Appendectomy 7

OR Setup and Port Placement

Acute

The patient is placed in the supine position with the left arm or both arms tucked.A foley

Appendicitis

catheter is always placed as in other pelvic or lower abdominal procedures to decrease

the risk of injury to the bladder during port placement. The surgeon and the assistant

both stand on the left side of the patient facing the monitor located on the right side of

the patient (Fig. 7.1).

Pneumoperitoneum is created in the standard fashion using either the Hasson

technique or a Veress needle. Care must be taken in patients who have had a longer

course of disease if using a Veress needle, as the inflammation of the omentum and sur-

rounding small bowel increase the risk of injury to the small bowel or other structures.

The ports are inserted in an extended triangulation fashion. The laparoscope is

placed at the umbilicus. Two 5 or 10 mm ports are inserted, one in the left lower quadrant

in a position corresponding but opposite to McBurney’s point, and the second is placed

in a suprapubic position. In a male patient, the right trocar is inserted in a position cor-

responding to the left (Fig. 7.2a). In a female patient, both trocars can be hidden in the

pubic hair line if cosmesis is an issue (Fig. 7.2b). If an additional trocar is needed for

bowel retraction or suctioning, a 5-mm port can be placed in the right upper quadrant.

Then the patient is placed in Trendelenburg position with the right side up.

Care must be taken to avoid a “knitting needle” effect between instruments and the

laparoscope; all ports should be placed in such a way that they have free movement and

do not interfere with one another. The body habitus of the patient will influence place-

ment of the ports to achieve this goal.