By Rob West

Contents
About appendicitis
History of appendectomy
Patient presentation
Workup and diagnosis
Treatment methods/Pre-op
Advantages of Laparoscopic method
Contraindications for laparoscopic method
OR setup
Instruments used
Port placement
Anatomy
Procedure overview
Procedure key steps
Complications
Post-op

The vast majority of appendectomies are due to

appendicitis.
Characterized by inflammation in the appendix
Caused by blockage of the appendix from fecal
impaction or lymphoid hyperplasia. Crohns and IBS
also increase risk of appendicitis
Inflammation compromises blood flow to appendix
tissue death rupture
Rupture bowel contents (including flora) spill into
abdominopelvic cavity; peritonitis, potentially fatal
Because rupture can occur within 72 hours of onset,
appendicitis is a MEDICAL EMERGENCY. A rapid
response is CRITICAL

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 1800s
Boston 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 1887
First performed laparoscopically by German OB/GYN Kurt Semm in
1981
Laparoscopic procedure was rejected originally as unethical,
but quickly became mainstream

First, vague pain around navel

With time, increases in intensity and sharpness
Pain migrates to RLQ (McBurneys Point)

Nausea/Vomiting
Severe abdominal pain
Fever
Reduced appetite
Constipation or diarrhea
Rebound tenderness

McBurneys point (1) appears about one-third of the distance along a

line starting at the right ASIS (3) and ending at the umbilicus (2).

Physical Exam: along with HPI often sufficient to

diagnose appendicitis

CT 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
similarly
As many as 20% of appendectomies may involve
removal of a healthy appendix

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 fast
Patient is administered antibiotics to
prevent peritonitis and other infections
Patient is sedated and given an IV drip to
hydrate

Shorter hospital stay

Fater recovery time
Lest post-operative pain
Fewer post-operative complications
Minimal scarring

Cardiac diseases/COPD: pneumoperitoneum

induced by insufflation may cause arrhythmias or
make breathing too difficult for patients with
these conditions.

Obesity

Previous abdominal surgeries

Patient is
supine, laying
flat
Surgeon and
assistant
positioned on
patients left
Monitors on
patients right,
facing surgeons
Anesthesiologist
conventionally
stationed at
patients head
(not shown)

Atraumatic grasper

Laparoscopic scissors
Dissector
Endo GIA (or stapler, or endoloop ligature
applicator)
Suction/irrigation device
Extraction tube
Extraction bag
Zero-degree scope
3 Trocars (two 5mm and one 10mm)
Alternately, electrocautery tools may also be
used

10-mm trocar
placed through
umbilicus (this
port holds camera)
5-mm trocar
placed at
suprapubic region
5-mm trocar
placed at LLQ
*A fourth port containing
extraction tube may be
placed closer to McBurneys
point later in procedure.

ABOVE: Internal anatomy of RLQ of abdominal cavity

HIGHLIGHTED IN RED: Appendix and mesoappendix
(medially; contains appendicular artery)

Ports placed at umbilicus, suprapubis, LLQ

Inspect abdominal cavity and located ileocecal junction
Retract bowel to expose appendix
Separate mesoappendix to locate appendicular artery
Divide appendix
Divide appendicular artery
Extract appendix
Irrigate thoroughly
Final inspection of abdominal cavity

Step 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).

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.

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).

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 the extraction tube. The appendix is placed in
bag tool
is placed
through
appropriate
10 mm
and from the abdomen through the extraction
the capture bag,
andport,
removed
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

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.

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 1:45
2nd port inserted at 1:45; 3rd port inserted at 3:40
Inspection of abdominal cavity 4:20-5:00
Bowel retracted to expose bladder 5:00 5:25
Appendicular perforation apparent at 5:30
Separation of mesoappendix from body of appendix ~6:45 7:30
Appendix position appropriately and divided 7:30- 9:50
4th port inserted at 10:10
Appendicular artery divided at 11:33
Appendix removed through 4th port at 14:00
Irrigation, suction, and final inspection occur from 14:10 31:30
(about 17 minutes)

Rupture: 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 needle

Adhesions

Wound-site infection

Hospital stay time 24-48 hours

Patient can walk around usually after 12 hours
Antibiotics
Pain management
Resume normal activities within 2 weeks

Mohan, V., M.D. (2010, March 1). Appendicitis. Retrieved from

http://www.webmd.com/digestive-disorders/digestive-diseasesappendicitis

Hunter, Any. (2008, June 4). How Your appendix works. Retrieved from
http://health.howstuffworks.com/appendix1.htm

Navez, B. (2001, April). Laparoscopic appendectomy. Retrieved from

http://chapters.websurg.com/technique/index.php?full=1&doi=ot02en213

McCarthy, Arthur C., MD, History of Appendicitis Vermiformis, its diseases

and treatment. 1927, University of Louisville
http://www.innominatesociety.com/Articles/History%20of
%20Appendicitis.htm

Bhattacharya K., Kurt Semm: A laparoscopic crusader. J Min Access Surg

[serial online] 2007 [cited2010 Apr 9];3:35-6. Available
from:http://www.journalofmas.com/text.asp?2007/3/1/35/30686