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ppendectomyamir Katkhouda, MD, FACS,* and Andreas M. Kaiser, MD, FACS†

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lmost exactly 300 years after the first description of ap-pendicitis by Heister (1683), Semm performed the first

aparoscopic incidental appendectomy by transsecting theppendix between two endoloops (1982).1,2 Laparoscopicurgery has since rapidly evolved and established itself inurgical practice and has become fairly routine. Althoughhere is still ongoing debate about indications and technicalefinements in various surgical fields, there has been ampleocumentation in the literature that laparoscopic appendec-omy for acute appendicitis is at least equally safe as conven-ional open appendectomy. Despite the initial lack of a sta-istical advantage of the laparoscopic approach compared topen appendectomy, the most recent data seem to corrobo-ate a solid benefit trend, with faster recovery, fewer compli-ations, and improved cosmesis after laparoscopic appendec-omy.3,4 This benefit has been shown through all age groups,ut elderly patients in particular experience an advantageith the minimally invasive approach.5

ndicationshe laparoscopic approach does not result in a change of

ndications. Any patient who, based on the overall assess-ent, requires and qualifies for a surgical exploration for

uspected acute appendicitis is a likely candidate for the lapa-oscopic procedure. In addition, there are a number of pa-ients in whom, despite multiple tests, diagnostic uncertaintyersists; in these patients, a diagnostic laparoscopy with pos-ible appendectomy may be indicated to clarify and treat theausative pathology. Another group of patients for whom aaparoscopic approach is recommended are those requiringn interval appendectomy and whose initial acute episodeas treated nonoperatively, for example, by means of percu-

aneous drainage of an appendiceal abscess combined withntibiotics.

Department of Surgery, Keck School of Medicine, University of SouthernCalifornia, Los Angeles, CA.

Department of Colorectal Surgery, Keck School of Medicine, University ofSouthern California, Los Angeles, CA.

ddress reprint requests to Namir Katkhouda, MD, Department of Surgery,Keck School of Medicine, University of Southern California, 1510 SanPablo Street, Suite 514, Los Angeles, CA 90033. E-mail: nkatkhouda@

rsurgery.usc.edu

1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2004.12.004

urgical Techniqueperating Room Setup and Port Placementfter induction of general anesthesia, the patient is placed in

he supine position with at least the left arm (or both arms)ucked to give both the surgeon and the assistant comfortableorking space. A Foley catheter and lower-extremity sequen-

ial pneumatic compression devices are placed routinely. In-ertion of a gastric tube for decompression depends on theatient’s presentation. The abdomen is prepared and draped

n a sterile fashion, exposing the entire abdomen from thepigastrium to the pubis and including both groins. Standardaparoscopic equipment is usually sufficient, as long as itncludes some atraumatic graspers, Babcock forceps, scis-ors, suction/irrigation, and a harvest bag.

Although the surgeon’s assistant initially stands on thepposite side until the ports have been inserted and theneumoperitoneum has been established, eventually bothhe surgeon and first assistant will be on the left side of theatient facing the monitor placed on the right side (Fig. 1).A pneumoperitoneum is created in a standard fashion,

ith either the Veress needle technique, the open Hassonechnique, or by insertion of a nontraumatic bladeless Opti-iew port (Ethicon Endosurgery, Cincinnati, OH).

“Port planning” means the steps and considerations takenefore inserting the actual ports to optimize the usability ofhe placed ports, ie, maximizing safety while minimizingorbidity and negative aesthetic impact. Considerations not

nly include the patient’s habitus and anatomic landmarkseg, epigastric vessels), but also aesthetic expectations andhe presence and location of scars from previous abdominalperations. As a result of the planning, the surgeon shouldave a clear concept of where the ports will be inserted, theize of ports needed, and the intended use of a particular port,or example, insertion of a stapling device or specimen re-rieval bag will typically require a larger port than insertion ofrasping instruments and endoloops alone. Care must beaken to avoid a “knitting needle” effect between instrumentsnd the laparoscope, that is, all ports should be placed inuch a manner that they have free movement and do notnterfere with each other. We prefer insertion of the ports inymmetric triangulation. The laparoscope is at the umbilicus.wo further ports are inserted symmetrically in the left andight lower quadrant. In a male patient, these are at McBur-ey’s point and at the corresponding point on the left sideFig. 2A). In a female patient, it is advisable for cosmetic

easons to move the port positions down toward the pubic

F

Appendectomy 9

igure 1 Patient positioning.

Figure 2 Trocar placement in male (A) and female (B) patients.

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10 N. Katkhouda and A.M. Kaiser

air (Fig. 2B). Other settings (eg, left lower quadrant plusuprapubic midline port or a port right under the right costalargin) are not recommended because they have functionalisadvantages or may be cosmetically inappropriate.

xposure of the Appendixfter insertion of the ports, a quick diagnostic laparoscopy iserformed to either confirm the diagnosis or assess otherathology (eg, female organs, diverticulitis, inguinal hernias,

iver/gallbladder disease, carcinomatosis). The sur-

igure 4 Mobilization of the cecumor retrocecal location of the appen-ix.

eon’s assistant and camera holder then moves to the pa-ient’s left side, cephalad to the surgeon. The patient isrought into the Trendelenburg position with the right sidelevated to facilitate the exposure of the right lower quadrant.

