Dr. Ali Ahmed Ali AbdulRaheem

1- Prepping and Draping:

Cleaing the abdomen from the level of breasts to the mid thigh using Petadine or chlorhexidine solution, urinary catheter inserted under aseptic technique to insure complete emptying of urinary bladder which in turn will reduce the risk of urinary bladder injury and facilitates the exploring of the pelvic organs and structures, then the patient is covered with draping (green sheet) or ready-made disposable drape.

2- OR Setting:

The procedure is 2 surgeon procedure, a camera man and operating surgeon. The ergonomics concept must be considered, where the target (appendix) and surgeons eyes and the screen is perfectly aliened in a straight line, the distance between the surgeons eyes and the screen must be comfortable preferably 3 times the diagonal measure of the screen, the screen is kept at the same level of his eyes. The instruments, light source cable, insufflators cable and the diathermy or Hormonic scalpel are set according to the standard way.

3- Placement of Ports and Pneumoperitoneum:

A small transverse incision is made at supra umbilicus area, and the abdominal cavity is insufflated using veress needle after being checked for function errors or factory defects, the abdominal wall is lifted up, the needle is inserted at 90 degree to the abdominal wall with tip directed to the anus, to clicks sounds must be hared, drop test and suction irrigation test can be performed to insure safe and correct insertion of the needle. The CO2 gas insufflation is started at rate of 1L/min till reaching the target intra-abdominal pressure which is between 12 to 15 mmHg, later one can be maintained at 4-5 L/min. Once the target pressure has been reached, a 10 mm trocar is inserted followed by the 10 mm 30 degree camera after being checked installed and white balanced by the assisting surgeon. Under vision, a 5 mm trocar is placed at the suprapubic area, and another second 5-mm trocar is placed at the LLQ, this allows triangulation and ergonomic instruments handling in the conventional manner, the ports insertion is following the baseball diamond concept.

  4- Laparoscopic Exploration and Appendectomy:

The intra abdominal area is inspected to orient the surgeon to the position of the appendix. Inspection will also alert surgeon to any anatomic variation or other pathological conditions such as ruptured hemorrhagic ovarian cyst, Mickle's Diverticulum ..etc. Many findings can be reported during exploration such as presence of pus, adhesions, biogenic membranes. Once the appendix found inflamed, appendectomy must be carried out immediately. The bowel is gently retracted away from the field of dissection for better view and safe dissection, the patient position on table is changed to insure that the appendix is situated at the highest point in the field, so head must be down and patient tilted to left side. Atraumatic grasper is used to hold the appendix. The mesoappendix is coagulated using Hormonic scalpel, the coagulation must be done close to the body of the appendix to avoid cecal injury, the mesenteric fat will be coagulated in this process till the base of the appendix, this will insure coagulation and selling of appendicular artery. Prior to dividing the appendix from the cecum, 2 PDS endoloops, are placed proximal to the cecum, and the second  loop is placed 1-2 cm distally to the later. The appendix is then divided between the two loops using scissors. The appendix then placed in retrieval Endobag and extracted. The abdominal cavity may be irrigated thoroughly with normal saline and suctioned clean several times in case of perforation and pus formation, pelvic drain maybe kept in the pelvis in certain cases.

5- Final Inspection and Closure:

The abdominal and pelvic organs must be inspected once before defilation of the abdomen, in this step, the surgeon must look for signs of infection such as missed pocket of pus, or other potential complications of which the surgeon might need to be aware. Before defilation of the abdomen, the surgeon must inspect the port sites while removing them looking for possible bleeding which can be controlled under vision. Following deflation of CO2, the 10 mm port at mid-line (supra umblicus port), must be closed with Prolene 1, or PDS-0, the skin is closed with prolene 3-0 interrupted sutures or clips followed by dressing.