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Laparoscopic Appendicectomy: How I Do It ?
The document outlines Dr. Mohamad Al-Gailani's approach to laparoscopic appendicectomy, emphasizing its advantages like reduced postoperative pain and shorter hospital stays compared to traditional methods. It also discusses considerations for different patient demographics, the necessity of removing normal-looking appendices, and the debated practice of interval appendectomy. Ultimately, the presentation advocates for the laparoscopic method due to its lower complication rates and improved recovery outcomes.
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Laparoscopic Appendicectomy: How I Do It ?
- 1. LAPAROSCOPIC APPENDICECTOMY: HOW I DOIT? DR. MOHAMAD AL-GAILANI FRCS الكيالني محمد الدكتور CONSULTANT SURGEON MEDICAL EDUCATION & TRAINING HEAD RIYADH, KSA FEBRUARY 2018
- 2. OUTLINE Introduction Advantages Preferred approach Remove a“normal” appendix? Do interval appendicectomy? How I do it Conclusion DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 2
- 3. ACUTE APPENDICITIS One ofthe most frequent indications for emergency abdominal surgical procedure worldwide Occurs most frequently in the second and third decades of life The incidence is approximately 233/100,000 population and is highest in the 10 to 19-year-old age group Male to Female ratio 1.4:1 Lifetime incidence 8.6 % DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 3
- 4. APPENDICITIS TREATMENT The treatment issurgery! Emergency appendicectomy Same day of presentation Open appendicectomy (traditional) Laparoscopic appendicectomy (new) But which approach is superior?? DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 4
- 5. ADVANTAGESOF LAPAROSCOPIC APPENDICECTOMY A lower rateof wound infections Less pain on postoperative day 1 Shorter duration of hospital stay Shorter duration for return of bowel function Fewer short and long term adhesive bowel obstructions DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 5
- 6. DISADVANTAGES OFLAPAROSCOPIC APPROACH: Learning curve Higher costof Equipment DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 6
- 7. THEPREFERRED APPROACH 1. Uncertain diagnosis 2.Elderly patients 3. Women of childbearing age 4. Obese patients DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 7
- 8. Uncertain Diagnosis Diagnostic Laparoscopy Through a 2cm umbilical port we can… Inspect the whole peritoneal cavity Establish the diagnosis If non surgical, end procedure Proceed with laparoscopic appendicectomy Plan any laparotomy incision accordingly DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 8
- 9. ElderlyPatients Shorter length ofhospital stay Higher rate of discharge to home rather than a step-down facility Fewer complications Lower mortality rate DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 9
- 10. WOMENOF CHILDBEARING AGE Some evidencethat open appendicectomy wound may lead to potential adhesions and affect future fertility Able to inspect pelvic organs Mittelschmerz syndrome Society Of American Gastrointestinal And Endoscopic Surgeons (SAGES) DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 10
- 11. THEOBESE Negate theneed for relatively large open appendicectomy incisions Less chance of SSI Less chance of wound haematoma Less chance of Incisional hernia Longer trocars and instruments may be needed DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 11
- 12. THESURGEONS OPERATIVE VIEW DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 12 OPEN APPROACH LAPAROSCOPIC APPROACH
- 13. SHOULDIREMOVE ANORMALLY LOOKINGAPPENDIX? DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 13 TO REMOVE OR NOT TO REMOVE?
