How to do a laparoscopic appendectomy


There are a couple of basic principles that apply to all types of surgery, on all parts of the body: the first principal is that you can't operate on it if you can't see it. The second principle is that surgery is a process of altering anatomy to change an anatomic problem - you want to change anatomy enough to fix a problem, but not so much that you create other problems.

The development of laparoscopic surgery takes surgery to unparalled access and exposure. When I was a medical student, back in the early 1980's, I realized very quickly that the student was never going to see anything in the abdomen, the student's job where I was a student was to pull hard on retractors and to try not to bother the surgeon too much. So I perfected a process that I called "water-skiing" where I would take a retractor in one hand, a retractor in the other, and then I would lean back, putting my weight into my retraction, and, in addition to providing exposure, it pulled my body back from the table, making more room for the surgeon and the residents. Finally, I found that, if I bent my knees some, I could fall asleep, still providing perfect exposure. During the course of my thoroughly worthless surgery rotation, I never saw the inside of an abdomen, but the attendings gave me very high marks, as I fulfilled my duties of providing exposure without bothering the surgeon. (I will reassure you all that surgery is learned during residency, not in medical school)

All of that changed with laparoscopy. With the scope the entire team can look at the operation, see the anatomy. Everyone can pitch in. The visualization is tremendous, the operation is generally safer because the exposure is better, and everyone can see and learn. Laparoscopic surgery is done by placing tubes, or trocars into the abdomen and then filling the belly with carbon dioxide gas. A lighted telescope with a tv camera is then placed through one of the tracers and instruments are placed through the other two. The diagram above shows one typical arrangement of trocar placements, with the location of the cecum (colon) and appendix marked in the right lower part of the abdomen.

Then the operation proceeds. This is one of my own appendectomies.

Step One - Expose the appendix. Frequently there is a lot of inflammation around the appendix. There will frequently be some inflamed fat around the appendix as well. In this clip you can sed the tip of the inflamed appendix grasped with the instrument on the left and the base on the right. I will begin to develop a plane with the tissues. This step really involves setting up and arranging the appendix so that it can be seen and dissected well and safely.

Step Two - In this step the appendix has been exposed as as the mesoappendix, the yellow fat at the bottom of the appendix which contains the blood vessels of the appendix. The appendix is grasped witht he right hand, and a window is made at the base of the appendix with the cecum with the left hand (I should note that I am very left handed).

Step Three - an automatic stapling device is used to divide the mesoappendix and the blood vessels. This very cool surgical device replaces ties or clips and with the squeeze of a handle fires two rows of staples that seal the blood vessels on either side, and separates the two staple lines with a sliding knife. I really, really wish that I had invented this instrument.

Step Four - A second stapler is used to seal and divide the appendix right where it emerges from the cecum. A reasonable question at this point would be "why use two staplers? " The answer is that the staples needed to seal blood vessels and the staples needed to seal bowel are different. They have different configurations and sizes, so we have to use two different sets of staples.

Step Five - The cut end of the appendix, because of its connection with the colon, has a lot of bacteria on the edge. We found early on that if we just drag the appendix out through the trocar or the hole in the skin, that there was a high chance of developing an infection. We found that if we put the appendix into a surgical plastic bag, and protected the wound as we pulled the appendix out, that the risk of wound infection was very low. So in this step the appendix is put into a surgical bag, another instrument that I wish that I had invented.

Step Six - In this step, the bag is pulled out of the abdomen,, and the trocars are removed. When this is completed, the incisions are closed with suture and the patients is woken up and taken to the recovery room.

With the operation completed, the patient has their diet advanced, and is taken either to the floor to recover from the anesthesia, or sent home. This patient went home two hours after this twelve minute operation, and did very well.