For performing appendectomy some surgeons prefer to use the lithotomy position in women. This allows to the perineum so that a cervical manipulator may be use to elevate and provide better visualization of the pelvic organs. We should tuck the patient’s arms at the sides. this is extremely important to allow sufficient room for the assistant and camera operator to move cephalad as required. The surgeon stands on the patients’ left side. We should place the monitor at the patient’s hip on the right or directly below the feet. We should place a Foley catheter to decompress the bladder.

Trocar position and choice of laparoscope

Surgeon should place the initial 10-mm trocar at the umbilicus. Use a 0-degree telescope for visualization. We should place the second 5-mm trocar in suprapubic midline to accommodate a grasping instrument. A 10-mm trocar may be needed to accommodate an endoscopic babcock clamp. This trocar must be placed far enough from the appendix to allow sufficient working distance. Occasionally it will need to be place in the right upper abdomen or even right lower quadrant. The third trocar is usually a 12-mm trocar inserted in the hypogastrium, if the endoscopic linear stapler is to be used, or a 5-or 10-mmtrocar if clips or ultrasonic scalpel will be employed. Place this trocar in the midline or lateral to the rectus muscle to avoid injury to the inferior epigastric vessels.

To perform laparoscopic Appendicectopy we should place the patient in steep trendelenburg position to allow the intestines to slide out of the pelvis, and perform a thorough exploration to confirm the diagnosis. If the appendix is normal, seek other sources for abdominal pain. If no other source is found, it is reasonable to proceed with appendectomy.in many cases a fecolith or other evidence of pathology will be found. Identify the appendix by blunt dissection at the base of the cecum. Elevate the cecum or terminal ileum with an endoscopic Babcock clamp, placed through the right upper quadrant trocar. Generally, the base of the appendix wil come into view first. We should grasp the appendix with an atraumatic grasper or babcock clam placed through the suprapubic trocar. An extremely inflamed appendix may be tied with suture ligature, which provides a handy way to elevate it with minimal trauma.

Depending upon how the appendix presents it may be simplest to divide the base before the mesentery.in general, dividing the mesentery first provides the greatest assurance that the dissection of the appendix is carried all the way to the base. We should divide the mesoappendix serially with clips, cautery, ultrasonic scalpel, or endoscopic stapler.

Surgeon should divide the base of the appendix. Ligatures or the endoscopic stapling device may be used. The endoscopic stapling device saves time but is costlier than using two prettied sutures. If the appendix is normal, the appendicular base and mesoappendix may be divided by a single application of the stapler. Surgeon should remove the appendix by pulling it into the 12-mm trocar and removing trocar and appendix together, thus protecting the abdominal wall from contamination.an extremely bulky or contaminated appendix may be placed in a specimen beg to facilitate removal.

Complications

1. bleeding

A.      Cause and prevention aggressive dissection of the mesoappendix may lead to troublesome bleeding. likewise, bleeding from omental vessels or the retroperitoneum may occur as the inflamed appendix is dissected out careful dissection with early control of the mesoappendix with minimal dissection should prevent this complication.

B.      Recognition and management. Bleeding is not difficult to recognize. Section, adequate lighting, and pressure will aid in identifying the bleeding site.an additional trocar may be needed to allow retraction around the field for grasping of the vessel. Control with an  endoloop or clip seems more certain that the application of cautery.

2. Leakage of appendicular pus or fecolith

A. Caused and prevention. This problem may be seen when the appendix is tensely distended and inflamed but not yet performed. Careful dissection with the use of a sterile specimen bag extraction may prevent leakage.

B. Recognition and management. this complication is easy to recognize and quite distressing. Irrigate the field and suction carefully after removal of the specimen. Retrieve any dropped fecoliths immediately, while still visible.it is easy for small object like a fecolith to become lost in the pelvis or between loops of bowel. Continue antibiotic coverage for several days after surgery, at least until the patient is afebrile with a normal white blood cell count.

3.Incomplete appendectomy

 A. cause and prevention. This problem, although rare, may lead to recurrent appendicitis it is caused by ligation of the appendix too far from the cecum it may be prevented by carefully identifying the junction of the base of the appendix with the cecum before ligating and dividing the appendix.

B. Recognition and management. the surgeon must be aware that a patient who has had a laparoscopic or open appendectomy may later present with signs and symptoms of appendicitis owing to this complication.