Presentation on theme: "Laparoscopic Appendectomy"— Presentation transcript:
1 Laparoscopic Appendectomy Use, history and performanceBy Rob West
2 In this presentation: Contents About appendicitis History of appendectomyPatient presentationWorkup and diagnosisTreatment methods/Pre-opAdvantages of Laparoscopic methodContraindications for laparoscopic methodOR setupInstruments usedPort placementAnatomyProcedure overviewProcedure key stepsComplicationsPost-op
3 AppendicitisThe vast majority of appendectomies are due to appendicitis.Characterized by inflammation in the appendixCaused by blockage of the appendix from fecal impaction or lymphoid hyperplasia. Crohn’s and IBS also increase risk of appendicitisInflammation compromises blood flow to appendix tissue death ruptureRupture bowel contents (including flora) spill into abdominopelvic cavity; peritonitis, potentially fatalBecause rupture can occur within 72 hours of onset, appendicitis is a MEDICAL EMERGENCY. A rapid response is CRITICAL
4 History of the Appendectomy The first recorded successful removal of an appendix was in 1735 by Claudius Aymand, but it was done during a hernia operation.Early cases of appendicitis were described as “iliac passion”. The disease was poorly understood, and the appendix was not implicated until the 1800’sBoston surgeon Reginald Fitz published a paper in 1886 establishing a link between appendicular inflammation and iliac passion (he was the first to call this pathology “appendicitis.”) A German physician named Matterstock published similar findings in Europe around that time.American Dr. Thomas Morton performed the first appendectomy for appendicitis successfully in 1887First performed laparoscopically by German OB/GYN Kurt Semm in 1981Laparoscopic procedure was rejected originally as “unethical,” but quickly became mainstream
5 Patient Presentation First, vague pain around navel With time, increases in intensity and sharpnessPain migrates to RLQ (McBurney’s Point)Nausea/VomitingSevere abdominal painFeverReduced appetiteConstipation or diarrhea“Rebound tenderness”
6 McBurney’s PointMcBurney’s point (1) appears about one-third of the distance along a line starting at the right ASIS (3) and ending at the umbilicus (2).
7 Workup and diagnosisPhysical Exam: along with HPI often sufficient to diagnose appendicitisCT scan or Ultrasound:Other diseases can present with similar symptoms (e.g. hernia, diverticulitis, hepatitis, some gynecological diseases). Imaging appendix can help determine if it is inflamed.Urine test might rule out UTI, which can present similarlyAs many as 20% of appendectomies may involve removal of a healthy appendix
8 Treatment methods/Pre-Op Though mild cases can be treated with antibiotics, many surgeons prefer to err on the side of caution and perform the surgery to avoid rupture.Determine how long it has been since patient has eaten; instruct patient to fastPatient is administered antibiotics to prevent peritonitis and other infectionsPatient is sedated and given an IV drip to hydrate
10 Contraindications for Laparoscopic Method Cardiac diseases/COPD: pneumoperitoneum induced by insufflation may cause arrhythmias or make breathing too difficult for patients with these conditions.ObesityPrevious abdominal surgeries
11 OR Setup Patient is supine, laying flat Surgeon and assistant positioned on patient’s leftMonitors on patient’s right, facing surgeonsAnesthesiologist conventionally stationed at patient’s head (not shown)
12 Instruments Used Atraumatic grasper Laparoscopic scissors Dissector Endo GIA (or stapler, or endoloop ligature applicator)Suction/irrigation deviceExtraction tubeExtraction bagZero-degree scope3 Trocars (two 5mm and one 10mm)Alternately, electrocautery tools may also be used
13 Port Placement10-mm trocar placed through umbilicus (this port holds camera)5-mm trocar placed at suprapubic region5-mm trocar placed at LLQ*A fourth port containing extraction tube may be placed closer to McBurney’s point later in procedure.
14 ABOVE: Internal anatomy of RLQ of abdominal cavity HIGHLIGHTED IN RED: Appendix and mesoappendix (medially; contains appendicular artery)
15 Procedure Overview Ports placed at umbilicus, suprapubis, LLQ Inspect abdominal cavity and located ileocecal junctionRetract bowel to expose appendixSeparate mesoappendix to locate appendicular arteryDivide appendixDivide appendicular arteryExtract appendixIrrigate thoroughlyFinal inspection of abdominal cavity
16 Procedure: Key StepsStep 1: Port placement A 10-mm trocar is placed at the umbilicus, and the abdominal cavity is insufflated to a pressure of 15 mmHg. The camera is also inserted through this larger trocar.A 5-mm trocar is placed at the suprapubis, and a second 5-mm trocar is placed at the LLQ. (Placement of the third port may vary by surgeon preference or as case dictates but LLQ is standard placement)Step 2: Inspect abdominal cavity The area is inspected to orient the surgeon to the position of the appendix. Inspection will also alert surgeon to any anatomic variation or pathological conditions that may be relevant (e.g. peritonitis).
