1. By Rob West

2.  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

3.  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. Crohn’s 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

4.  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 1800’s
 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

5.  First, vague pain around navel
 With time, increases in intensity and sharpness
 Pain migrates to RLQ (McBurney’s Point)
 Nausea/Vomiting
 Severe abdominal pain
 Fever
 Reduced appetite
 Constipation or diarrhea
 “Rebound tenderness”

6. McBurney’s point (1) appears about one-third of the distance along
a line starting at the right ASIS (3) and ending at the umbilicus (2).

7.  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

8.  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

9.  Shorter hospital stay
 Fater recovery time
 Lest post-operative pain
 Fewer post-operative complications
 Minimal scarring

10.  Cardiac diseases/COPD: pneumoperitoneum induced
by insufflation may cause arrhythmias or make
breathing too difficult for patients with these
conditions.
 Obesity
 Previous abdominal surgeries

11.  Patient is supine,
laying flat
 Surgeon and
assistant
positioned on
patient’s left
 Monitors on
patient’s right,
facing surgeons
 Anesthesiologist
conventionally
stationed at
patient’s head
(not shown)

12.  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

13.  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 McBurney’s
point later in procedure.

14. ABOVE: Internal anatomy of RLQ of abdominal cavity
HIGHLIGHTED IN RED: Appendix and mesoappendix
(medially; contains appendicular artery)

15.  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

16. 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).

17. 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.

18. 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).

19. 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 appropriate
10 mm port, and the extraction
bag tool is placed through the extraction tube. The appendix is placed in the
capture bag, and removed from the abdomen through 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 deemed unnecessary.
The image above comes from a different case.)

20. 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.

21. 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)

22.  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

23.  Hospital stay time 24-48 hours
 Patient can walk around usually after 12 hours
 Antibiotics
 Pain management
 Resume normal activities within 2 weeks

24.  Mohan, V., M.D. (2010, March 1). Appendicitis. Retrieved from
http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis
 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 [cited 2010 Apr 9];3:35-6. Available
from: http://www.journalofmas.com/text.asp?2007/3/1/35/30686