Large Intestine: Appendectomy

Trocar Placement

Normal Placement

  • Access: Hasson or Veress Needle
  • 10 mm Port: Infraumbilical or Supraumbilical
  • 5 mm Ports (x2): LLQ & Suprapubic
    • *Some Elect for Two Left Sided Ports Instead to Avoid Bladder Injury

Placement In Pregnancy

  • *Need to Avoid Gravid Uterus in Second & Third Trimesters
  • First Trimester
    • Normal Placement
  • Second Trimester
    • Access: Hasson (May Consider Veress at Subxiphoid or Left Costal Margin)
    • 10 mm Port: Supraumbilical
    • 5 mm Ports (x2): LLQ & RLQ
  • Third Trimester
    • Access: Hasson (Consider Veress Subxiphoid or Left Costal Margin)
    • 10 mm Port: Supraumbilical
    • 5 mm Ports (x2): Two Along Right Side
      • RLQ, Right Mid-Abdomen, RUQ or Subxiphoid
  • Also Consider Positioning in Full or Partial Left Lateral Decubitus During the Second/Third Trimesters

Basic Procedure

Laparoscopic Appendectomy

  • Position Supine, Left-Arm Tucked, Left-Side Down & Trendelenburg
  • Identify & Expose the Appendix Along its Length from Base to Tip
  • Bluntly Create a Tunnel Through the Mesoappendix at the Base
  • Staple Across the Mesoappendix Near the Appendix
    • Grey Staple Load (2.0 mm) Preferred – White Staple Load (2.5 mm) Has Significantly Higher Risk of Postoperative Bleeding
  • Staple Across the Base of the Appendix
  • Remove Appendix Through an Endoscopic Bag
  • Aspirate Overt Fluid but Avoid Peritoneal Irrigation (May Increase Risk of Abscess)
  • Close the Port Sites

Open Appendectomy

  • Incision Options:
    • McBurney’s Incision – Oblique Following Skin Lines
      • Center Incision at Site of Most Pain on Exam or at McBurney’s Point
    • Rockey-Davis Incision – Transverse Incision
    • If Converting from Laparoscopic: Low Midline Laparotomy (Connecting Periumbilical & Suprapubic Incisions
  • Using a Muscle Splitting Technique Dissect Through the Abdominal Wall
  • Locate the Ascending Colon/Cecum & Then Identify the Appendix
  • Mobilize Appendix into the Opening
  • Divide the Mesoappendix
  • Divide the Appendix at its Base
  • Close the Abdominal Wall & Incision

Laparoscopic Appendectomy 1

Appendix Anatomy 2

Complications

Surgical Site Infection

  • Most Common Complication
  • Laparoscopic Risk: 1.9-3.7%
  • Open Risk: 4.3-7.0%

Intraabdominal Abscess

  • Risk:
    • Overall: 2-4%
    • If Perforated: 6-10%
  • Higher Rates in Laparoscopic Than Open Surgery
  • Tx: Percutaneous Drainage

Stump Appendicitis

  • Recurrent Appendicitis Due to Incomplete Appendectomy Leaving an Excessively Long Stump
  • More Common After Perforation
  • Tx: Stump Resection
    • May Require Partial Cecectomy or Bowel Resection

Other Complications

  • Bleeding/Hematoma (1%)
  • Bowel Injury
  • Incisional Hernia

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)
  2. Bakar SM, Shamim M, Alam GM, Sarwar M. Negative correlation between age of subjects and length of the appendix in Bangladeshi males. Arch Med Sci. 2013 Feb 21;9(1):55-67.(License: CC BY-NC-ND-3.0)