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Laparoscopic abdominal exploration and appendectomy is indicated when acute appendicitis is suspected. The laparoscopic approach is particularly advantageous in young women, in obese patients, or when the diagnosis is in doubt.
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PREOPERATIVE PREPARATION
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In the majority of cases, the diagnosis is easily established by clinical history and physical examination. Laboratory evaluation such as a complete blood count and urinalysis, may provide supportive data. When warranted, ultrasound or computed tomography (CT) scans may confirm the diagnosis. The patient is given appropriate intravenous antibiotics prior to surgery.
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General anesthesia with endotracheal intubation is necessary for this operation. Complete neuromuscular blockade is required. If there has been little bleeding during the laparoscopic dissection, ketorolac may be given at procedure completion to diminish postoperative pain.
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The patient is positioned supine with arms tucked at the sides. This allows the surgeon and assistant to move cephalad as required. The surgeon stands on the patient’s left side; the assistant stands near the patient’s left shoulder. The operative monitor is placed near the patient’s hip on the right side (Figure 1).
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OPERATIVE PREPARATION
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A Foley catheter and orogastric tube are placed after the induction of anesthesia. Decompression of the bladder is of particular importance if a suprapubic port site is used. The abdomen from the nipple lines to the pubis is shaved with clippers after induction of anesthesia, and the abdomen is sterilely prepped in the routine manner.
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Depending on the surgeon’s preference, the appendectomy may be performed with an endoscopic linear stapler, ultrasonic dissector, or pretied surgical ligature. Generally a 10-mm, 30-degree and a 5-mm, 30-degree laparoscope are made available for dissection and specimen extraction, respectively.
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Laparoscopic appendectomy is performed with a three-trocar technique. The size of the trocars depends on the instrumentation. Maximum flexibility is obtained by using one 12-mm trocar and two 5-mm trocars.
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Because the abdominal wall is thinnest in the region of the umbilicus, this operation commences with insufflation of the abdomen using the Veress needle technique placed through the umbilicus. Alternatively, initial access is achieved via the Hasson technique at the umbilicus.
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A 12-mm port is placed at the umbilicus. A 10-mm 30-degree laparoscope is placed through this trocar and used to guide the placement of additional trocars. A 5-mm port is then placed in the left lower quadrant, keeping lateral to the rectus muscle to avoid injury to the inferior epigastric vessels. The third port is a 5-mm port placed in the midline suprapubic position. Placement of this port is often aided by using ...