Gangrenous or Perforated Appendicitis

If the tip of the appendix is not clearly visible, a retrograde appendectomy can be performed using the stapler (Fig. 7.6a). The visible base of the appendix is transected after creation of an appropriate window, followed by the mesoappendix, and finally the whole appendix is dissected out from the base to the tip. This is done as in open surgery and does not require specific skills. It is also possible to utilize the “clip-cut” technique (Fig. 7.6b). This is especially useful in a case of retrocecal appendicitis. The base of the appendix is stapled; clips are placed on the mesentery, and more clips are then placed until the tip of the appendix is completely mobilized.With the appendix removed, care is taken to perform thorough suctioning of the area without much irrigation, so that a drain is not necessary.

When the surgeon encounters an appendiceal phlegmon, it can be difficult to identify the appendix. In these circumstances, it may be necessary to mobilize the cecum first. This mobilization should be as conservative as possible so as not to open retroperitoneal spaces that might be contaminated (Fig. 7.3).

The cecum can then be flipped over and the appendix visualized. If this is still not possible, the only way forward is to convert to an open operation. The projection of the cecum is marked on the abdominal wall using transillumination of the laparoscope, and a corresponding incision is then made.

Alternatively, in difficult circumstances it is possible to remove the port from the right lower quadrant and insert a finger in the opening to perform an atraumatic mobilization of the cecum under laparoscopic guidance (Fig. 7.7a, b). This “fingeroscopy” technique allows blunt dissection of a phlegmon when it is difficult to define healthy bowel from necrotic tissue. It will speed the procedure and restore tactile feeling. It should be considered as the last step in situations where conversion seems inevitable. The combined use of the irrigation and suction device and the finger is particularly useful to break the loculations and aspirate the pus.

The greater hazard of laparoscopic appendectomy is the possibility of residual intraabdominal infection leading to pelvis abscess. This is especially true in the case of perforated or suppurative appendicitis. Figure 7.8 depicts the maneuver for irrigation of the pelvis in open surgery. The problem is that some of the infected irrigation fluid is left behind in the pelvis, further contributing to the risk of pelvic abscess. To aspirate the cul de sac under direct vision, a specific maneuver is required. The patient is placed in Trendelenberg position and the surgeon who was looking to the right side now looks at the pelvis (Fig. 7.9). Using both trocars, the sigmoid colon is retracted with the left hand, thus exposing the cul de sac (Fig. 7.10); irrigation is performed and all the fluid is sucked under direct vision (Fig. 7.11). This maneuver will dramatically reduce the risk of intra abdominal abscess especially in the pelvis. The supra-hepatic area is also checked for the presence of purulent fluid that needs to be suctioned.

Gangrenous or Perforated Appendicitis