LAPAROSCOPIC APPENDECTOMY OPERATIVE EXAMPLE
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute purulent appendicitis.
OPERATION PERFORMED: Laparoscopic appendectomy.
ESTIMATED BLOOD LOSS: Minimal.
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought into the operating room and laid supine on the operating table for laparoscopic appendectomy. Anesthesia was induced. She was intubated without difficulty. Sequential compression devices were placed on the lower extremities prior to induction of anesthesia for DVT prophylaxis. A Foley catheter was placed at the beginning of the procedure and removed at the end. Her abdomen was prepped and draped in the normal sterile fashion using ChloraPrep.
Abdomen was entered through a supraumbilical incision, vertical, for 12 mm port site. The incision was made with a knife and carried down through the fascia under direct visualization, entering the peritoneum under direct visualization with an 11 blade. The local anesthetic used at all port sites was 0.25% Marcaine with epinephrine.
Once the umbilical port site was created, then the trocar was inserted bluntly, and the abdomen was insufflated to 15 mmHg pressure with CO2 gas. Initially, a 0-degree, 10 mm Olympus laparoscope was used to inspect her abdomen. The ascites, as noted, was observed and a circumferential view was taken of her abdomen. The adhesions above her liver were noted. Her gallbladder appeared somewhat edematous but soft and thought to be probably in reaction to the surrounding abdominal inflammation.
The appendix was located in its more standard position in the right lower quadrant. It was covered by omentum and a portion of the distal ileum. The scope was then switched to a 45-degree, 10 mm scope and the two operating trocars were placed using 5 mm trocars, one suprapubic and one between the umbilicus and the pubic trocar. These were placed by creating an incision with a knife and then the trocars were inserted under direct visualization.
First, the ascites was suctioned, and there was some fibrinopurulent material overlying her uterus and along the lateral border of the liver on the right side, and all of this was suctioned until clear and then swab cultures were taken of this fluid by swabbing the tip of the suction instrument. Aerobic and anaerobic cultures were sent.
Once this was done, then the areas were irrigated with saline until the pus was cleared. Then, attention was placed towards dissecting the appendix, which was easily dissected free of its adhesions to the omentum bluntly and to the ileum, which had rolled over it bluntly.
There were some peritoneal attachments inferiorly and laterally along the cecum that required lysing and mobilization. This was done with electrocautery with a hook of the ConMed instrument and blunt dissection, so that the base of the appendix could be identified as it is separated away from the cecum.
Once this was done, a Maryland dissector was used to dissect the neck of the appendix. Then, a blue load of the 45 GIA was used to transect the base of the appendix. This was done without difficulty. The area was inspected. The staple line was noted to be secure, and there were some attachments medially to the distal ileum that were lysed with blunt dissection and electrocautery, allowing the mesoappendix then to be able to pull away from the distal ileum and pelvis so that then a white load of the GIA was used to transect the mesoappendix. The staple line was inspected and noted to be hemostatic.
The appendix was then placed within an EndoCatch bag after switching to a 5 mm, 45-degree scope. The EndoCatch bag was placed through the umbilicus and the appendix placed within it. The bag was closed and left in the abdomen until the end of the procedure.
Then, we proceeded to more thoroughly wash the abdomen now that the appendix was isolated. This was done with about total of 2000 mL of saline, irrigating all four quadrants until all the irrigant fluid was clear. Again, the staple lines were inspected and noted to be secure. Then, a 19 Blake drain was cut to size and placed through the umbilical trocar and brought out through the most inferior trocar sutured to the skin with 2-0 nylon. The tip of the drain was placed at the pelvic brim with the shaft of the drain between the rectum and the uterus.
Once this was in place, then the trocars were removed. The appendix was removed through the umbilicus within its bag without spillage. Closure of the fascia of the umbilicus was then done with 0 Vicryl figure-of-eight sutures. The skin was reapproximated with 4-0 Monocryl subcuticular sutures. The umbilicus was packed with 2 x 2 gauze. Mastisol and Steri-Strips placed on the 5 mm port site. Gauze and Tegaderm were placed around the drain site. The Foley catheter was removed.
The patient tolerated the laparoscopic appendectomy procedure well. The patient was awoken, extubated, and transferred to the recovery room in stable condition.
