Laparoscopic appendectomy. Technique of execution.
Laparoscopic appendectomy is the gold standard for the treatment of acute appendicitis. Often this is the first operation performed by a young surgeon.
<12
hours
Preparation
30-180
minutes
Operation time
5-7
days
period
Complexity:
Средняя
Type of anesthesia:
ЭТН
Diagnostic minimum:
- Chest X-ray
- Abdominal X-ray
- Abdominal US
- Coagulogram
Preoperative preparation:
Position of the patient on the table:
Location of the operating team:
Video operations:
Technique of operation: Step 1.
Access by Hassen / Veresa needle
Enter the abdominal cavity by accessing Hassen or Veresk's needle. After installing the 10 mm trocar in the near-umbilical area, connect the insufflator tube to it and start the air supply. The optimal pressure in the abdominal cavity is 8-10 mm Hg.
Technique of operation: Step 2.
Installing additional ports
After a 10 mm trocar, insert a laparoscope into the abdominal cavity, with it, install an additional 5 mm trocar in the left iliac region and a 10 mm trocar in the right iliac region. Their position may vary depending on the location of the appendage.
Technique of operation: Step 3.
Examination of the abdominal cavity, search of the appendage, its evaluation, determination of further tactics
Move the patient to the Trendelenburg position, then tilt the table to the left side 20 degrees. With the help of tools, inspect all the abdominal cavity and small pelvis in order. The inspection is done clockwise. Find the dome of the cecum with appendix, assess its condition.
Technique of operation: Step 4.
Capture of the appendage, coagulation and intersection of its mesentery
A surgical clamp inserted through a 10 mm port in the right ileal region, try to grab the apex of the appendage, if possible. Using forceps for bipolar coagulation or a hook portion, coagulate and cross the mesentery of the appendage until you reach its base.
Technique of operation: Step 5.
Applying loops / clips to the base of the appendix
Using the Röder loop, apply two ligatures to the base of the appendix, closer to the dome of the cecum and one loop a few millimeters distal. Instead of ligatures you can use clips.
Technique of operation: Step 6.
Cutting and stump processing
Using scissors, cross the process between the distal and proximal ligatures, hold the detached appendix with a clamp. Using bipolar forceps, treat the stump of the shoot.
Technique of operation: Step 7.
Evacuation of the appendage
Through a 10 mm port, use a clamp to insert a container into the cavity to evacuate the appendage, place an appendix in it, helping yourself with the instrument. Securely grasp the container with a clamp and evacuate it through the trocar, while opening the valve. Send the outgrowth for histological examination.
Technique of operation: Step 8.
Control examination and toilet of the abdominal cavity, if necessary, drainage
Closely inspect the dome of the cecum, the stump of the appendix, all the nearby anatomical structures. Perform additional hemostasis or rinse the abdominal cavity, if necessary, drain with an aspirator or swab. Perform a follow-up examination of all parts of the abdominal cavity. If necessary, install drainage in the right ileal region.
Technique of operation: Step 9.
Десуффляция
Transfer the patient to a horizontal position, remove the laparoscope from the abdominal cavity, open the valve at the 10 mm port and maximally release the gas. Remove the trocar.
Technique of operation: Step 10.
Layered suturing of operating wounds, treatment, application of dressings
Treat the wound area with a napkin with an antiseptic, layer-by-layer suturing the wounds, paying special attention to the seams on the aponeurosis in the area of 10 mm ports. Re-treat the skin in the area of the seams and apply aseptic dressings.
Postoperative period:
- Pharmacotherapy
- Bed rest
- Restriction of physical activity
- Wearing a bandage
- Daily dressings with treatment of wounds with antiseptic before the removal of stitches
- Removal of drainage on the second day under conditions: Detachable serous-hemorrhagic <50ml / day
Typical errors:
- Wrong setting of Trocars
- Laparoscope sweating
- Insufficient coagulation of mesentery
- Perforation of the appendage
- Leaving the long stump of the appendage
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Instruments
Access
- Шприц 10мл
- Скальпель, лезвие 11/21
- Пинцет хирургический 2шт
- Троакар 5мм
- Троакар 10мм
- Канюля 5мм
- Канюля 10мм
- Кожно-бельевые цапки
- Крючок однозубый
- Зажим Микулича
Operative reception
- Endomedosurgical instrument
- Camera
- Atraumatic clamp
- Surgical clamp
- Trocar adapter 10mm for 5mm
- Climber / lowering knot
- Dissector
- Hook
- Bipolar
- Scissors
- Container for evacuation
Exiting the operation