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INDICATIONS
Acute appendicitis is a clinical diagnosis, whichdespite improved modern diagnostic
imaging techniquesstill 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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