Laparoscopic Assisted Appendectomy |
129 |
Fig. 7.12 Laparoscopically-assisted appendectomy (useful in pediatric appendectomy)
In some cases, especially in children, where the appendix is extremely long and the work- |
Laparoscopic |
ing space small, the laparoscopic “assisted” technique is an easy way of performing an |
Assisted |
appendectomy. |
Appendectomy |
The mesoappendix is first controlled with a harmonic scalpel. Next, the port is |
|
removed with the appendix inside. The entire appendix is exteriorized and ligated out- |
|
side the abdomen before the cecum is pushed back inside the abdomen (Fig. 7.12). |
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Care is needed to avoid infecting or contaminating the abdomen. For this reason, |
|
maneuvers should be minimized while pulling the appendix out of the incision. |
|
130 |
Chapter 7 Appendectomy |
Selected
Further
Reading
Des Groseilliers S, Fortin M, Lokanathan R, Khoury N, Mutch D (1995) Laparoscopic appendectomy versus open appendectomy: retrospective assessment of 200 patients. Can J Surg 38(2):178–182
El-Ghoneimi A,Valla JS, Limonne B et al (1994) Laparoscopic appendectomy in children: report of 1, 379 cases. J Pediatr Surg 29(6):786–789
Faiz O, Clark J, Brown T, Bottle A, Antoniou A, Farrands P, Darzi A, Aylin P (2008) Traditional and laparoscopic appendectomy in adults: outcomes in English NHS hospitals between 1996 and 2006. Ann Surg 248(5):800–806
Fujita T (2009) Is laparoscopic appendectomy associated with better outcomes? Ann Surg 249(5):867
Fujita T, Yanaga K (2007) Appendectomy: negative appendectomy no longer ignored. Arch Surg 142(11):1023–1025
Frazee RC, Bohannon WT (1996) Laparoscopic appendectomy for complicated appendicitis. Arch Surg 131(5):509–511
Frazee RC, Roberts JW, Symmonds RE et al (1994) A prospective randomized trial comparing open versus laparoscopic appendectomy. Ann Surg 219(6):725–728
Gotz F, Pier A, Bacher C (1990) Modified laparoscopic appendicectomy in surgery. A report on 388 operations. Surg Endosc 4:6–9
Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP (1997) Appendectomy: a contemporary appraisal. Ann Surg 225(3):252–261
Hansen JB, Smithers BM, Schache D, Wall DR, Miller BJ, Menzies BL (1996) Laparoscopic versus open appendectomy: prospective randomized trial. World J Surg 20(1):17–20 Heinzelmann M, Simmen HP, Cummins AS, Largiader F (1995) Is laparoscopic appen-
dectomy the new “gold standard”? Arch Surg 130(7):782–785
Ikard RW, Federspiel CF (1995) Laparoscopic versus open appendectomy. N Engl J Med 333(13):881–882
Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R (2005) Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg 242(3): 439–448
Katkhouda N, Friedlander M, Grant S, Achanta K, Essani MR, Paik P, Campos G, Mason R, Mavor E (2000) Intra-abdominal abscess rate following laparoscopic appendectomy. Am J Surg 180:456–459
Katkhouda N, Mavor E, Campos G, Mason R, Waldrep D (1999) Finger assisted laparoscopy (fingeroscopy) for treatment of complicated appendicitis. J Am Coll Surg 189:130–133
Kluiber RM, Hartsman B (1996) Laparoscopic appendectomy. A comparison with open appendectomy. Dis Colon Rectum 39(9):1008–1011
Kollias J, Harries RH, Otto G, Hamilton DW, Cox JS, Gallery RM (1994) Laparoscopic versus open appendectomy for suspected appendicitis: a prospective study. Aust N Z J Surg 64(12):830–835
Leung TT, Dixon E, Gill M, Mador BD, Moulton KM, Kaplan GG, MacLean AR (2009) Bowel obstruction following appendectomy: what is the true incidence? Ann Surg 250(1):51–53
Lujan-Mompean JA, Robles-Campos R, Parrilla-Paricio P, Soria-Aledo V, Garcia-Ayllon J (1994) Laparoscopic versus open appendectomy: a prospective assessment. Br J Surg 81(1):133–135
Lukish J, Powell D, Morrow S, Cruess D, Guzzetta P (2007) Laparoscopic appendectomy in children: use of the endoloop vs the endostapler. Arch Surg 142(1):58–61
McCahill LE, Pellegrini CA, Wiggins T, Helton WS (1996) A clinical outcome and cost analysis of laparoscopic versus open appendectomy. Am J Surg 171(5):533–537
Martin LC, Puente I, Sosa JL et al (1995) Open versus laparoscopic appendectomy. A prospective randomized comparison. Ann Surg 222(3):256–261
Selected Further Reading |
131 |
Neugebauer E, Troidi H, Kum CK, Eypasch E, Miserez M, Paul A (1995) The E.A.E.S. Consensus Development Conferences on laparoscopic cholecystectomy, appendectomy, and hernia repair. Consensus statements September 1994. The Educational Committee of the European Association for Endoscopic Surgery. Surg Endosc 9(5):550–563
Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B (1995) A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Laparoscopic Appendectomy Study Group. Am J Surg 169(2):208–212
