Caecum

    Trace the Taenia down


    Difficulty

    Abnormal Caecal position


    Difficult Appendiceal position
    Retrocaecal – Mobilise the caecum
    Paracaecal – Retract the caecum
    Retroileal – Put the small bowel loops up
    Division of the
    Mesoappendix
    Cautery
    Release of the lateral attachment
    Clip to the meso-appendix
    Divide the meso-appendix
    Skeletonisation
    May need multiple clips
    Division of the Mesoappendix

    Edematous meso-appendix ?
    Fatty meso-appendix?

    Stay close to the appendix


    Use bipolar
    Retrograde technique

    Para-caecal appendix with short meso appendix


    Ligation and Division
    Confirm the base
    Two Endo-loops – adjustment of the loop
    Less than 5mm in-between loops
    Third loop in purulent cases
    Risk of avulsion
    Division of the appendix
    Extraction
    Under vision
    Into the reducer sleeve first
    Division of the meso-appendix
    Endobag
    Risk of loss of specimen
    Care of the Stump and
    Completion of the procedure

    Povidone Iodine
    Electrocautery

    Examination of the small bowel – Meckel’s!


    Peritoneal lavage and Drainage
    Paediatric cases
    Lesser working space
    Movement of the trocars
    Diathermy injury to the ports
    Acute appendicitis
    Difficulty in exposure – omentum
    Difficulty in grasping
    Edematous mesoappendix
    Friable base
    Difficulty in extraction
    Peritoneal contamination
    Drainage
    Perforated appendix

    Confined perforation with Abscess


    Perforation with generalised peritonitis
    Appendicular Abscess
    Appendicular Abscess

    Gentle separation of the mass with suction nozzle


    Suck out the pus immediately
    Perforation at the tip – easy to manage the base
    Perforation at the base – Suture or no suture
    Additional retractors
    Perforation with Peritonitis

    Thorough wash – first step


    Rest of the steps – similar to the
    confined perforation
    Drainage is essential
    Mass and abscess
    General Principles

    Select only the early cases


    Gentle separation with nozzle
    Drain the pus immediately
    Risk of bowel perforation
    Identification of the appendix
    Unvisualised Appendix

    Sloughed appendix

    Interval appendicectomy
    Submucosal Appendicectomy

    Appendix firmly adherant the bowels

    Split the muscle layer

    Removal of the mucosa


    Post operative care
    Oral fluids
    Clean cases – after 5 hrs
    Difficult cases – After flatus

    Normal diet
    Clean cases – I POD
    Difficult cases – 3-4 days
    Conclusion
    Appendix is one of the simple procedure to start

    Not all the appendicectomies are easy

    Convert when there is difficulty

    With adequate experience even the most difficult


    Cases Can be managed laparoscopically
    Thank you

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