Laparoscopic Cecal Wedge Resection Appendectomy

CHAPTER 1

My name is Dr. Fisichella.My name is Dr. Levin.So what are we doing today?Today we are doing a laparoscopic appendectomy.This is a 66-year-old gentleman with a history of polyps,who undergoes colonoscopic surveillance every 3 years.In a recent colonoscopic surveillance,he was found to havean incidental polyp at the appendiceal orifice.The biopsy showedadenoma. Therefore, weare doing a laparoscopic appendectomyand we will take a portion,a small portion of the cecum with our procedure.Our approach is to do an umbilical incision.A marking pen? Yes.We will also be placing a subcostal,doing a subcostal incisionand a left lower quadrant... Suprapubic.Suprapubic incision for the first one, and mostlikely another port here.And the distance between the ports is usually 5fingerbreadths from each other.Otherwise, the instruments will clash together.In order to gain accessto the abdomen we may puta Veress trocar here or in thesubcostal margin. That's the reason whywe prepped the entire abdomen.The patient only had an open -open cholecystectomy before, sowe don't expect him to have many adhesions.Can we have two Adsons?Any questions or concerns?No, the only prob- concernwas the high blood pressure, but theanesthesiologist will take care of those.

CHAPTER 2

Just make an incision, yes.Right on the crease.The crease on top.Yeah, yeah.Incision. Nice.Perfect.Perfect. Towards you. Okay.Okay. Let me see...Can I have a Kocher?Let go.S-retractors.One second.I need to see the fascia, okay?Let go. Sorry.You don't have that Kocher? Kocher.Let me see.Perfect. Can you hold this?Okay. As you can see, this is the fascia.Okay. Can I have the Veress needle, please?

Can I have the drop test?Okay, so now the Veress needleis placed inside the abdomen. Thedrop of normal saline goes all the way down.Now we're going to connectit to the gas.Okay.Can I get gas on high flow?What's the opening pressure?Three. Perfect.So there is a good opening pressure.There is-it's on high flow.And no obstruction whatsoever.So the reason why I'm graspingthe fascia of the abdomen with a Kocheris so it gives usat least one inch of distance betweenthe abdominal contents and the abdominal wall.That will avoidpuncturing either the abdomen or the major vessels.Often the vena cava split at the levelof the umbilicus, so one of thecomplications of putting the first trocar in, orcomplication in placing the Veress needleright in the umbilicus inthe midline, is to hit the major vessels.So this is a trickthat we use to avoid that happening.Okay, the pressure is set to 15.So that's the maximum that we had.So I'm going to release the clamp.There is a good pneumoperitoneum here.We're going to get- no - yes, this, the camera.Perfect.

So this one here is an Optiview trocarthat has a clear tipthat will allow us to see exactly thelayers of the abdominal wall under direct vision.So there are different kinds of trocars.This one here is splitting. So ifI touch, I don't cut myself.The way it works is that by twistingleft and right, the muscles are spreador a cut is madeinto fascial structures.That's the fascia of theabdominal wall, right there.See we are spreading and spreading.That's preperitoneal fat.That's some of the muscles.Okay and this one here, we are inside the abdomen.And as you can see,when there is black, blackmeans that there is always air, sowe are safe right there.You can see the edge of the peritoneum.We're going to go back again in.I'm going to take it out.And that's the inside of the abdominal cavity.Perfect. As you can see there isno intra-abdominal injuries and then we're goingto put the -the next trocar right here.

This one here is the bladder.Can I have a local, please?So, this one here is that I wantto see exactly...Can you hold this?Okay. Can I have a knife, please?Let me do this.

Can I have a trocar?Okay, the reason why I wantto put it myself is just I want tomake sure that I don't go into the bladder,because this one here,this structure here is the bladder.Okay, so we're far away but in themiddle, in the midline. Okay.Okay, so the appendix is going to be there.Can you put the patient right-side up, please?So we're gonna put the -we put the patient in right-side up,so the gravitycan help us, mobilizing the smallbowel and give us exposure.Like this.A good way tounderstand the anatomy here is-these are - that's the right colon.These are the teniae. If you followthe teniae down, you will see the appendix and...Let me see.So this loop here is thelast loop of the small bowel. The terminalileum that attaches there -onto the colon, right there.

Okay, let's see if we can put the other trocar.Can I have the local again?Perfect.Knife.

Thank you.Okay, let's go back.Yes. And the other good bowel grasper.