Richards KF, Fisher KS, Flores JH, Christensen BJ (1996) Laparoscopic appendectomy: com parison with open appendectomy in 720 patients. Surg Laparosc Endosc 6(3):205–209
Sleem R, Fisher S, Gestring M, Cheng J, Sangosanya A, Stassen N, Bankey P (2009) Perforated appendicitis: is early laparoscopic appendectomy appropriate? Surgery 146(4):731–737
Somerville PU, Lavelle MA (1996) Residual appendicitis following incomplete laparoscopic appendectomy. Br J Surg 83(6):869
Tang E, Ortega AE, Anthone GJ, Beart RW Jr (1996) Intraabdominal abscesses following laparoscopic and open appendectomies. Surg Endosc 10(3):327–328
Tate JJ (1996) Laparoscopic appendectomy. Br J Surg 83(9):1169–1170
Towfigh S, Formosa C, Katkhouda N, Kelso R, Sohn H, Berne T (2008) Obesity should not influence management of appendicitis. Surg Endosc 22:2601–2605
Towfigh S, Chen F, Mason R, Katkhouda N, Chan L, Berne T (2006) Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis. Surg Endosc 20:495–499
Wagner M,Aronsky D,Tschudi J,Metzger A,Klaiber C (1996) Laparoscopic stapler appendectomy. A prospective study of 267 consecutive cases. Surg Endosc 10(9):895–899 Varela JE, Hinojosa MW, Nguyen NT (2008) Laparoscopy should be the approach of
choice for acute appendicitis in the morbidly obese. Am J Surg 196(2):218–222 Zaninotto G, Rossi M, Anselmino M et al (1995) Laparoscopic versus conventional sur-
gery for suspected appendicitis in women. Surg Endosc 9(3):337–340
Colorectal 8
Procedures
Triangulation of ports and the creation of appropriate working space by tilting the table and using gravity for organ retraction are concepts now familiar to the reader. These principles govern the techniques of laparoscopic colorectal procedures.
The surgeon uses both hands with the camera positioned between them, always positioned on the opposite side of the lesion. For both left and right colectomies, the first assistant stands facing the surgeon. The assistant is therefore watching the monitors in mirror fashion, and all his or her maneuvers are slowed down. That should be understood and accepted by the surgeon. The camera assistant stands on the left of the surgeon. It is necessary to use the traction countertraction concept,whereby the surgeon pulls on one side and the assistant asserts gentle traction on the opposite side to put the tissue under tension.
Principles of
Laparoscopic
Colectomies
The patient is placed in the supine position in such a way that the team can move around |
Right |
the patient with ease. The surgeon stands on the patient’s left, watching the monitor on |
Hemicolectomy |
the other side (Fig. 8.1). Five ports are inserted (Fig. 8.2). |
|
The operation can be performed in two fashions: medial to lateral or lateral to |
|
medial. In the medial to lateral technique, the peritoneal adhesions of the colon to the |
|
abdominal wall are used as counter-traction while dissecting and dividing the ileocolic |
|
vessels. The patient is placed in Trendelenberg and right side up to remove the small |
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bowel from pelvis and right lower quadrant. First, the terminal ileum is grasped with the |
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left hand and pulled towards the anterior abdominal wall placing tension on the ileo- |
|
colic vessels.A window is made around the vessels and they are divided with the vascular |
|
Endo-GIA. Then the line of Toldt is taken down using the harmonic shears. |
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N. Katkhouda, Advanced Laparoscopic Surgery,
DOI: 10.1007/978-3-540-74843-4_8, © Springer-Verlag Berlin Heidelberg 2011
134 |
Chapter 8 Colorectal Procedures |
Fig. 8.1 Patient’s setup for right assisted hemicolectomny. S surgeon; FA first assistant; CA camera assistant
In the lateral to medial technique, the operation is begun by mobilizing the white line of Toldt and the cecum. For this, the patient is put in the Trendelenburg, right side up position, putting the cecum under tension and facilitating the dissection. Next follows mobilization of the hepatic flexure. For this, the patient is put in reverse Trendelenburg, right side up. Once again, this puts the appropriate tension on the hepatic flexure to assist the dissection.
The mesocolon should now be clearly identifiable, and if the patient is not too obese, it is possible to perform intra-abdominal division of the vessels with vascular staplers. Harmonic shears can also be used in this setting. Otherwise, if mobilization of the colon is sufficient, it is possible to deliver the whole right colon and the terminal ileum through a right upper quadrant muscle splitting incision, followed by an anastomosis outside the abdomen.
If a hand assisted port is used, a midline incision is used for the hand port, which can be used to deliver the colon and construct the anastomosis at the end of the case.