Apendicectomia Laparoscopica

 

                                                                      

 

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      INDICATIONS Acute appendicitis is a clinical diagnosis, which—despite improved modern diagnostic imaging techniques—still has a preoperative accuracy of only about 85 percent. The diagnosis is made using a combination of history, physical examination, and laboratory tests plus an elevated temperature and white blood cell count. A positive imaging study is helpful and gives reassurance about the diagnosis. In equivocal cases, serial observations and studies over time improve the accuracy of diagnosis, but at the risk of an increasing rate of perforation. Laparoscopic appendectomy is appropriate for virtually all patients and is preferred in obese patients, who require longer open incisions with increased manipulation and the resultant increase in surgical-site infections. The laparoscopic technique is also indicated in females, especially during the reproductive years, when tubal and ovarian pathology may mimic appendicitis. Laparoscopy not only provides direct observation of the appendix but also allows evaluation of all intra-abdominal organs, especially those in the female pelvis. Laparoscopic appendectomy has been shown to be as safe as open appendectomy in the first trimester of pregnancy; however, there is always risk to the fetus with any anesthesia or operation. Later or third-trimester pregnancies as well as any process that creates intestinal distention will make entering the intraperitoneal space more difficult and leave no room for maneuvering the instruments for a safe operation. Finally, laparoscopic appendectomy results in less incisional pain after surgery, allows a faster return to normal function or work, and produces a better cosmetic result. PREOPERATIVE PREPARATION

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As healthy youngsters and young adults constitute the most common population with appendicitis, the usual preoperative evaluation for anesthesia and surgery is performed. Intravenous fluids for hydration and preoperative antibiotics are given. Extra time may be needed in the very young or old for correction of electrolyte and fluid imbalances. Hyperpyrexia should be treated with antipyretics or even external cooling, so as to lessen the risk of general anesthesia. Additional discussion concerning preparation is contained in the discussion accompanying Appendectomy, Figures 1 through 13. ANESTHESIA General anesthesia with placement of an endotracheal tube is preferred. After induction, an orogastric tube may be placed by the anesthesiologist. This tube is removed before the end of the case or is replaced with a nasogastric tube if prolonged decompression is anticipated. POSITION The patient is placed in a supine position. The right arm may be extended for intravenous and blood pressure cuff access by the anesthesiologist while the left arm with the pulse oximeter is tucked in at the patient's side. This allows for easier movement by the surgeon and the assistant operating the videoscope. The fiberoptic light cable and gas tubing are usually placed to the head of the table; the video monitor is placed across from the operating team; and the electrocautery and suction irrigator are placed toward the foot of the table, where the scrub nurse and Mayo instrument tray are positioned. OPERATIVE PREPARATION A Foley catheter is usually placed and the abdomen is prepped in the routine manner. DETAILS OF PROCEDURE A typical placement for access ports is shown at the umbilicus, left lower quadrant, and lower midline (Figure 1). Some surgeons prefer a right-upper-quadrant port instead of the one in the left lower quadrant. As in most laparoscopic procedures, some form of triangulation is employed, with the longest and widest angle given to the operating ports and instruments. The videoscope port is created first. Although some use an initial inflation of the abdomen with a Veress needle (see Cholecystectomy, Laparoscopic, Figures 1, 2, 3, 4, 5, and 6), most general surgeons employ the open Hasson technique (see Cholecystectomy, Hasson Open Technique, Laparoscopic). The surgeon may enter at the superior or inferior margin of the umbilicus with either a vertical or semicircular transverse incision. After the Hasson port is placed and secured with the stay sutures, the abdomen is inflated with CO2. The surgeon sets the maximum gas pressure (

15 mmHg) and flow rate while he or she monitors the actual

intra-abdominal pressure and the total volume of gas insufflated. The abdomen then enlarges and becomes tympanitic. The videoscope is attached to the telescopic instrument, which may be straight (zero degree) or angled. The system is white-balanced and the focus adjusted. After the optical end of the instrument has been cleaned with antifog solution, it is introduced down the Hasson port. A