The surgeon’s left hand operates a Babcock grasper (Ethi-on Endosurgery, Cincinnati, OH) to retract the cecum andubsequently to expose the appendix (if the appendix is in itssual paracecal position). Particularly if the appendix is sig-ificantly inflamed and friable, it is advisable not to grasp

Figure 3 Exposure of the appendixand creation of a window in the me-soappendix.

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Appendectomy 11

he appendix itself but rather to place the Babcock around itr at the level of the mesoappendix (Fig. 3). Occasionally, anndoloop can be placed around the appendix and mesoap-endix to create a handle to hold the appendix. The surgeon’sight hand operates a Kelly grasper or electrical scissors toreate a window in the mesoappendix (Fig. 3). If the appen-ix is not clearly identifiable because it is retrocecal, theecum needs to be mobilized and retracted medially (Fig. 4).

ranssection Techniquesnce the appendix has been completely skeletonized, it is

mputated at the base. In general, there is no need for inver-ion of the appendiceal stump, but it is of crucial importanceo divide the appendix in healthy appearing tissue, if neces-ary at the level of the cecum, to avoid a breakdown of theigation or stapler line.

There are two possibilities to divide the appendix and theesoappendix—the endoloop technique and the stapling

echnique. The former is cheaper and requires only a 5-mmort on the left side; however, it requires more skill and may

nitially take more time. The stapling technique needs lesskill and initially saves time, but it is more expensive and itill require a 12-mm port.

ndoloop Techniquen this technique, the mesoappendix is first divided by meansf cautery, and the appendix is subsequently divided be-ween two endoloops. The appendix should be clearly visiblerom tip to base. Special bipolar cautery forceps are used toauterize and “crush” the mesoappendix. Care has to beaken not to touch and burn adjacent loops of bowel with theot forceps. Portions of the mesoappendix are cauterized andubsequently cut with the scissors until the base of the ap-endix is identified and completely freed. Two endoloops are

igure 5 Endoloop technique: tran-ection of the appendix between twooops.

nserted and tied at the base, leaving sufficient space to trans- p

ect the appendix. After transsection, the appendiceal stumpucosa is cauterized carefully (Fig. 5).

tapling Techniquen this technique, a 30-mm white vascular endostapler (Ethi-on Endosurgery) is used to divide the mesoappendix, and a0-mm blue endostapler is employed for the appendix aslose as possible to the cecum, leaving only a very shorttump. A window is created at the base of the mesoappendixn the avascular plane between the base of the appendix andhe appendiceal artery. The first stapler with appropriate car-ridge (white for vessel, blue for bowel) is inserted and firedFig. 6), followed by a second stapler for completion of theransection (Fig. 7). Care should be taken to avoid a “junkard” by losing unused staples into the surgical field. Afterring, the staplers should therefore be opened very carefully,

ust enough to release the tissue, but then they immediatelyhould be closed again before dropping the unused staples.

pecimen Retrieval

are is needed to avoid contamination of the abdomen andort site wounds; the appendix is therefore placed in a re-rieval bag before removing it from the abdomen. Alterna-ively, if the appendix is not too large, it can be pulled into theort and withdrawn with the port. Rupture of the retrievalag within the abdominal wall because of an inadequate fas-ial gap should be avoided under any circumstances. If de-ivery of the endobag is difficult, it is advisable to widen theascial incision.

rrigation and Drainagehe purpose of irrigation is to remove all debris, purulentuid collections, and blood from the surgical area. In early

hlegmonous appendicitis without any pus, there is no ad-

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12 N. Katkhouda and A.M. Kaiser

antage to irrigation but rather risks spreading contaminateduid throughout the abdomen. Otherwise, with the appen-ix removed, a thorough lavage of the area is performed. Inarticular, the pelvis has to be well exposed and any residualontaminated fluid should be aspirated and irrigated by re-racting the sigmoid colon and exposing the pouch of Doug-as.

In the overwhelming majority of cases, a drain is not nec-

igure 7 Stapler technique: transec-ion of the appendix.

ssary. However, if residual contaminated fluid is to be left inhe peritoneal cavity or if the appendiceal/cecal stump is ofuboptimal quality, placement of a small drain may be pru-ent. It should be brought in through a separate 4- to 5-mm

ncision in the right lower quadrant, that is, not through onef the trocar sites, and laid along the cecum into the pelvis torain those dependent areas. The drain can be removed afterfew days once the quality of the fluid is serosanguinous.

Figure 6 Stapler technique: transec-tion of the mesoappendix.