17 Procedure: Key Steps (cont.) Step 3: Expose appendix The bowel is gently retracted rostrally using atraumatic graspers to allow access to appendix.Step 4: Locate and separate appendicular artery The mesoappendix is separated from the body of the appendix, and the mesenteric fat is separated to reveal the appendicular artery. This is best done using the “spreader” action of a dissector.
18 Procedure: Key Steps (cont.) Step 5: Divide appendix from cecum Using an endoloop, two loops are placed proximal to the cecum, and a third loop is placed 1-2 cm distally to these. The appendix is then divided between the two proximal and 3rd distal loops using scissors or cautery. Staples may be substituted for loops.UK surgeons tend to use the Endo GIA tool, which simultaneously seals and cuts, eliminating the need for loops or staples.Step 6: Divide appendicular artery The artery is divided using the Endo GIA or the endoloop method described above (two ligatures proximally, one distally).
19 Procedure: Key Steps (cont.) Step 7: Extract appendix A fourth port (10 mm) may be placed containing the extraction tube. Alternately, the camera may be withdrawn and the existing 10 mm port used for extraction (a 5 mm camera is inserted into one of the smaller ports in these cases).In either case, an extraction tube is placed through the appropriate 10 mm port, and the extractionbag tool is placed through the extraction tube. The appendix is placed in the capture bag, and removed from the abdomen through the extraction tube.*(It should be noted that in the accompanying video, a non-conventional extraction technique is used, probably because the appendix had already ruptured and the extraction bag was deemed unnecessary. The image above comes from a different case.)
20 Procedure: Key Steps (cont.) Step 8: Irrigate The abdominal cavity should be irrigated thoroughly with sterile saline and suctioned clean several times. In the event of a rupture, great care should be taken to ensure all pus or other infectious fluids have been removed.Step 9: Final inspection The abdominal and pelvic cavities are inspected one final time for any signs of infection, errors, or other potential complications of which the surgeon might need to be aware. This can often be done simultaneously with irrigation.
21 Key Step times for reference video Title of video: “Dr. Iocono, Laparoscopic Appendectomy 03/8/2010”Sedation, insufflation, umbilical port and trocar/laparoscope insertion are achieved at time 0 (prior to video)Some basic inspection/orientation from time 0:30 – 1:452nd port inserted at 1:45; 3rd port inserted at 3:40Inspection of abdominal cavity 4:20-5:00Bowel retracted to expose bladder 5:00 – 5:25Appendicular perforation apparent at 5:30Separation of mesoappendix from body of appendix ~6:45 – 7:30Appendix position appropriately and divided 7:30- 9:504th port inserted at 10:10Appendicular artery divided at 11:33Appendix removed through 4th port at 14:00Irrigation, suction, and final inspection occur from 14:10 – 31:30 (about 17 minutes)
22 ComplicationsRupture: more advanced inflammation is more susceptible to rupture during the procedure. A rupture during the procedure warrants extra care in irrigation, and extra care in inspecting for pus and signs of peritonitis before closing. A pre-operative rupture may warrant more aggressive post-operative antibiotic course.Intra-abdominal abcess: drained surgically or with CT-guided needleAdhesionsWound-site infection
23 Post-Operative care Hospital stay time 24-48 hours Patient can walk around usually after 12 hoursAntibioticsPain managementResume normal activities within 2 weeks
24 SourcesMohan, V., M.D. (2010, March 1). Appendicitis. Retrieved fromHunter, Any. (2008, June 4). How Your appendix works. Retrieved fromNavez, B. (2001, April). Laparoscopic appendectomy. Retrieved fromMcCarthy, Arthur C., MD, History of Appendicitis Vermiformis, its diseases and treatment , University of LouisvilleBhattacharya K., Kurt Semm: A laparoscopic crusader. J Min Access Surg [serial online] 2007 [cited 2010 Apr 9];3:35-6. Available from: http://www.journalofmas.com/text.asp?2007/3/1/35/30686