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An appendectomy can be described as the surgical excision of the appendix. The appendix is a hollow pouch shaped like a worm that is joined to the cecum. The cecum is the located at the start of the large intestine. When the appendix becomes inflamed and infected, and appendectomy is performed. Once anesthesia is administered, the surgeon removes the appendix either by use of traditional open procedure which involves making a 2-3inch incision in the abdomen, or else through laparoscopy, in which four 1inch incisions are made on the abdomen.
The introduction of high definition video laparoscopy has eased the performance of the laparoscopic appendectomy procedure and made it more elegant and reliable. The duration of time taken to perform the entire procedure is usually 20-30 minutes. There are those who claim that there is no significant difference between this procedure and the more traditional one in terms of fiscal savings or patient recovery. However, this is disproved by the fact that the procedure is important for the diagnosis of abdominal pain when further exploration is advised. Patients with perforated appendicitis presenting with or without intra-abdominal abscess also benefit from this procedure. Furthermore, laparoscopic appendectomy transforms this operation into an outpatient procedure. The patient is able to return to normal diet only a few hours after undergoing the laparoscopic appendectomy and is able to be discharged within a day or a day and a half.
When a surgeon does an appendectomy using a laparoscope, he/she make four incisions of about one inch each. These are one near the umbilicus, the next one is between the umbilicus and pubis and the other two are smaller and are located on the right lower abdomen. The camera and other special instruments are then passed through these incisions. These instruments are used to provide a visual aid for examination of the abdominal cavity and identification of the appendix. This organ is then detached from its connections and extracted. The former area of attachment of the appendix, the cecum, is sewn up and appendix removed through an incision. This is followed by removal of the instruments and closure of the incisions (Eypasch et al. 2002). This essay will seek to outline the entire procedure of a laparoscopic appendectomy beginning from the moment of first incision to when the patient is closed up. It will list the instruments used and the sequence of events that take place from the moment the patient enters the operating room. Finally, discharge instructions given to the patient will be discussed.
Operation Room Setup
The Operating Table is electric with the patient lying supine on it. The surgeon stands to the left of the patient and there is no need of a dedicated assistant. The nurse is positioned next to the surgeon. The equipment required includes pneumatic stockings and a Foley, as well as monitors at a minimum height of five feet. A Mayo stand is located at the left foot of the patient.
The laparoscopic cart contains a telescope which is straight forward 10mm. or 5mm. 3O Deg. It also has a Storz 3C High Definition Camera, a high flow insufflators and as an option, a video out.
Other essential instruments include the Veress needle or Surgineedle, a Versastep trocar which is 5-12mm., a Versaport trocars, 5mm., Versport trocars 5-11mm., Endoshears, 5mm. Storz dolphin nose - 35cm., 5mm. Storz Claw Grasper, USSC Endo Gia 30 with white or blue cartridges, USSC ENDO CATCHTM 10mm. retrieval specimen bag and a three way irrigation cannula also by Storz, 5mm. (Pier, 1991).
The pneumoperitoneum is produced and the trocars inserted. This is followed by insertion of a traumatic grasper that can be either an Endo Babcock or Dolphin Nose Grasper. It is inserted through the right upper quadrant trocar. There is a retraction of cecum upward toward the liver. This should have the effect of positioning the appendix to an elevated level in the telescope’s optical field. A 5mm. claw-type grasper is used to take hold of the appendix and this is inserted through the suprapubic trocar. The grasper positions the appendix toward the wall of the abdomen (Frazee et.al, n.d.).
This is done using a dolphin nose grasper beneath the base of the appendix. The mesenteric window is created as close as can be to the base of the appendix and it is about 1 cm. across. Transaction of the appendix is done through insertion of a MULTIFIRE ENDOGIA 30™ through the RUQ trocar. This is a blue cartridge, 3.5. which is closed around the base of the appendix and fired. This area is examined for haemostasis and the surgeon waits for a few minutes to see if bleeding on the staple line will resolve itself. If not, then measures are taken to stop bleeding. The MULTIFIRE ENDOGIA 30™ cartridge is substituted for a white 2.5 vascular cartridge which is used to transect the mesoappendix. It may be necessary to use several cartridges (Quilici, 1990).
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The appendix is amputated from the gastrointestinal tract. Insertion of a 10mm. ENDO CATCH™ is done through the right upper quadrant trocar and this is positioned in the intra-abdominal cavity. It is then placed in the specimen bag with a grasper, removed through the supra-pubic trocar. The specimen bag is closed and removal of the ENDO CATCH™ with the trocar is done. Once out of the cavity the ENDO CATCH™ and the trocar are separated and reinsertion of the trocar is done. Irrigation of the intra-abdominal cavity is done using normal saline. If the appendicitis was perforated with or without an abscess in the intra-abdominal cavity, a Blake Drain™ is left in the pelvis and right lower quadrant (Quilici, 1990).
Irrigating the intra-abdominal cavity with normal saline is aimed at reducing the post-operative sepsis and intra-abdominal abscess. This does not mean that they do not occasionally occur, and if this happens, the procedure is to admit to surgical service, administer IV antibiotics and conduct a CT scan of abdomen and pelvis. Should there be no indication of localized fluid collection or abscess, IV antibiotics will be continued but should they be present, a CT guided drainage (Quilici, 1992).
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Before inception of the ENDO CATCH™ there was a large number of trocar site infections reported. The solution was to open and drain the incisions at the bedside.
With removal of the infected specimen by the ENDO CATCH™, only one wound infection is reported, which is irrigated with normal saline at the conclusion of the procedure to mitigate against the gross contamination (Quilici, 1992).
When there is a severe perforation of the appendix, it may be difficult to find. It is important to just keep looking until it is found (Lane, 2001).
Severe, Acute Necrotizing Appendix
This condition could lead to unsuitability of the base of the appendix to transaction using MULTIFIRE ENDOGIA™. The solution is to perform either a partial or full cecectomy with the same stapling device (Lane, 2001).
On discharge the patient is put on the regular diet without any physical restrictions. The patients are encouraged to walk at least a mile or two every day. Should they experience nausea or vomiting, diarrhea or fever, they need to consult with the doctor. A prescription of antibiotics is given and an appointment is made one week after discharge from the hospital. Mild painkillers are used to control pain. If pain becomes more severe, a prescription is issued for stronger medication (Pier, 1991).
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To conclude, the laparoscopic procedure is a non-intrusive way to remove the appendix when it is inflamed. It involves making incisions more commonly known as trocars. These trocars are situated in different places on the abdomen. The first is done on the upper right quadrant, 5-12mm; the next one is to be located at the sub-umbilical position from 5-11mm, and the last one is at suprapubic position at 5mm. After the incisions are made they serve as a conduit for insertion of the cameras and other equipment. This is followed by location of the appendix. Once located, the appendix is separated from its attachments and then removed from the intra-abdominal cavity. The resultant bleeding must then be controlled, first by waiting a few minutes to determine whether it will stop on its own. If not, surgical intervention occurs. The abdominal cavity is then stapled shut and the instruments removed. Then there is the irrigation done with normal saline on all the wounds and the patient is treated with antibiotics to mitigate infection. Depending on the patient’s progress they are able to be discharged within 24-36 hours of the procedure and are able to resume their regular daily activities as they deem able. Mild painkillers are prescribed for any residual pain that may occur, but these can be revised to moderate analgesics should the pain prove severe. Exercise is recommended to help speed recovery, with walking being the recommended activity. Should complications ensue, the patient is returned to the OR for further treatment.