1. In The Name of GOD

2. Laparoscopic appendectomy: Selection the method of stump closure
Mohammad Kermansaravi
MD.Fellowship of Advanced Minimally Invasive and Bariatric Surgery, Minimally Invasive Research Center, Iran University of Medical Science, Tehran, Iran
MISTIC 2016: 9 November 2016

3. The most common acute abdominal pathology requiring emergency surgery is acute appendicitis.
Laparoscopic appendectomy for acute appendicitis is one of the most common emergency laporoscopic procedures in general surgery performed in the US.
Laparoscopic appendectomy is currently a well-established and widely accepted method.
Semm first defined laparoscopic appendectomy
(LA) in 1983 as an alternative approach to open surgery.

4. Indications: 1)Clinically suspected or confirmed acute appendicitis
2)Morbidly obese patients
3)Women of child-bearing age in whom the diagnosis is uncertain
4)Pediatric population
5)Interval appendectomy

5. Contraindications: 1)Lack of surgeon experience
2)Inability to tolerate general anesthesia
3)Refractory coagulopathy
4)Diffuse peritonitis with hemodynamic compromise
5)Extensive previous surgery(Relative)
6)Portal hypertension(Relative)
7)Severe cardiopulmonary disease(Relative)
8)Advanced pregnancy(Relative)

6. Surgical Anatomy:

7. Patient Position and Room Setup:

8. Trocar Position and Choice of Laparoscope:

9. Procedure: 1)Identify and mobilize the appendix
2)Mobilize The cecum if needed
3)Retract the cecum medially
4)Grasp the appendix with an atraumatic grasper
5)Transect The appendix at its base(How?)
6)Divide the mesoappendix

10. The ideal method : Methods for closure of appendix stump: 1)safety
2)Accessiblilty
3)Technically simple to use
4) Cost effectiveness

11. 1. Polymeric Clips(Hem-o-Lock)
Capable of securing tissue bundles up to 16mm in thickness
Safe to use electrocautery near the clip
(Nonconductive and inert)
Contraindications:
1) Severe inflammation
with associated poor tissue quality
2)Tissue diameter > 16mm

12. Absorbable polymeric surgical clips(Lapro-clips)
The clip can close tissue with a diameter ≤ 12 mm witout residual FB
Adverse risk factors associated with the use of absorbable clips in LA :
1)BMI ≥ 27.5 kg/m2
2)Diabetes
3)ASA degree ≥ III
4)Gangrenous appendicitis
5)Severe inflammation of the appendix base
6)Appendix perforation
7)Absence of peritoneal drainage

13. Titanium endoclip Closure of appendices with a diameter of 20 mm
Contraindications:
Necrosis or very large thickening of the inflamed appendicular base

14. Endoloop
Made of silk or polyglactin.

15. Hand made endoloop
Analogous to Endoloop
Advantage: Cheap

16. Suture Knot
Intracorporeal tie knot requires more experience than other methods.
Advantage: Cheap
Disadvantage : Prolonging the operation time

17. Extra-corporeal Ligation
Extracorporeal tie knot: Simple and Cheap

18. Laparoscopic Linear-stapler
Staplers allow simultaneous sealing and division of both the mesoappendix and the appendix base.
Safe even when the appendix base is inflamed and its diameter is too large.

19. Vessle sealing devices
In Experimental Studies:
1)Bipolar coagulation:for approximately 90 sec
2)Ligasure
3)Harmonic Scalpel

20. Cost Endostapler 200-300 $ Vessle Sealing Handle 250-500 $ Endoloop
20-40 $
Hem-o-lock
15-30 $
Titanium clip
5-10 $

21. Conclusion: The selection of stump closure’s techniqe,
must be modified based on:
Safety of technique
Condition of appendix base
Diameter of appendix base
Surgeon experience
Applicablity of technique
Cost of technique

22. Thanks for Attention