CHAPTER 3

That's the terminal ileum over here.This is the teniae. Follow downthe teniae, there should be the appendix.Can you put the patient -a little bit more right-side -up?I'm gonna move the bed.Yeah.Stop. Stop, stop.Okay, andfoot down. Head up.Okay, thank you. Stop.Can you put the patient head down, head up, more?More head up? Head up.I'm gonna move the bed. Yeah.Okay, stop.Okay, can you put it in, head down, again?Like it was in a flat position. Flat.Gonna move the bed. Yes, thank you.Thank you.Oh man.

CHAPTER 4

Okay, let's try it with a Bovie.Closer.Okay.Okay. Let me get the Hunter.Okay.We may need to have that thing open now.The suction-irrigator open, yeah.Yeah, no, let open.Open, yeah. On the field, yes.One second.One second. Yes.Do you want one or three liters of saline?Three.So this is the appendix, it looks like,and I'm trying to go behindto see - so it's the only place. It is stuck somewherenear the small bowel. Maybe here,the previous appendicitis. That I cannot tell.Thank you. Hold this, please?Back up the camera.Okay.So this one here,looks like an artery that comes from behind.Yep.Oh, let me tell you.So, we follow the teniae and the teniaetook us to the appendix.That's the base of the appendix.This one here is theposterior portion of the mesentery.This one here is the mesentery. Okay?And the artery is somewhere there, it's a little bit, you know,oozy, but that's fine.

So can we have the LigaSure in the -in the room?The LigaSure is in the room. Would you like it opened?Yeah, open.And the reason why - the LigaSure is going to giveus the hemostasis to take out the artery.Usually, what we do is to put -make a hole here and take this portion with -you see that's the arteryright there -with a -with a stapler.But in this case the LigaSure may be much better.Perfect. This one here is the base of the appendix.Okay, this onehere is the colon that is attachedto the abdominal wall right here.That's the right colic gutter.That's our appendix, here.Okay.

Okay, so that's the base of the appendix.Now remember we are to take a cuff.Most likely we are to go across fromhere to here without damagingthe ileocecal valve.Okay, so the ileocecal valve is right there.Perfect. That's the base of the appendix.And that's the lumen, right there, okay.So that's the ileocecal valve, right there.Okay, so we are to go take a cuff,making sure that we don't bust.Okay, do you have -open Ray-Tec?Grasper.Hold this.Okay, put the trocar in.Thank you.Perfect.So this one here is going to make surethere is some hemostasis there,okay, in the meantime,this is going to clean also the blood.So we can -do a better operation.Okay.So the polyp is somewhere inside here, okay, at this level.So we have to make sure that wetransect this, making sure that there is no -we don't make any more trouble.Okay.Actually maybe you can see the polyp right here.That's where the polyp is.Look at this. Yeah.You see?That's where the polyp is.You can see really good.Okay.

Again, this is terminal ileum, the ileocecal fat pad,the cecum with the teniae.Following down the teniae, there is -following down the teniae here,you'll see the appendix.The appendix is free from the mesentery. We're goingto pull it up and thentransect the base.Okay, come closer. No.I'm going to try to take this thing off.Perfect. Thank you.Okay, so what do we think?Okay, so one second. Make sure...Let's go on the other side here.Okay, perfect. We're not taking anything bad.Okay?Here, we are not taking -the valve, okay?Ready? Okay.Let's check again.We're not taking -I need to see the valve, my friend. Right here.Perfect.There's no stricture in the valve,which is there. Put it like this.Okay.Perfect.We're not taking the valve.And that's a little bit up thing and then maybethe thing is right there.The polyp is right there.Okay.Maybe. Let me see.Come closer.Scissors.Sure.That's going to bleed.Come closer.Yeah.Okay. Do you have the bag?

Yes.Right here.Ten introducer.No, the other one.Okay.

CHAPTER 5

Can I open this thing?I need...A towel? A towel, yes.You have, 4-by-4?This one here is the appendix. Okay? Very short.This is our staple line.Take it out. I need your help, here.Do you have a Hudson?Okay.I don't know.Can I have some water in here?Water, a small little cup.And sure enough, here is the polyp.Ta-da!So, it was like this.Okay, that's the base of the rec-of the cecum.This is the line of transection.Open it up, and in the lumenthere is a polyp.With its...With a base. That's the base of the polyp.Okay?Yes, formalin.So next step, we're going tocheck the hemostasis on the stapleline, making sure that the ileocecal valveis not being compromised.

