TASK ANALYSIS FOR LAPAROSCOPIC APPENDICECTOMY
Dr Akutu A. Munyika
MBCHB (UCT, SA), MMED gen surg. (UZ, ZIM)
Adjunct lecturer UNAM (SOM)
Consultant General Surgeon
Onandjokwe Hospital
Department of Surgery
Ondangwa, Namibia

1. Surgical team: Surgeon, Anaesthetist, Assistant, Scrub nurse

2. Equipment needed:
a. Laparoscopic towel with insufflator, Light source, HD camera with 30 degree telescope, bipolar machine, unipolar machine
b. Ports: One 10mm reusable port with 5mm reducer, two 5mm ports
c. Suction and irrigation
d. Basic laparoscopic appendectomy set with Marilyn, semi-atraumatic graspers, hook, scissors, harmonic, size A endobag or glove endobag.
e. Vicryl  2.0 round needle, Vicryl 0.0 round needle, size 11 blade, 10mm syringe and  skin staples

3. Method of anaesthesia: General Anaesthesia

4. Setting of the equipment
a. Pre-set pressures of the insufflator to 12–15mmHg 
b. White balancing with white gauze and focusing at about 10cm range

5. Position of patient:
a. Supine position in Trendelenburg position and 15 degree tilt to the left

6. Position of the surgical team and equipment:
a. Surgeon on the left, in line with target (appendix) and monitor, 5 times diagonal length of the screen
b. Assistant on the right of the surgeon
c. Sister on the left of the surgeon
d. Anaesthetist on the usual position, cephalad

7. Attainment of pneumoperitoneum and introduction of ports
a. Surgeon makes a stab wound with size 11 blade at the inferior crease of umbilicus
b. Surgeon check the spring of veress needle as well as patency with saline in 10mm syringe
c. Surgeon grab entire thickness of the infra-umbilical midline wall of abdomen
d. Veress needle pointing towards anus, perpendicular to entry point and 45 degrees to the supra-umbilical abdominal wall
e. Surgeon advances the veress needle and feels 2 clicks (one on rectus sheath and one on peritoneum
f. Surgeon carry out the injection/aspiration test and saline drop test with a 10mm syringe with saline, to confirm correct positioning of veress needle
g. Switch on the insufflator and monitor that the insufflator is confirming correct positioning of veress needle
h. Once pressure reached pre-set pressure, Surgeon uses size 11 blade to make a smiley skin incision in the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a 10mm port for estimation of incision.
i. Surgeon insert the telescope and inspect the entire abdomen 
j. Surgeon reach out to the target organ (appendix), just about to touch it with tip of telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target. 
k. Surgeon uses baseball diamond concept to mark the position of the additional 5 mm ports
l. Surgeon uses the 11mm blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.
m. Surgeon inserts the 5mm ports under direct vision

8. Identification of appendix:
a. Surgeon finds the caecum and follow tinea coli to the base of appendix

9. Mesoappendix
a. With the help of the harmonic, making sure that the silicon jaw is towards important structures like bowel, the meso-appendix is coagulated and cut, while the left hand holds the appendix with atraumatic grasper
b. The meso-appendix is coagulated and cut up until the base of the appendix

10. Appendicectomy
a. A pre-formed loop using extra-corporeal knot using meltzer’s knot is made with 2.0 vicrly and delivered into the abdomen through the 5mm port.
b. The appendix is delivered into the loop and the loop tightened at the base of the appendix with a knot pusher 
c. With the help of the harmonic, the appendix is sealed at about 0.5mm above the knot. There is no need for a second suture

11. Delivery of the appendix
a. A simple appendix can be delivered by grabbing the cut end with ovum forceps through 1mm port on the umbilical, under vision with the 5mm telescope
b. An inflamed, swollen, infected appendix can be delivered through the 10mm port in the umbilicus in the glove endobag or commercial endobag. The endobag can be pulled out together with the 10mm port and limbs of the endobag spread open to extract the appendix

12. Lavage of the abdomen, especially in cases of complicated appendix is done, with 3 to 6L of saline needed in ruptured appendix

13. Placement of Drain in cases of ruptured appendix, by placing naso gastric tube through a separate stab incision on the right iliac fossa

14. The 10mm umbilical port facia is closed using a veress needle as a suture passer. 

15. The two 5mm ports are removed under direct vision

16. The 10mm port is removed together with telescope

17. The 5mm ports, only skin is closed with vicryl 3.0

18. The 10mm port is closed with subcutaneous vicryl 3.0 on a cutting needle

19. This procedure can also be performed with 2 ports and striker mini alligator. The 10mm port in the umbilicus will be for camera, plus a 5 mm port in the left iliac fossa, then the striker mini alligator pass percutaneously in the right iliac fossa for grabbing the appendix to allow dissection and placement of suture through the 5mm port.