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Appendectomy 13

echnical Variationsetrograde Appendectomyhen the tip of the appendix is not clearly visible, a retro-

rade appendectomy can be performed with the stapler (Fig.). The visible base of the appendix is transected after cre-tion of an appropriate window, followed by the mesoappen-ix, and finally the whole appendix is dissected from the base

igure 8 Retrograde dissection withransection of the appendiceal baserst, followed by its mobilization to-ards the tip.

o the tip. This is performed as in open surgery and does notequire specific skills.

ifficult Appendicitishen the surgeon encounters a gangrenous or perforated

ppendicitis or an appendiceal phlegmon, it can be difficultnitially to recognize the appendix. In these circumstances, it

Figure 9 Fingeroscopy.

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14 N. Katkhouda and A.M. Kaiser

ay be necessary to mobilize the cecum first. This mobiliza-ion should be as conservative as possible to avoid openingnd contaminating retroperitoneal spaces. The cecum canhen be flipped over and the appendix visualized. If this istill not possible, “fingeroscopy” or conversion to an openrocedure has to be considered (Fig. 9). The former tech-ique involves removal of the port from the right lower quad-ant and insertion of the index finger to restore the tactileensation and to perform blunt, atraumatic mobilization sim-lar to the open procedure but under laparoscopic guidance.6

his will speed up the procedure and should be considered ashe last step in situations where conversion seems inevitable.ingeroscopy can only be performed if the right lower quad-ant incision is close enough to the surgical area (see sectionn port placement).If still no satisfactory progress is made, the only way for-

ard is to convert to an open operation. The projection of theecum is marked on the abdominal wall via transilluminationf the laparoscope, and an incision is then made appropriateo the operation to be performed.

aparoscopically Assisted Appendectomyn some cases, especially in children where the appendix isxtremely long and the working space is small, the “assisted”echnique is an easy way of performing an appendectomy.he mesoappendix is first controlled by means of bipolarlectrocautery. The right lower quadrant port is then re-oved with the appendix inside. The whole appendix is

xteriorized and ligated outside the abdomen before the ce-um is pushed back inside the abdomen.

pecial Problemsiagnostic Uncertainty and Normal Appendixncountering a normal appendix occurs in patients in whomither preoperative studies and assessment were inconclusiver proved to be falsely positive. A careful assessment has to beerformed of the whole peritoneal cavity, including runninghe small bowel. If a different intraabdominal pathology isound, that disease process should be appropriately treatednd the appendix should be left in place. If no other pathol-gy is found, we recommend removing the appendix andaving it assessed by the pathologist.

regnancycute appendicitis with any type of appendectomy carries a

isk for the pregnant patient and for her unborn fetus. Al-

hough pregnancy in and of itself is not necessarily a contra-ndication for the laparoscopic approach,7 the following re-uirements have to be respected. The surgeon ought to be anxperienced laparoscopist, the operation should under noircumstances be prolonged, and the trocars should alwayse placed via an open access technique.

ontrol of Intraoperative Bleedinglthough bleeding complications are relatively rare, theyost commonly arise from the appendiceal artery. Bleeding

elated to trocar placement (eg, epigastric or iliac vessels)hould be avoided by careful and visually controlled inser-ion of the ports. Prompt reaction in a controlled fashion aimst localizing the bleeder and stopping it without delay. Dif-use and uncontrolled cautery use to arrest bleeding shoulde avoided. It may be helpful to bring in a 2 � 2 cm ra-iopaque-labeled gauze to temporarily compress the area.ith a suction tip in one hand and a fine grasping instrument

n the other, the surgeon must identify and grasp the vesseln which a clip or figure-eight stitch may be placed. If theleeding cannot be stopped in a timely fashion, the proce-ure has to be converted to an open operation.

ostoperative Carehe postsurgical management depends on both the intraop-rative findings and the patient’s symptoms. Duration of an-ibiotics is determined by the extent of the inflammation andhe presence of perforation, rather than by the surgical ap-roach. Early ambulation and resumption of an oral diet arencouraged; the latter should be advanced as tolerated.

eferences. Semm K: Endoscopic appendectomy. Endoscopy 15:59-64, 1983. Kaiser AM, Corman ML: History of laparoscopy. Surg Oncol Clin N Am

10:483-492, 2001. Guller U, Hervey S, Purves H, et al: Laparoscopic versus open appen-

dectomy: outcomes comparison based on a large administrative data-base. Ann Surg 239:43-52, 2004

. McKinlay R, Mastrangelo MJ Jr: Current status of laparoscopic appen-dectomy. Curr Surg 60:506-512, 2003

. Guller U, Jain N, Peterson ED, et al: Laparoscopic appendectomy in theelderly. Surgery 135:479-488, 2004

. Katkhouda N, Mason RJ, Mavor E, et al: Laparoscopic finger-assistedtechnique (fingeroscopy) for treatment of complicated appendicitis.J Am Coll Surg 189:131-133, 1999

. de Perrot M, Jenny A, Morales M, et al: Laparoscopic appendectomy

during pregnancy. Surg Lap Endosc Perc Techn 10:368-371, 2000