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careful visualization of all four quadrants of the abdomen is performed and a record is made of all normal and abnormal findings. Under direct vision with the videoscope, two additional 5-mm ports are put into the abdomen. One is in the left lower quadrant and is placed lateral to the rectus muscle with its epigastric vessels. The light of the videoscope is used to transilluminate the abdominal wall at the proposed site so as to avoid trocar placement through vessels in the oblique muscles. The surgeon infiltrates the 5-mm site with local anesthetic. This infiltrating needle can be advanced through the abdominal wall and the videoscope will see the needle enter the anticipated site for this port. A 5-mm skin incision is made and the subcutaneous tissue dilated with a small hemostat down to the level of the fascia. The 5-mm port is placed through the abdominal wall while the surgeon views the safe entrance of the pointed trocar into the intraperitoneal space. The third port is placed through the midline linea alba in a suprapubic position so as to avoid the bladder, which has been decompressed with a Foley catheter. The strategy for a widely spread (hand's breadth) triangular pattern of port placement now becomes apparent as the three instruments complete for room to maneuver. The patient is placed in the Trendelenburg position and the right side of the operating table may be elevated using gravity to hold the small bowel away from the right lower quadrant. If a normal appendix is found, a search for other inflammatory processes is begun. Tubo-ovarian diseases, inflammatory bowel disease, and Meckel's diverticulitis are most commonly found. Once the diagnosis of appendicitis is established, the appendix is mobilized. The appendix and its mesentery must be clearly visualized. The position of the appendix is quite variable, and it may be covered with peritoneum or even the cecum (Figure 2). Safe opening of any peritoneal covering or the equivalent of the lateral line of Toldt along the cecum may require placement of an additional operating port. If the surgeon cannot obtain complete visualization of the appendix, mesoappendix, and base of the cecum for a safe transection, the operation is converted to an open procedure. Laparoscopic removal begins with a splaying out of the mesoappendix using a grasping forceps upon the mesentery (Figure 3). The inflamed tip of the appendix is not grasped, as this could cause it to rupture. The surgeon opens through the mesentery at the base of the appendix using a dissecting instrument. If maneuvering of the appendix and its mesentery is difficult using the grasping forceps, some surgeons prefer to lasso the inflamed end of the appendix with a loop suture that is applied snugly. The cut end of this suture may be grasped more securely with the maneuvering forceps (Figure 4). The mesoappendix is divided (Figure 4) in one or more transections using a vascular stapling instrument that is passed through the large Hasson port. This assumes that a 5-mm videoscope is available for use through the leftlower-quadrant port. Otherwise, the left-lower-quadrant port is enlarged to 10 mm, as both the videoscope and endoscopic stapler require large ports. The base of the appendix is divided with the stapler (Figure 5). An important maneuver with any division using this stapler is to rotate it about 180 degrees, so as to visualize the entire length and the contents within its jaws. This rotation should also be done during the stapling of the mesoappendix (Figure 5A).

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A small, minimally inflamed appendix can be removed safely through the shaft of a 10-mm port. Most surgeons place an enlarged or suppurative appendix into a plastic bag for removal through the abdominal wall (Figure 6). This lessens the chances of infection at the surgical site. The appendiceal stump and stapled mesoappendix are inspected for security and hemostasis. The area is lavaged with the suction irrigator and a regional inspection is made to verify the integrity of the cecum and small bowel. Each of the 5-mm ports is removed under direct vision with the videoscope to make sure that there are no bleeding abdominal wall vessels. CLOSURE The abdomen is decompressed and the Hasson port removed. Routinely, only the 10-mm port sites require fascial closure. Some surgeons tie the stay sutures together if this provides a secure closure to inspection and finger palpation. Others place new 00 delayed absorbable sutures through the fascia for its closure. Scarpa's fascia and the subcutaneous fat are not closed. The skin is approximated with fine 00000 absorbable sutures. Adhesive skin strips and dry sterile dressings (Band-Aids) are applied. POSTOPERATIVE CARE The orogastric tube is removed before the patient awakens from anesthesia. The Foley catheter is discontinued as soon as the patient is alert enough to void. If a long-acting local anesthetic was used at the port sites, postoperative pain can be controlled with oral medications. There may be some transient nausea, but most patients can be weaned from intravenous fluid to simple oral intake within a day. Antibiotic therapy is often perioperative but may continue for a few days, depending on the operative findings. Most patients are discharged home within a day or two. ALTERNATIVE METHODS There are many variations upon the technique described above. These involve the placement of the ports and the methods for transecting the appendix and mesoappendix. Virtually all laparoscopic appendectomies begin with placement of the videoscope through an umbilical site. Insufflation using the Veress needle technique is preferred by some, although most general surgeons enter the abdomen in a more controlled, open manner using the Hasson technique. Placement of additional ports is determined by the surgeon's preference. In general, the sites should be widely spaced to avoid instrument competition. The size of the second port is a function of whether or not the surgeon has a 5-mm videoscope and whether he or she plans to use (1) the vascular stapler or (2) large ultrasonic, cautery, or laser devices for transection and hemostasis. Most of these devices currently require a 10-mm port. Alternatively, some surgeons use metal clips for transection of the mesoappendix and a pair of absorbable loop sutures for occlusion of the stump of the appendix, whose mucosal center is cauterized. However, vascular staples are preferred by most for their security and the avoidance of unrecognized thermal damage.

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