1. Introduction

2. Draping

3. Gain Laparoscopic Access via Cut Down Technique at Umbilicus

a. Identify Cecum and Appendix

b. Adhesiolysis

c. Make Window into Mesentery at Junction with Cecum

4. Dissection

5. Transect Base of Appendix from Cecum with Abdominal Load Stapler

a. Mobilize Appendix

b. Divide Mesentery and Blood Supply with Vascular Load Stapler

c. Inspect for Hemostasis Along Staple Lines

d. Place in Specimen Bag and Remove from Abdomen

e. Remove Ports and Desufflate Abdomen

6. Remove Appendix

a. Identify Hernia Defect

b. Amputate Stalk Completely

c. Remove Hernia Sac

d. Repair Opening in Fascia

e. Reattach Umbilical Stalk to Fascia

7. Umbilical Hernia Repair

8. Closure

9. Post-op Remarks

Acute appendicitis is a medical condition where the appendix becomes inflamed and causes pain in the lower right quadrant of the abdomen. In addition to pain, appendicitis can cause peritonitis, perforations, and can lead to death if left untreated. Laparoscopic appendectomy is the standard surgical procedure to treat the symptoms of appendicitis as well as prevent further spread of infection. While appendicitis typically advances in an irreversible fashion necessitating surgery, conservative management with antibiotic therapy can sometimes resolve symptoms. In this case, a 24-year-old patient had a delayed presentation with acute perforated appendicitis. Following successful non-operative treatment with antibiotics, she presented for a laparoscopic interval appendectomy. She also had a non-symptomatic umbilical hernia, which was repaired following removal of the laparoscopic ports for the appendectomy.

<h4>CHAPTER 1</h4>

<p>So this is a healthy 24-year-old female who initially presented with perforated appendicitis.
Since it was somewhat delayed when she presented, she was managed
conservatively with antibiotics and then subsequently came back to clinic
and felt very strongly about getting her appendix out.
She was therefore booked for what we call an interval appendectomy - we
usually like to wait about 6-8 weeks for the inflammation to settle down
from the perforation, and then we go in and actually remove the appendix.
The key steps for any appendectomy are number 1, prepping the abdomen and draping
in accordance with the usual surgical standard.
We then turn our attention to gaining access to the abdomen.
So we usually make an infraumbilical incision.
This is to permit the camera port.
This is then dissected down to level of the fascia.
We then place our camera port in and insufflate to about 15 mmHg.
We like that insufflation level just because it still allows
good perfusion to the abdomen and minimizes any risk of CO2 absorption by the patient.
And then, under direct visualization, we then place 2 additional
ports that are 5 mm. One is actually on the opposite side of the
appendix, on the left side in the left lower quadrant, and then an additional one
above the pubic symphysis with care not to injure the bladder.
Find the cecum
and where it joins with the appendix. Lift and elevate that.
We then make a small hole into the mesentery,
which is the blood supply of the appendix,
and then that allows us to place a special surgical instrument that is a stapler with
appropriately-sized staples for the the intestinal width.
After that's done, we then use
a vascular load stapler that's actually a little bit smaller in terms of the staple.
The appendix is then delivered into a bag and removed from the umbilicus.
She had an umbilical hernia, so we will be doing a couple additional steps.
Number 1, we're going to be dissecting around the stalk of the umbilical hernia,
then isolating that off of the fascia, and just kind of lifting it right up.
We'll reduce the contents, and then after that we will then repair the area
where there's an opening in the fascia in a primary fashion.
Anything under 2 cm usually can be done primarily with just some sutures.
After that we basically will tack down the stalk and then we
will close the skin of the 5-mm ports and the umbilical port, and just place -
I like to use skin glue because I think this makes patients realize their incisions are quite small.</p>

<h4>CHAPTER 2</h4>

<p>[No Dialogue.]</p>

<h4>CHAPTER 3</h4>

<p>So to begin our procedure, we're going to have a little local.
We're going to gain access to the abdomen at the umbilicus - you can see the patient
has a small umbilical hernia that we'll eventually
incorporate into the repair at our umbilical access site.
Yep. Perfect. And you can make it semi-large
because we're going to have to deal with that umbilical hernia at the end. Yeah, good.
The bovie is used to separate the soft tissues down to the level of the fascia.
And then using blunt separation, we expose
the fascia.
Snap and cut, please.
I'll take another snap and another cut.
Needle back. I'll take the gas on please. Okay.
The camera port is inserted in the umbilicus, and the abdomen
is insufflated to 15 mmHg. Opening pressure is 5.
Good, pull that back just a little bit, perfect. Okay.</p>

<h4>CHAPTER 4</h4>

<p>The cecum is identified in the right lower quadrant.
The omentum is retracted away from the cecum.
The terminal ileum is seen coming in to the cecum.
The appendix is identified.</p>

<p>And some adhesions are gently dissected.
This patient had perforated appendicitis 6 weeks ago,
was treated with antibiotics, and is here for interval appendectomy.</p>

<p>Probably make your window. Yeah.
Can I get the Maryland?
The junction of the appendix and the cecum is identified.
And a window is made into the mesentery.
Beautiful. Yep.
We're going to need a - the purple and the tan load.
Good. Now, back out. Yep.</p>

<h4>CHAPTER 5</h4>

<p>I need a little more. Yep, you do.
Good. Okay.
You can take that.</p>

<h4>CHAPTER 6</h4>

<p>The adhesive bands are sharply divided.
Just foreshorten the mesentery a little bit, which is...
Yep.
Yep. That stuff right there.</p>

<p>Yep. Good, now lift off the RP. Good.
Okay. Yep, okay, I'm okay with that. So like right there?
And just lift a little bit away.
Okay. Great.</p>

<p>We inspect for hemostasis along the staple lines.</p>

<p>Can we level her out, please?
And removed.
Good.</p>

<p>Okay, we can take that out.</p>

<h4>CHAPTER 7</h4>

<p>Snap.
Okay.</p>

<p>So, right there. Yep. Good.</p>

<p>That's fine.
Good.
A little fat.
Incarcerated umbilical fat is separated from the stalk.
And the hernia sac removed.</p>

<p>Okay. Figure-of-eights are utilized.
Okay, snap and a cut.
Snap and a cut, thanks.
I think it's back further, yeah.
Like this? Like that, yep.
And can I get the skin glue for closing?
Sure.</p>

<p>Okay, and - yep, suture scissors - and you guys can feel free to count.
We're just going to need the Monocryl.</p>

<h4>CHAPTER 8</h4>

<p>[No Dialogue.]</p>

<h4>CHAPTER 9</h4>

<p>I think the case overall went well, as we mobilized,
the appendix came down and made a hairpin turn, and when it
does that, it actually kind of crinkles the mesentery for the stapler loads across it,
so we have to spend some time taking down those adhesions to straighten it, so
that we can come across the bottom and get the blood supply clearly without,
you know, encroaching upon the retroperitoneum where important structures like the ureter are,
and without coming across the appendix itself as well.
Other than that, I think everything went pretty straightforwardly.
I was very happy. Also, we did an additional
umbilical hernia repair that went quite well, and we got good closure and
no complications, and I think she'll do well and be able to be discharged
from the postanesthesia care unit.</p>




Watch this narrated surgical video of a laparoscopic interval appendectomy and open umbilical hernia repair performed at MGH by Dr. Noelle Saillant.

Massachusetts General Hospital