Laparoscopic Cecal Wedge Resection Appendectomy

CHAPTER 1

My name is Dr. Fisichella. My name is Dr. Levin. So what are we doing today? Today we are doing a laparoscopic appendectomy. This is a 66-year-old gentleman with a history of polyps, who undergoes colonoscopic surveillance every 3 years. In a recent colonoscopic surveillance, he was found to have an incidental polyp at the appendiceal orifice. The biopsy showed adenoma. Therefore, we are doing a laparoscopic appendectomy and we will take a portion, a small portion of the cecum with our procedure. Our approach is to do an umbilical incision. A marking pen? Yes. We will also be placing a subcostal, doing a subcostal incision and a left lower quadrant... Suprapubic. Suprapubic incision for the first one, and most likely another port here. And the distance between the ports is usually 5 fingerbreadths from each other. Otherwise, the instruments will clash together. In order to gain access to the abdomen we may put a Veress trocar here or in the subcostal margin. That's the reason why we prepped the entire abdomen. The patient only had an open - open cholecystectomy before, so we don't expect him to have many adhesions. Can we have two Adsons? Any questions or concerns? No, the only prob- concern was the high blood pressure, but the anesthesiologist will take care of those.

CHAPTER 2

Just make an incision, yes. Right on the crease. The crease on top. Yeah, yeah. Incision. Nice. Perfect. Perfect. Towards you. Okay. Okay. Let me see... Can I have a Kocher? Let go. S-retractors. One second. I need to see the fascia, okay? Let go. Sorry. You don't have that Kocher? Kocher. Let me see. Perfect. Can you hold this? Okay. As you can see, this is the fascia. Okay. Can I have the Veress needle, please?

Can I have the drop test? Okay, so now the Veress needle is placed inside the abdomen. The drop of normal saline goes all the way down. Now we're going to connect it to the gas. Okay. Can I get gas on high flow? What's the opening pressure? Three. Perfect. So there is a good opening pressure. There is-it's on high flow. And no obstruction whatsoever. So the reason why I'm grasping the fascia of the abdomen with a Kocher is so it gives us at least one inch of distance between the abdominal contents and the abdominal wall. That will avoid puncturing either the abdomen or the major vessels. Often the vena cava split at the level of the umbilicus, so one of the complications of putting the first trocar in, or complication in placing the Veress needle right in the umbilicus in the midline, is to hit the major vessels. So this is a trick that we use to avoid that happening. Okay, the pressure is set to 15. So that's the maximum that we had. So I'm going to release the clamp. There is a good pneumoperitoneum here. We're going to get- no - yes, this, the camera. Perfect.

So this one here is an Optiview trocar that has a clear tip that will allow us to see exactly the layers of the abdominal wall under direct vision. So there are different kinds of trocars. This one here is splitting. So if I touch, I don't cut myself. The way it works is that by twisting left and right, the muscles are spread or a cut is made into fascial structures. That's the fascia of the abdominal wall, right there. See we are spreading and spreading. That's preperitoneal fat. That's some of the muscles. Okay and this one here, we are inside the abdomen. And as you can see, when there is black, black means that there is always air, so we are safe right there. You can see the edge of the peritoneum. We're going to go back again in. I'm going to take it out. And that's the inside of the abdominal cavity. Perfect. As you can see there is no intra-abdominal injuries and then we're going to put the - the next trocar right here.

This one here is the bladder. Can I have a local, please? So, this one here is that I want to see exactly... Can you hold this? Okay. Can I have a knife, please? Let me do this.

Can I have a trocar? Okay, the reason why I want to put it myself is just I want to make sure that I don't go into the bladder, because this one here, this structure here is the bladder. Okay, so we're far away but in the middle, in the midline. Okay. Okay, so the appendix is going to be there. Can you put the patient right-side up, please? So we're gonna put the - we put the patient in right-side up, so the gravity can help us, mobilizing the small bowel and give us exposure. Like this. A good way to understand the anatomy here is- these are - that's the right colon. These are the teniae. If you follow the teniae down, you will see the appendix and... Let me see. So this loop here is the last loop of the small bowel. The terminal ileum that attaches there - onto the colon, right there.

Okay, let's see if we can put the other trocar. Can I have the local again? Perfect. Knife.

Thank you. Okay, let's go back. Yes. And the other good bowel grasper.