CHAPTER 6

We need 2-0, Vicryl.No, sorry, 0-Ethibond.Can you give me a 10-mm scope, please?10-30.We took out the appendix with the base.We found the polyp.We are checking hemostasis. And close.I like the thirty,here, because its a better qualityof image than the five.If we have theluxury of using it, we will use it.Do you have two bowel graspers?Don't worry. Cut the needle away.Come closer, there.Okay, so come closer,closer, closer, so we can see the staple line.Staple line is okay. It's not bleeding, okay?And we go below here.Slowly.It's kind of really dry.Let me see what's going on there.That's someirrigation.Okay.Go in.It's mostly clear, okay? There's no bleeding.Okay.Perfect.There's no problem there.No problem there.I see the ileocecal valve,which has not been compromised.Okay?Okay.Now we need the 5-mm scope, please.Let's go around here and see ifwe have any problem.That's okay. Right there.Okay. It's okay there.Okay, those are the adhesionsfrom his previous cholecystectomy.Okay.

CHAPTER 7

The last thing that we're going to do now thathemostasis is done, we're going toclose the 11-mm port.Okay, do you have the Carter-Thomason?Yes, the full length. Yes. Hold this.It's a figure-of-eight. Look at this.Okay?Okay. Now what we do, take everything out.Gas off.Is it off?Gas off.Okay. We're going to deflate the abdomen. Like this.Is the patient flat?The patient is flat.Yes.Scissors, please.Let me see.Okay.Do you have something to clean? Like water?Okay, go on the other side.No, stay here, Scott.We need two Adsons.We used them on the appendix. They are off the field.No problem - something - yes, they're fine.You and I have to make the hemostasis here, okay?I don't know where it's coming, just go deeper.Nice. Let go.Good. So we'll just come in from the skin, then.Here we got to do the same.Let go. See what happens.One second, let me do this.Now stick it in there.Can you close this? Yes.Okay.

CHAPTER 8

So the first case was a patient with an adenomaof the appendiceal orifice.This was discovered by routine colonoscopy.Because it was quite difficult toexcise the adenomawith endoscopy, wedecided to take the patient to the operating roomand takethe appendix out together with the adenoma.The challenging fact in thiscase was that it was very difficult for usto understand where wasthe location, the correct locationof the adenoma. We didn'tknow if it was withinthe lumen of the appendix or if it wasright at the appendiceal orifice.And this is important becausewhat we have done during the operation wasto take the baseof the appendix together withat least one centimeter of the wallof the cecum.At the same time that exposed us to the dangerof stapling the cecum too closeto the ileocecal valve.So the challenging portion was tryingto achieve a good resection of the appendixtogether with the adenoma, butat the same time,being mindful of not taking down ornarrowing the ileocecal valve.In this case the patient was relatively healthy.He only had hypertension thatwas very well controlled with antihypertensive medication.And we chosethe laparoscopic approachbecause the patient did not have an appendicitis before,so the amount of adhesionsand the anatomy would have beenparticularly prone to the laparoscopic approach.We discharge the patient rightafter the operation.Another thing that waschallenging was finding the appendix.When the appendix is inflamed,it's usually swollen with a big diameter.In some cases the appendixis very long, but in this case, the appendix wasless than a centimeter in diameterand it was also very short.So, we found the colon first. And to find the colon weput the patient with a left lateral decubitus,which means the right sidewas placed up, and the left side was placed down.So we swept the small bowelto the most dependent portion toexpose the cecum and the right colon.Once we saw the cecum, weidentified one of the teniae,and by following it down wewere able to identify both theileocecal valve and the appendix.So, the first thingI did after I saw the appendix,we grasp it and traction, apply traction.The appendix wasvery densely adherent to the ileocecal valve,so we took the mesentery downfrom the ileocecal valve using the cautery.The appendiceal arterywas taken down with a LigaSure,which is this instrument thatcoagulates the vessels and cutsthem at the same time, providing hemostasis.And then, we wentall the way down to thebase of the appendix to make sure thatwe were able to pullat least a centimeter of thececal wall in order to make surethat we couldget the adenomawithin the specimen.The operation went well.The staple line was free of any bleeding,and the operation took about an hour.The patient will be sent home later today,and he will resume a generaldiet and all the physical activities tomorrow morning.And we will see him backin clinic in a week.Once we took out the specimen,we opened it ontable and we were able to find thatthe adenoma was withinthe lumen of the appendix,and there was at least one and a halfcentimeter of margin clear from the adenoma,compared to the staple line.