Techniques for Multiple Laparoscopic Procedures: Cholecystectomy, Ovarian Drilling, and Appendectomy

Laparoscopy has revolutionized abdominal and pelvic surgery by offering minimally invasive techniques that reduce recovery time, minimize scarring, and decrease the risk of complications. This document delves into the techniques and considerations for performing multiple laparoscopic procedures in one session, specifically cholecystectomy, ovarian drilling, and appendectomy.

1. Laparoscopic Cholecystectomy

Indication: Laparoscopic cholecystectomy is performed for gallbladder diseases, primarily gallstones causing cholecystitis, cholelithiasis, or biliary colic.

Procedure:
1. Patient Positioning: The patient is placed in the supine position with a slight reverse Trendelenburg tilt (head up, feet down) and left-side tilt to allow the intestines to fall away from the gallbladder.
2. Port Placement:
- A 10-12 mm port at the umbilicus for the laparoscope.
- A 10 mm port in the epigastrium for the working instrument.
- Two 5 mm ports in the right upper quadrant for the dissecting and grasping instruments.
3. Critical View of Safety: Achieving the critical view of safety is essential. This involves clearing the hepatocystic triangle and ensuring only two structures (the cystic duct and artery) are entering the gallbladder.
4. Dissection:
- The cystic duct and artery are clipped and divided.
- The gallbladder is dissected from the liver bed using electrocautery.
5. Extraction: The gallbladder is placed in an endoscopic retrieval bag and removed through the umbilical port.

2. Laparoscopic Ovarian Drilling

Indication: Ovarian drilling is used in women with polycystic ovary syndrome (PCOS) who are resistant to clomiphene citrate and have not responded to other treatments for ovulation induction.

Procedure:
1. Patient Positioning: The patient is placed in the lithotomy position, and a steep Trendelenburg tilt (head down) is applied to move the intestines away from the pelvis.
2. Port Placement:
- A 10-12 mm port at the umbilicus for the laparoscope.
- Two 5 mm ports in the lower abdomen for the working instruments.
3. Ovarian Access:
- The ovaries are visualized and manipulated into the field of view.
4. Drilling:
- A monopolar needle or laser is used to puncture the ovarian cortex at 4-10 sites on each ovary. Each puncture should be about 2-4 mm deep and 4-5 mm apart.
5. Hemostasis: Hemostasis is achieved using electrocautery or bipolar coagulation.

3. Laparoscopic Appendectomy

Indication: Appendectomy is performed for acute appendicitis, which is an inflammation of the appendix that can lead to perforation and peritonitis if not treated promptly.

Procedure:
1. Patient Positioning: The patient is placed in the supine position with a Trendelenburg tilt and slight left tilt to move the small bowel away from the appendix.
2. Port Placement:
- A 10 mm port at the umbilicus for the laparoscope.
- Two 5 mm ports in the lower abdomen for the working instruments.
3. Identification:
- The appendix is identified and mobilized by dividing the mesoappendix using electrocautery or an energy device.
4. Appendix Removal:
- The base of the appendix is ligated with endoloops or a stapler and divided.
- The appendix is placed in an endoscopic retrieval bag and removed through the umbilical port.
5. Closure: The stump is inspected for bleeding and the mesoappendix for adequate hemostasis. The port sites are closed.

Considerations for Multiple Procedures

1. Patient Selection:
- Patients must be thoroughly evaluated to ensure they can tolerate multiple procedures. Comorbidities, age, and overall health play a crucial role in decision-making.

2. Timing and Sequence:
- The order of the procedures should be planned to minimize contamination and optimize surgical efficiency. Generally, starting with the cleanest procedure (e.g., cholecystectomy) and ending with the potentially more contaminated procedure (e.g., appendectomy) is advisable.

3. Anesthesia:
- Anesthesia must be managed to account for the prolonged operative time. Adequate analgesia, fluid management, and monitoring are critical.

4. Port Management:
- Ports can often be reused for multiple procedures, but care must be taken to avoid cross-contamination. Instruments should be sterilized or changed between procedures.

5. Team Coordination:
- The surgical team must be well-coordinated, with each member aware of the procedural steps and the sequence of operations to ensure a smooth and efficient process.

6. Postoperative Care:
- Postoperative care involves managing pain, monitoring for complications, and ensuring recovery from anesthesia. Patients may require extended monitoring due to the combined effects of multiple procedures.

Conclusion

Performing multiple laparoscopic procedures in a single session can be advantageous for patients by reducing overall recovery time and exposure to anesthesia. However, it requires meticulous planning, careful patient selection, and a highly coordinated surgical team. Mastery of the individual techniques for cholecystectomy, ovarian drilling, and appendectomy is essential for ensuring patient safety and optimal outcomes.