CHAPTER 3

That's the terminal ileum over here. This is the teniae. Follow down the teniae, there should be the appendix. Can you put the patient - a little bit more right-side - up? I'm gonna move the bed. Yeah. Stop. Stop, stop. Okay, and foot down. Head up. Okay, thank you. Stop. Can you put the patient head down, head up, more? More head up? Head up. I'm gonna move the bed. Yeah. Okay, stop. Okay, can you put it in, head down, again? Like it was in a flat position. Flat. Gonna move the bed. Yes, thank you. Thank you. Oh man.

CHAPTER 4

Okay, let's try it with a Bovie. Closer. Okay. Okay. Let me get the Hunter. Okay. We may need to have that thing open now. The suction-irrigator open, yeah. Yeah, no, let open. Open, yeah. On the field, yes. One second. One second. Yes. Do you want one or three liters of saline? Three. So this is the appendix, it looks like, and I'm trying to go behind to see - so it's the only place. It is stuck somewhere near the small bowel. Maybe here, the previous appendicitis. That I cannot tell. Thank you. Hold this, please? Back up the camera. Okay. So this one here, looks like an artery that comes from behind. Yep. Oh, let me tell you. So, we follow the teniae and the teniae took us to the appendix. That's the base of the appendix. This one here is the posterior portion of the mesentery. This one here is the mesentery. Okay? And the artery is somewhere there, it's a little bit, you know, oozy, but that's fine.

So can we have the LigaSure in the - in the room? The LigaSure is in the room. Would you like it opened? Yeah, open. And the reason why - the LigaSure is going to give us the hemostasis to take out the artery. Usually, what we do is to put - make a hole here and take this portion with - you see that's the artery right there - with a - with a stapler. But in this case the LigaSure may be much better. Perfect. This one here is the base of the appendix. Okay, this one here is the colon that is attached to the abdominal wall right here. That's the right colic gutter. That's our appendix, here. Okay.

Okay, so that's the base of the appendix. Now remember we are to take a cuff. Most likely we are to go across from here to here without damaging the ileocecal valve. Okay, so the ileocecal valve is right there. Perfect. That's the base of the appendix. And that's the lumen, right there, okay. So that's the ileocecal valve, right there. Okay, so we are to go take a cuff, making sure that we don't bust. Okay, do you have - open Ray-Tec? Grasper. Hold this. Okay, put the trocar in. Thank you. Perfect. So this one here is going to make sure there is some hemostasis there, okay, in the meantime, this is going to clean also the blood. So we can - do a better operation. Okay. So the polyp is somewhere inside here, okay, at this level. So we have to make sure that we transect this, making sure that there is no - we don't make any more trouble. Okay. Actually maybe you can see the polyp right here. That's where the polyp is. Look at this. Yeah. You see? That's where the polyp is. You can see really good. Okay.

Again, this is terminal ileum, the ileocecal fat pad, the cecum with the teniae. Following down the teniae, there is - following down the teniae here, you'll see the appendix. The appendix is free from the mesentery. We're going to pull it up and then transect the base. Okay, come closer. No. I'm going to try to take this thing off. Perfect. Thank you. Okay, so what do we think? Okay, so one second. Make sure... Let's go on the other side here. Okay, perfect. We're not taking anything bad. Okay? Here, we are not taking - the valve, okay? Ready? Okay. Let's check again. We're not taking - I need to see the valve, my friend. Right here. Perfect. There's no stricture in the valve, which is there. Put it like this. Okay. Perfect. We're not taking the valve. And that's a little bit up thing and then maybe the thing is right there. The polyp is right there. Okay. Maybe. Let me see. Come closer. Scissors. Sure. That's going to bleed. Come closer. Yeah. Okay. Do you have the bag?

Yes. Right here. Ten introducer. No, the other one. Okay.

CHAPTER 5

Can I open this thing? I need... A towel? A towel, yes. You have, 4-by-4? This one here is the appendix. Okay? Very short. This is our staple line. Take it out. I need your help, here. Do you have a Hudson? Okay. I don't know. Can I have some water in here? Water, a small little cup. And sure enough, here is the polyp. Ta-da! So, it was like this. Okay, that's the base of the rec- of the cecum. This is the line of transection. Open it up, and in the lumen there is a polyp. With its... With a base. That's the base of the polyp. Okay? Yes, formalin. So next step, we're going to check the hemostasis on the staple line, making sure that the ileocecal valve is not being compromised.

