1. MEDCARE HOSPITAL SHARJAH PRESENTED BY:KAVYA STEPHEN RN OPERATING ROOM LAPROSCOPIC APPENDECTOMY

2. INTRODUCTION The laparoscopic (minimally invasive) surgical technique involves making several tiny cuts in the abdomen and inserting a miniature camera and surgical instruments. As many as three or four incisions are made. The surgeon then removes the appendix with the instruments, so there is usually no need to make a large incision in the abdomen. The camera projects a magnified image of the area onto a television monitor which helps guide the surgeons as they remove the appendix.

3. DEFINITION Appendectomy is an operation to remove the appendix when it has become inflamed; an inflamed appendix is called appendicitis A laparoscopic or “lap” appendectomy is a minimally invasive surgery to remove the appendix through several small incisions, rather than through one large one.

4. INDICATIONS  All kinds of appendicitis  Appendicular abscess  Specially suited for obese patients  Females of reproductive age group

5. CONTRA INDICATIONS Patients with-  Cardiac diseases\COPD  Previous lower abdominal surgeries  Coagulopathy

6. ADVANTAGES  Less operative trauma and complications  Early mobilization and return to work-discharge within 24-36 hours  Less post operative pain  Cosmetically better acceptable

7. EQUIPMENTS  Standard laproscopic video system  Carbon di oxide insufflator  10mm trocar-2  5 mm trocar-1  Atraumatic grasper like babcocks  Laproscopic scissors  Maryland’s dissector  Bipolar forceps  Endoloop  Endobag (optional)

8. PORTS OF DIFFERENT SIZES

9. STEPS OF PROCEDURE 1. INSERTION OF PORTS  Camera is introduced through the periumbilical port.  This port is placed using a Hassan technique or direct cut down method.  A diagnostic laparoscopy is performed.  A 5mm port is introduced in the right lower quadrant under vision.  A non traumatic grasper is introduced through this port to identify the appendix.

10. Continuation…. 2. EXPOSURE OF THE APPENDIX  At this point the small is lifted out of the pelvis exposing the inflamed appendix. Careful manipulation is essential without directly grasping it to avoid bowel injury.  A 10mm port is introduced in a suprapubic site.  The appendix is grasped with the left hand instrument exposing the mesoappendix. This is adherent to the small bowel mesentery and requires careful sharp dissection with scissors and diathermy.

11. Continuation…. 3. ISOLATION OF MESOAPPENDICULAR ARTERY  We then commence scoring the mesentery with scissors and diathermy.  A Maryland grasper is introduced and a window is created in the mesentery to isolate the appendicular artery.

12. Continuation…. 4. CLIPPING AND DIVIDING OF THE ARTERY  Three clips are applied to the isolated vessel. The vessel is divided between clips leaving two clips on the patient side.  We then use diathermy to divide the rest of the mesentery.

13. Continuation…. 5. APPLICATION OF ENDOLOOPS  An endo-loop is introduced and placed at the base of the appendix. It is critically important to visualize the knot of the endo-loop because if this is outside the field of view it can snag onto other structures. The attached thread is divided with scissors. The two remaining endo-loops are placed and the appendix is divided between the second and third endo-loop leaving two endo-loops on the patient side

14. Continuation…. 6. DIVISION OF THE APPENDIX  At this point we assess the appendix stump and divided vessel to ensure hemostasis

15. Continuation…. 7.RETRIEVAL OF THE APPENDIX IN AN ENDOBAG  The appendix is then grasped. The camera is switched to the suprapubic port. An endo-bag is introduced through the periumbilical port and the appendix is retrieved in this.  The balloon is deflated and the specimen is retrieved.  The remaining port is removed under vision.  The 5mm port is closed with monocryl.  The fascia of the 10mm sites is closed with vicryl.  The skin is close with monocryl.  Local anaesthetic is injected into the incisions and dressings are applied.

16. COMPLICATIONS  Bleeding-managed by bipolar cautery  Spillage of appendeceal contents-managed by thorough toileting,putting a drain

17. NEWER TECHNIQUES  Single port lap appendectomy  NOTES (Natural Orifice Transluminal Endoscopic Surgery )

18. NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES)  An experimental surgical technique whereby "scar less" abdominal operations can be performed with an endoscope passed through a natural orifice (mouth, urethra, anus, etc.) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars

21. Continuation…

22. REFERENCE  emedicine.medscape.com/article/773895-treatment  https://www.slideshare.net/drsreejoypatnaik/laparoscopic- appendectom  https://www.scribd.com/doc/28298226/Appendicitis- Appendectomy  https://www.facs.org/~/media/files/education/patient%20ed /app.ash  https://www.sages.org/publications/.../guidelines-for- laparoscopic-appendectomy  https://en.wikipedia.org/wiki/Natural_orifice_transluminal_e ndoscopic_surgery