Laparoscopic Appendectomy

PREOPERATIVE DIAGNOSIS: Acute appendicitis.

POSTOPERATIVE DIAGNOSIS: Acute appendicitis.

OPERATION PERFORMED: Laparoscopic appendectomy.

FINDINGS:  Minimally dilated appendix with adhesions. Small right ovarian cyst.

OPERATION:  The patient was placed in supine position on the operating table.  The patient was placed under general endotracheal anesthesia.  A Foley catheter was placed in her bladder and an orogastric tube was passed.  Her lower extremities were placed in SCDs.  Her abdomen was prepared with chlorhexidine.  The patient was draped in standard sterile fashion.  Preoperative time-out was performed.  The patient received preoperative antibiotics, and again her lower extremities were placed in SCDs.

We began the operation by infiltrating the superior aspect of her umbilicus with local anesthetic consisting of 4% Marcaine with epinephrine.  Small incision was then made with a #11 blade.  Penetrating towel clips were placed in this incision and the umbilicus and the abdominal wall was elevated.  A Veress needle was then carefully passed in the peritoneal cavity.  The abdomen was insufflated with carbon dioxide until adequate pressures were achieved approximately 12 mmHg.  Following insufflation, a 5-mm trocar was placed into the peritoneal cavity under direct laparoscopic visualization.  Using the 5-mm zero-degree laparoscope placed into the serially dilating noncutting trocar.  The optical trocar allowed us to visualize placement into the peritoneal cavity.  The inner cannula of the trocar was removed and the laparoscope was reintroduced.  We then changed to a 30 degree 5-mm scope.  Two additional trocars were then placed under direct visualization with the laparoscope.  A second 5-mm trocar was placed inferiorly in the midline and a 12-mm trocar was placed in the left lower quadrant.  Again both trocars were placed after infiltrating local anesthetic and under direct visualization with the scope.  At this point, the patient was placed in a slightly left-side-down Trendelenburg position.  The appendix was identified and elevated.  There were some adhesions of the distal appendix.  These were taken down with a 5-mm Marilyn dissector.  A window was created in the appendiceal mesentery near the base of the appendix with a 5-mm Marilyn dissector.  The Endo GIA Universal stapler was then used to divide the appendix at its base.  A white load was used to accomplish this.  The mesentery of the appendix was then taken down with sequential firings of gray vascular load.  The appendix was placed into an EndoCatch bag, removed from the abdominal cavity.  We sent permanent specimen through the left lower quadrant trocar.  The staple lines on the appendiceal mesentery and the cecum were examined and found to be intact and hemostatic.  We then focused our attention on the pelvis.  The right and left ovaries were identified and elevated.  There were some very small cysts on the right ovary and fallopian tube and the clear fluid in the pelvis was evacuated.  The left side appeared grossly normal.  At this point, we surveyed the abdomen with laparoscope and no other gross abnormalities were encountered.  Her staple lines remain hemostatic and intact.  We then used the Carter-Thomason fascial closure device to place an 0-Vicryl fascial suture at the 12-mm left lower quadrant trocar site.  We then deflated the abdomen and all trocars and instruments were removed.  The fascial suture was tied and cut.  The subcutaneous tissues irrigated.  Skin was closed with 4-0 Monocryl subcuticular suture.  Mastisol Steri-Strips were placed on the skin.

All sponge needle instrument counts were correct in the case.  The patient tolerated the procedure well.  There are no apparent complications.  The patient was awakened from anesthesia extubated, and transported to postanesthesia care unit in stable condition.  The orogastric tube, Foley catheter removed at the end of the case.