Surgical Techniques

Elective laparoscopic appendectomy in gynecologic surgery: When, why, and how

OBG Manag. 2013 March;25(3):42-49

References

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When the appendix is not easily accessible, or the surgical complexity of the gynecologic procedure prevents the surgeon from safely performing an appendectomy, it is better to complete the planned gynecologic surgery and forgo the appendectomy. It is acceptable to make the decision to refrain from the appendectomy intraoperatively if the risk of complications outweighs the likely benefits. The practice of cautionary discretion demonstrates sound judgment and avoids compromising the safety of the patient.

How to perform appendectomy

1. Maintain at least three laparoscopic sites

After the laparoscopic gynecologic procedure, maintain three trocar sites—preferably, two 5-mm trocars and one 12-mm trocar.
The first 5-mm trocar, at the umbilical incision, accommodates the laparoscopic camera. The second 5-mm trocar serves as an accessory port for laparoscopic instruments and is inserted into the RLQ.
The 12-mm trocar in the left lower quadrant (LLQ) is also used to insert endoscopic instruments. This trocar site will be used at the conclusion of the appendectomy to accommodate the mechanical stapling device and the specimen bag for removal of the excised organ.

FIGURE 1: Visualize the appendix. Identify the cecum and ileocolic junction to locate the appendix.

2. Identify the appendix

Perform a careful visual exploration of the abdominal contents to exclude other intra-abdominal pathology.
Identify the cecum and ileocolic junction to locate the appendix (FIGURE 1).
Visually inspect the appendix and identify any gross appendiceal pathology.

FIGURE 2: Divide the mesoappendix
Isolate, cauterize, and divide the mesoappendix using 5-mm ultrasonic shears.

3. Dissect the appendix (VIDEO 1)

Insert an atraumatic forceps through the 5-mm right accessory trocar.
Grasp the fatty tissue at the tip of the appendix and provide some traction.
Elevate the appendix to facilitate visualization of the mesoappendix.
Isolate the mesoappendix and cauterize and divide it using 5-mm ultrasonic shears inserted through the RLQ trocar (FIGURE 2).
Release some of the upward tension from the specimen retraction by dropping the height of the instrument to prevent undue trauma and bleeding.
Make a window between the mesentery and the base of the appendix to facilitate dissection.
Skeletonize the mesoappendix at the junction of the appendiceal base and the cecum.
During skeletonization, pay special attention to the appendiceal artery at the base of the mesoappendix.

FIGURE 3: Apply the stapling device
Apply the stapling device across the base of the appendix.

4. Resect the appendix (VIDEO 2)

Insert an automatic stapling device through the 12-mm port and apply it across the base of the appendix (FIGURE 3).
Apply the mechanical stapling device for 15 seconds to crush the base of the appendix and empty its contents.
Visualize both sides of the stapler to ensure that it is placed at the base of the appendix.
Always check the tip of the device to ensure that the jaws of the stapling device fully compress the appendix and have not inadvertently grasped other abdominal contents.
With the stapling device compressing the base of the appendix, release some of the upward tension on the specimen by dropping the height of the retraction.
Activate the stapling device and completely excise the appendix from its base
(FIGURE 4).
Thoroughly inspect the appendiceal stump to ensure hemostasis (FIGURE 5).

FIGURE 4: Excise the appendix
Activate the stapling device and completely excise the appendix from its base.

FIGURE 5: Ensure hemostasis
Thoroughly inspect the appendiceal stump and ensure hemostasis.

5. Remove the specimen (VIDEO 3)

Remove the stapling device and replace it with a specimen retrieval bag, inserting it through the 12-mm port.
Place the amputated appendix in the specimen retrieval bag to prevent abdominal contamination (FIGURE 6).
Close the specimen retrieval bag inside the abdomen.
Refrain from removing the specimen bag through the trocar or forcefully passing the appendix through a small incision. We usually withdraw the 12-mm trocar, then remove the cinched bag containing the resected appendix under direct visualization. We take all precautionary measures to prevent breakage of the bag, which would leak appendiceal contents into the abdomen.

FIGURE 6: Remove the specimen
Place the amputated appendix in the specimen retrieval bag and remove it, intact, through the patient’s abdomen.

6. Perform a few last measures

If the surgeon chooses, suction and irrigation can be performed at the completion of the appendectomy procedure.
Send all surgical specimens to pathology for evaluation.
Complete the operation in the usual laparoscopic fashion. Remove all instruments, and close the 12-mm trocar port site using the Carter Thomason fascial closure device. Close the remaining port sites using 2-0 interrupted suture (Monocryl). Apply skin adhesive to all laparoscopic incisions.
For more on surgical technique of appendectomy, see Baggish,¹⁹ Jaffe and Berger,²⁰ and Daniell and colleagues.²¹