and Simon A. Clarke2
(1)
Department of General Paediatric Surgery, Chelsea Children’s Hospital, Chelsea and Westminster Hospital, London, UK
(2)
Department of Pediatric Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
Abstract
Appendicectomy is the most common laparoscopic procedure performed in children. The laparoscopic approach allows for improved cosmesis, reduced wound infection, and an earlier recovery to activities. Laparoscopy also proves a useful diagnostic tool in investigating other paediatric abdominal pathology that may mimic appendicitis.
Keywords
AppendixLaparoscopyEndoloopSILS22.1 General Information
Appendicectomy is the most common laparoscopic procedure performed in children. The laparoscopic approach allows for improved cosmesis, reduced wound infection, and an earlier recovery to activities. Laparoscopy also proves a useful diagnostic tool in investigating other paediatric abdominal pathology that may mimic appendicitis.
Laparoscopic appendicectomy can be single-port or multiport. Operative technique varies from simple electrosurgical dissection with endoscopic loop ligation to linear stapling and the use of tissue sealing devices.
22.2 Positioning and Preparation
Careful preoperative setup is essential to ensure that this common operation is performed efficiently, ergonomically, and economically. The patient should be supine on the table under general anaesthesia and should have appropriate intravenous antibiotics. A nasogastric tube is inserted to decompress the stomach, and a urinary catheter to empty the bladder, enabling an improved view of the pelvis. Patients with a diagnosis of mild appendicitis may be asked to pass urine before the procedure, reducing the need for urethral instrumentation. The monitor should be in line with the surgeon and the right lower abdominal quadrant (Fig. 22.1).
Fig. 22.1
(a, b) Position of patient and monitor
Checking all instruments, ports, and sutures with the nursing team is essential before scrubbing. The patient is draped to allow four-quadrant access to the abdomen. Three ports are required: umbilical (optical) (variable 5–12 mm) and two instrument ports (5 mm). The larger variable optical port is used at the umbilicus to allow the appendix to be removed without wound contact, or if necessary to allow for the insertion of Endo Catch™ retrieval bags (Covidien; Mansfield, MA, USA).
The first instrument port should be inserted in the left iliac fossa (LIF) at the level of the appendix (Fig. 22.2). The second instrument port should be inserted in the suprapubic area to allow good triangulation when operating. The camera can be moved between the LIF port and the umbilicus, depending upon the surgeon’s preference.
Fig. 22.2
Port positions: Umbilical camera/instrument port (green) and instrument ports (blue)
22.3 Working Instruments
Other instruments to include in the set (Fig. 22.3):
1 × 5-mm 30° camera
Equipment for suction and irrigation (up to 3 l of normal saline)
Culture swab (can be placed down a port)
5-mm Maryland/Kelly’s grasper
Soft bowel clamp
Hook diathermy
Endoloop® ligatures (Ethicon Endo-Surgery; Cincinnati, OH, USA), or surgeon’s preferred device for ligating and resecting the appendix
Fig. 22.3
(a) Instruments ready for procedure. (b) Laparoscopic tools: soft bowel clamps, Maryland grasper, ratcheted grasper. (c) Endoloop® ligatures (Ethicon Endo-Surgery; Cincinnati, OH, USA)
22.4 Surgical Technique
- 1.
Port insertion. An incision can be made in the superior or inferior umbilical crease and the peritoneum entered by carefully incising each layer between forceps (Fig. 22.4). A pursestring suture is placed in the umbilical fascia. The 5–12 mm optical port is then inserted approximately 2–3 cm under direct vision. The pursestring suture is tightened and tied once before securing to the port. This prevents leak and port dislodgement.
Fig. 22.4
(a–d), Inserting the umbilical port, using a supraumbilical incision. Careful dissection continues down to the peritoneum
The anaesthetist should be informed before insufflation and the creation of the pneumoperitoneum. Pressures vary according to the size of the patient but usually range between 8 and 12 mmHg, with a flow rate of 1–3 l per min. Place the patient head down (Trendelenburg position) and right side up. Inspect the abdomen for pathology, position of the appendix, and the presence of pus, and decide upon the placement of the instrument ports.
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