Fig. 7.3 Mobilization of the cecum in the event of a retrocecal appendix

Technique

There are two possible techniques that can be used to divide the appendix and mesoappendix: an endoloop technique or a stapling technique.

 Endoloop Technique. The adhesions from the appendix to the surrounding organs and the mesentery are divided using the harmonic scalpel or bipolar forceps. The base of the appendix is identified next. Two endoloops are inserted and tied at the base. Another loop is then inserted next to the first two loops and the appendix is transected between the two proximal loops and the distal loop. Finally, the mucosa is cauterized (Fig. 7.4).

 Stapling Technique. A window is created at the base of the mesoappendix and a 30-mm white vascular stapler inserted (Fig. 7.5). The mesoappendix is transected, followed by the base of the appendix, using a 30-mm blue stapler. The appendix is cut as close as possible to the cecum leaving a very short stump. The mesentery and base of the appendix are checked for any evidence of bleeding. If bleeding is present from staple line, it should be controlled by placing a clip. The appendix is placed in a bag and removed from the abdomen.Alternatively, if the appendix is thin, it can be pulled into the port and withdrawn with it, so the wound is not contaminated.

a

b

Fig. 7.6   (a) Retrograde appendectomy when the tip of the appendix is not visible (base→  tip), using firings of the stapler. (b) Retrograde appendectomy using clips and scissors (“clipcut” technique)