CHAPTER 6

We need 2-0, Vicryl. No, sorry, 0-Ethibond. Can you give me a 10-mm scope, please? 10-30. We took out the appendix with the base. We found the polyp. We are checking hemostasis. And close. I like the thirty, here, because its a better quality of image than the five. If we have the luxury of using it, we will use it. Do you have two bowel graspers? Don't worry. Cut the needle away. Come closer, there. Okay, so come closer, closer, closer, so we can see the staple line. Staple line is okay. It's not bleeding, okay? And we go below here. Slowly. It's kind of really dry. Let me see what's going on there. That's some irrigation. Okay. Go in. It's mostly clear, okay? There's no bleeding. Okay. Perfect. There's no problem there. No problem there. I see the ileocecal valve, which has not been compromised. Okay? Okay. Now we need the 5-mm scope, please. Let's go around here and see if we have any problem. That's okay. Right there. Okay. It's okay there. Okay, those are the adhesions from his previous cholecystectomy. Okay.

CHAPTER 7

The last thing that we're going to do now that hemostasis is done, we're going to close the 11-mm port. Okay, do you have the Carter-Thomason? Yes, the full length. Yes. Hold this. It's a figure-of-eight. Look at this. Okay? Okay. Now what we do, take everything out. Gas off. Is it off? Gas off. Okay. We're going to deflate the abdomen. Like this. Is the patient flat? The patient is flat. Yes. Scissors, please. Let me see. Okay. Do you have something to clean? Like water? Okay, go on the other side. No, stay here, Scott. We need two Adsons. We used them on the appendix. They are off the field. No problem - something - yes, they're fine. You and I have to make the hemostasis here, okay? I don't know where it's coming, just go deeper. Nice. Let go. Good. So we'll just come in from the skin, then. Here we got to do the same. Let go. See what happens. One second, let me do this. Now stick it in there. Can you close this? Yes. Okay.

CHAPTER 8

So the first case was a patient with an adenoma of the appendiceal orifice. This was discovered by routine colonoscopy. Because it was quite difficult to excise the adenoma with endoscopy, we decided to take the patient to the operating room and take the appendix out together with the adenoma. The challenging fact in this case was that it was very difficult for us to understand where was the location, the correct location of the adenoma. We didn't know if it was within the lumen of the appendix or if it was right at the appendiceal orifice. And this is important because what we have done during the operation was to take the base of the appendix together with at least one centimeter of the wall of the cecum. At the same time that exposed us to the danger of stapling the cecum too close to the ileocecal valve. So the challenging portion was trying to achieve a good resection of the appendix together with the adenoma, but at the same time, being mindful of not taking down or narrowing the ileocecal valve. In this case the patient was relatively healthy. He only had hypertension that was very well controlled with antihypertensive medication. And we chose the laparoscopic approach because the patient did not have an appendicitis before, so the amount of adhesions and the anatomy would have been particularly prone to the laparoscopic approach. We discharge the patient right after the operation. Another thing that was challenging was finding the appendix. When the appendix is inflamed, it's usually swollen with a big diameter. In some cases the appendix is very long, but in this case, the appendix was less than a centimeter in diameter and it was also very short. So, we found the colon first. And to find the colon we put the patient with a left lateral decubitus, which means the right side was placed up, and the left side was placed down. So we swept the small bowel to the most dependent portion to expose the cecum and the right colon. Once we saw the cecum, we identified one of the teniae, and by following it down we were able to identify both the ileocecal valve and the appendix. So, the first thing I did after I saw the appendix, we grasp it and traction, apply traction. The appendix was very densely adherent to the ileocecal valve, so we took the mesentery down from the ileocecal valve using the cautery. The appendiceal artery was taken down with a LigaSure, which is this instrument that coagulates the vessels and cuts them at the same time, providing hemostasis. And then, we went all the way down to the base of the appendix to make sure that we were able to pull at least a centimeter of the cecal wall in order to make sure that we could get the adenoma within the specimen. The operation went well. The staple line was free of any bleeding, and the operation took about an hour. The patient will be sent home later today, and he will resume a general diet and all the physical activities tomorrow morning. And we will see him back in clinic in a week. Once we took out the specimen, we opened it on table and we were able to find that the adenoma was within the lumen of the appendix, and there was at least one and a half centimeter of margin clear from the adenoma, compared to the staple line.