Necessary Equipment for a SILS appendectomy:
12 millimeter trocar (for the Umbilicus)
10mm Laparoscope with a 5mm working channel
Millimeter laparoscopy.
Extralong instruments:
Serrated bow grasp
Endoscopic scissors
Maryland dissector
atraumatic bowel grasp
Electric hook
Cautery probe
Aspirator probe
Surgery steps:
We start focusing on the right lower quadrant and peel omentum away as needed.
Once we have adequate visualization and we can see where the appendix is sitting, we focus on the attachment between the cecum, and the retroperitoneum.
We gently mobilize the cecum bluntly by delicately opening up the attachment between the cecum and the body wall, taking care not to injure structures right beneath.
Sometimes you can take the tip of the instrument and gently grasp a bit of peritoneum and sweep towards the liver to make an opening into the retroperitoneum.
The degree of mobilization varies depending on how mobile the appendix is to start with, and how thick the abdominal wall is.
Once we feel we might have full mobilization, we grasp the appendix and see if we can bring it up towards the liver.
If it can, then most likely it will be able to be delivered up through the abdominal wall.
At this point, we’ll want to grasp the tip of the appendix with a locking grasper
The key is to get a good squeeze of the tip of the appendix, and to be able to have a firm grip.
Once the appendix has been grasped, we bring it up to the level of the trocar and remove the gas from the abdomen.
Once we have that done, we remove the trocar and gently bring the appendix up, through the wound, grasping it often with a gauze.
Once you have the appendix mobilized into the abdominal wall, perform an appendectomy for your reference. Here’s how Doctor Rosen does it.
So appendix is dissected and divided between clamps, and the patient’s base is located with a little bit of traction on the appendix.
We verify if there are any residual bands or mesoappendix left that will get in the way of a good low ligation, and anything remaining is dissected and either ligate it or cauterized.
Once the appendix seal single junction is adequately dissected, it may be ligated.
Here we affect the suture ligation of the base of the appendix. The tie is held in the clamp to be able to avoid the stump slipping back in the abdomen after division.
A clamp is placed across the appendix defining the stump, and a scalpel is used to divide it.
The stump is cauterized and irrigated before returning to the peritoneal cavity.
Once the appendix seal stomp has been returned back to the abdominal cavity. We often put the trocar back in and reinsert the laparoscope to take a look.
Early in performing this procedure, it’s nice to get a good intracorporeal view of the base ligature to make sure that you’ve gotten flush enough into the cecum and are not leaving a segment of appendix. We’re inspect to make sure we have good hemostasis.
Any irrigation or aspiration can be done at this time. And once we’re satisfied that everything is fine and prepare neatly, the scope is removed and wound closure finishes the surgery.
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