Why should I choose Laparoscopic Appendicectomy? Should I remove a normal looking Appendix? Should I always do an Interval Appendicectomy? Tips and Tricks! How I Do It? Dr. Mohamad Al-Gailani FRCS Consultant Surgeon Al Hammadi Hospital, Nuzha Riyadh Kingdom of Saudi Arabia

1. LAPAROSCOPIC
APPENDICECTOMY:
HOW I DO IT?
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?
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3. ACUTE
APPENDICITIS
 One of the 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?
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4. APPENDICITIS
TREATMENT
The treatment is surgery!
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?
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5. ADVANTAGESOF
LAPAROSCOPIC
APPENDICECTOMY
A lower rate of 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?
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6. DISADVANTAGES
OFLAPAROSCOPIC
APPROACH:
Learning curve
Higher cost of Equipment
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7. THEPREFERRED
APPROACH
1. Uncertain diagnosis
2. Elderly patients
3. Women of childbearing age
4. Obese patients
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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
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9. ElderlyPatients
Shorter length of hospital stay
Higher rate of discharge to home
rather than a step-down facility
Fewer complications
Lower mortality rate
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10. WOMENOF
CHILDBEARING
AGE
 Some evidence that 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)
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11. THEOBESE
 Negate the need 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
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12. THESURGEONS
OPERATIVE
VIEW
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OPEN APPROACH
LAPAROSCOPIC APPROACH

13. SHOULDIREMOVE
ANORMALLY
LOOKINGAPPENDIX?
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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TO REMOVE OR NOT TO
REMOVE?

14. SHOULDIREMOVE
ANORMALLY
LOOKING
APPENDIX?
YES
 Macroscopically normal appendixes 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
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15. INTERVAL
APPENDECTOMY
ISITNECESSARY?
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APPENDICULAR MASS

16. INTERVAL
APPENDECTOMY
ISITNECESSARY?
 Interval Appendicectomy has 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?
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17. INTERVAL
APPENDECTOMY
ISITNECESSARY?
YES
 Retrospective review of 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
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18. COMPLICATIONS
OF
APPENDICECTOMY
 Average morbidity near 10%
 Surgical Site Infection (SSI)
 Adynamic ileus
 Pelvic or abdominal abscess
 Incisional hernia (open)
 Caecal fistulas (rare)
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19. CONCLUSION:
The 10
REASONS
WHY
LAPAROSCOPIC
APPROACH?
1. Diagnostic ability 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
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20. HOW I DO IT
LAPAROSCOPIC APPENDICECTOMY
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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21. PREOPERATIVE
CONSENT
 CONSENT FOR LAPAROSCOPIC
APPENDICECTOMY
 DOCUMENT POSSIBLE CONVERSION
TO OPEN
 MENTION POTENTIAL
COMPLICATIONS
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22. PROPHYLACTIC
ANTIBIOTIC&
ANALGESIC
CEFUROXIME 1.5 G IV +
METRONIDAZOLE 0.5 G IV
XEFO (LORNOXICAM)16 MG
IV
No need for Foley’s catheter
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23. THEATRE
POSITION
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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CAMERA
PERSON
SURGEON
HEAD DOWN
RIGHT SIDE
UP
MONITOR

24. PORTSITES
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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10 mm
10 mm Camera
5 mm

25. PORTSITE
LOCAL
ANAESTHETIC
WOUND
INFILTRATION
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0.25%
BUPIVACAINE

26. OPENPORT
INSERTION
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NO VERESS NEEDLE!
BLUNT, NEVER SHARP
TIPPED!

27. GENERAL
LAPAROSCOPY
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28. IDENTIFYING
THEAPPENDIX
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RETROCAECAL
PELVIC
FOLLOW THE
ILEUM OR
TAENIA

29. FREEANDLIFT
THEAPPENDIX
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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30. DEALINGWITH
THE
MESOAPPENDIX
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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HOOK OR GRASPER
DIATHERMY

31. ENDOLOOP
APPLICATION
X2
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32. RETRIEVAL
BAG?
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NOT ALWAYS NECESSARY!

33. SKINCLOSURE
SUBCUTICULAR
MONOCRIL
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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AESTHETIC SCARS

34. VIDEO 1
SUPPURATIVE
APPENDICITIS
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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35. VIDEO 2
JET-DISSECTION
DR. AL-GAILANI LAPAROSCOPIC APPENDICECTOMY: HOW I DO IT?
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DR. AL-
GAILANI
JET
DISSECTION

36. VIDEO 3
RETRIEVALOF
THEAPPENDIX
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DR. AL-
GAILANI

37. 37
‫الرياض‬
‫السعودية‬ ‫العربية‬ ‫المملكة‬