- 14. SHOULDIREMOVE ANORMALLY LOOKING APPENDIX? YES Macroscopically normalappendixes may have abnormal histopathology Several studies have shown a 19% - 40% rate of pathologically abnormal appendix in the setting of no visual abnormalities The risk of leaving a potentially abnormal appendix must be weighed against the risk of appendectomy in each individual scenario Cases of postoperative symptoms requiring reoperation for appendectomy have been described in patients whose normal appendix was left in place at the time of the original procedure DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 14
- 15. INTERVAL APPENDECTOMY ISITNECESSARY? DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 15 APPENDICULAR MASS
- 16. INTERVAL APPENDECTOMY ISITNECESSARY? Interval Appendicectomyhas been recommended following conservative treatment of acute appendicitis. Usually after 6-8 weeks The need for interval appendectomy is however debated, with some studies suggesting that interval appendectomy is unnecessary? DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 16
- 17. INTERVAL APPENDECTOMY ISITNECESSARY? YES Retrospective reviewof 1012 patients treated non-operatively for acute appendicitis: 864 patients did not undergo an interval appendectomy Of those (4.5 percent) required an appendectomy at a median follow-up of four years After successful nonsurgical treatment a malignant disease was detected in 1.2 % Recurrent appendicitis developed in 7.4 % Interval appendectomy for most adult patients is recommended Appendiceal neoplasms occur in 1 % of all appendectomies but in 10 % of interval appendectomies. Colonoscopy should be considered prior to appendectomy in patients over 50 DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 17
- 18. COMPLICATIONS OF APPENDICECTOMY Average morbiditynear 10% Surgical Site Infection (SSI) Adynamic ileus Pelvic or abdominal abscess Incisional hernia (open) Caecal fistulas (rare) DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 18
- 19. CONCLUSION: The 10 REASONS WHY LAPAROSCOPIC APPROACH? 1. Diagnosticability of laparoscopy 2. Decreased postoperative pain 3. Earlier discharge 4. Shorter time to return to normal 5. Lower incidence of SSI 6. Lower incidence of Incisional hernia 7. Lower incidence of Dehiscence 8. Lower incidence of Adhesions 9. Better aesthetic result 10.Training opportunity for laparoscopic skills DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 19
- 20. HOW I DOIT LAPAROSCOPIC APPENDICECTOMY DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 20
- 21. PREOPERATIVE CONSENT CONSENT FORLAPAROSCOPIC APPENDICECTOMY DOCUMENT POSSIBLE CONVERSION TO OPEN MENTION POTENTIAL COMPLICATIONS DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 21
- 22. PROPHYLACTIC ANTIBIOTIC& ANALGESIC CEFUROXIME 1.5 GIV + METRONIDAZOLE 0.5 G IV XEFO (LORNOXICAM)16 MG IV No need for Foley’s catheter DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 22
- 23. THEATRE POSITION DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 23 CAMERA PERSON SURGEON HEAD DOWN RIGHT SIDE UP MONITOR
- 24. PORTSITES DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 24 10 mm 10 mm Camera 5 mm
- 25. PORTSITE LOCAL ANAESTHETIC WOUND INFILTRATION DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 25 0.25% BUPIVACAINE
- 26. OPENPORT INSERTION DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 26 NO VERESS NEEDLE! BLUNT, NEVER SHARP TIPPED!
- 27. GENERAL LAPAROSCOPY DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 27
- 28. IDENTIFYING THEAPPENDIX DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 28 RETROCAECAL PELVIC FOLLOW THE ILEUM OR TAENIA
- 29. FREEANDLIFT THEAPPENDIX DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 29
- 30. DEALINGWITH THE MESOAPPENDIX DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 30 HOOK OR GRASPER DIATHERMY
- 31. ENDOLOOP APPLICATION X2 DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 31
- 32. RETRIEVAL BAG? DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 32 NOT ALWAYS NECESSARY!
- 33. SKINCLOSURE SUBCUTICULAR MONOCRIL DR. AL-GAILANI LAPAROSCOPICAPPENDICECTOMY: HOW I DO IT? 33 AESTHETIC SCARS
- 34. VIDEO 1 SUPPURATIVE APPENDICITIS DR. AL-GAILANILAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 34
- 35. VIDEO 2 JET-DISSECTION DR. AL-GAILANILAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 35 DR. AL- GAILANI JET DISSECTION
- 36. VIDEO 3 RETRIEVALOF THEAPPENDIX DR. AL-GAILANILAPAROSCOPIC APPENDICECTOMY: HOW I DO IT? 36 DR. AL- GAILANI
- 37.