We utilize a three-port technique, with one umbilical and one suprapubic port in order to perform an appendicitis surgery. Although the third port can be placed in either the left or right lower quadrant, we prefer the left lower quadrant. This follows the laparoscopic principle of triangulation, such that the port locations direct the camera and instruments toward the right lower quadrant for optimal visualization of the appendicitis.
The appendicitis patient is positioned supine on the operating room table with the left arm tucked . The video monitor is placed at the patient’s right side, because once pneumoperitoneum is performed, the surgeon and assistant both stand on the patient’s left. A single dose of a second-generation cephalosporin is administered prophylactically. Prior to incision, a nasogastric tube and a Foley catheter are placed to decompress the stomach and urinary bladder. All midline incisions should be oriented vertically, in case conversion to an open midline incision is necessary. A 1- to 2-cm vertical incision is made just inferior to the umbilicus and carried down to the midline fascia. A 12-mm trocar is placed using either Hassan or Veress technique, depending on surgeon preference. After insufflation of the abdomen and inspection through the umbilical port, a 5-mm suprapubic port is placed in the midline, taking care to avoid injury to the bladder, and another 5-mm port is placed in the left lower quadrant. These port sites typically provide excellent cosmesis postoperatively due to their small size and peripheral location on the abdomen.
A 5-mm 30° laparoscope is inserted through the left lower quadrant trocar. Placing the laparoscope in the left lower quadrant allows triangulation of the appendix in the right lower quadrant by instruments placed through the two midline trocars. The surgeon operates the two dissecting instruments and the assistant operates the laparoscope. The appendix is identified at the base of the cecum, and any adhesions to surrounding structures can be lysed with a combination of blunt and sharp dissection supplemented with electrocautery. If a retrocecal appendix is encountered, division of the lateral peritoneal attachments of the cecum to the abdominal wall often improves visualization. Care must be taken to avoid underlying retroperitoneal structures, specifically the right ureter and iliac vessels. The appendix or mesoappendix can be gently grasped with a Babcock clamp placed through the suprapubic port and retracted anteriorly. A dissecting forceps placed through the umbilical port creates a window in the mesoappendix at the appendiceal base. Caution should be taken not to injure the appendiceal artery during this maneuver. As in the open procedure, the base of the appendix should be adequately dissected so that it can be divided without leaving a significant stump. We try when possible to staple at the confluence of the appendix and cecum, or just onto the cecal wall, to avoid the possibility of stump appendicitis or mucocele.
The appendix can be removed in a retrograde fashion, first dividing the appendix, followed by division of the mesoappendix. A laparoscopic gastrointestinal anastomosis (GIA) stapler is placed through the umbilical port and fired across the appendiceal base. After reloading, the stapler is again inserted through the umbilical port and placed across the mesoappendix, which is divided with firing of the stapler. Alternatively, the appendix and mesoappendix can be secured using an endoloop.If desired, the appendix can be removed antegrade, by first dividing the mesoappendix prior to directing attention to the base. The appendix should be placed in a retrieval bag and removed through the umbilical port site to minimize the risk of wound infection. The operative field is inspected for hemostasis and irrigated with saline. Finally, the fascial defect at the umbilicus is closed with interrupted 0 absorbable suture, and all skin incisions are closed with fine subcuticular absorbable suture.