Laparoscopic Appendectomy with Lysis of Adhesions for Appendicitis

CHAPTER 1

My name is Helen Wei. I am one of the AAST Acute Care Surgery Fellows at Mass General Hospital, and today we did a laparoscopic appendectomy with a lysis of adhesions. The important thing to know about this patient is that he previously had an umbilical hernia repair as a child. For the procedure, we accessed the abdomen in the left upper quadrant. We used a Veress needle. We then insufflated the abdomen, and we used an optical 12 trocar to then access the abdomen supraumbilically away from his prior umbilical hernia repair incision. When we did the surgery, we realized that there was still a number of adhesions stuck to his midline by his prior hernia repair, and so we had to lyse those adhesions before we proceeded with the surgery itself, which was the appendectomy. For the appendectomy, it was pretty straightforward. The appendix was inflamed but it was easily identifiable, so we took the mesentery using a bipolar sealing energy device and then we stapled off the base of the appendix. For closure, we used a Carter-Thomason suture passer to close the fascia, and the skin closed with Monocryl in the usual fashion.

CHAPTER 2

The incision looked so basic 'cause he had this as an infant. Right, right. Lemme just give us a little more tiny - we have prepped up there, I imagine. Okay. Now try to aim a little bit towards the left shoulder. That makes it-- I find it a little easier. There's some. Pull back a little. Yeah, perfect. He probably has a lot of omentum, so probably in the omentum. Let me just feel this. All right, so he had a prior umbilical incision here, so I think maybe we should just go a little higher than usual 'cause normally I'd go down here, but we wanna avoid this scar here. True, here? Yeah, maybe like here. If you're too high it's gonna become difficult to access the appendix, but like maybe... This is a 5 or are you gonna do a 12? This will be a 12. Right here, come down? Yeah, sure, let's try that. I think we do have a broken camera. A little bit bigger, slightly more down? Yeah, just a tiny bit. Yeah. The camera doesn't work? Oh, we'll need the 10 to start. And then try not to skive too much towards the right 'cause then wouldn't be like... So you want to go straight down? Yeah, that's fine. Might be in, uh... It's not in right yet. I think we are. We might be in some omentum. Got some omentum, I'm gonna try to come this way. Just pull back a little bit. Because - it might be like adhered omentum from his prior surgery. Let's see if we can pick a different direction to come out of. One sec. Maybe if we point this way. Let me see. That looks like fascia there, so I wonder if we can go this way? Yeah, because I think we're... Might be in an adhesion. Yeah, that's okay. All right. Let's switch to... Hold on, I'm gonna get under here. Yeah, I think we're just through his umbilical hernia repair incision from, like, his infancy. So let's come this way, then we'll take a little peek at it from different port. Okay. Take that out. Oh, are we switching? Do we have the other camera? Not yet. Let me just see. Let's look for the epigastrics. Can we have the patient in Trendelenburg? And then roll towards me? No, it's gonna be hard to put the ports in then. I'm just doing that because I want the intra-abdominal contents to go up and out of the way a little bit. Yeah, I'm just gonna... Yeah. You good with the spot? Just look at the epigastrics. Can't see them. So, all right. Hold on a second. Lemme just look. ASIS is here. So I think, yeah, like here will be good because... Again, we have this adhesion. Show me over here? Just, I can't because it's in the adhesion, so you gotta come this way. Yeah. That's good. All right. Can we have that 5 scope? Do we have the 5 yet? Yeah, I need to see this, the adhesion on the umbo. Okay, we'll just take a look and see what's going on here. Here, let me just take this and we need to defog it, okay? All right. We'll just look up for a second. Yeah. 'Cause this, this port, look, because it's in this fat to the left. So if you take the, just put- turn the post the other way. Which way do you want to... And then I wanna look, yeah, I wanna look from this side. I think it's right here. Like this port, you see that? I do. It's 'cause we just went through this fascial defect. Okay, that's fine. And then can you look in the left upper quadrant at the Veress, we never did that part. Okay. Just look down. It looks pretty good. Okay. All right. We just need to wait for the new, like the, the clean functioning scope. All right. We can probably get this. Yeah, I think we still have to, we are probably gonna have to take these adhesions down to do this 'cause we're not gonna be able to get the stapler in and everything. All right, let's put this lower port in. Let me see the midline a little. Can we see the bladder at all? I think that's the bladder, right? I'm gonna cheat a little higher. Alright, can I have the local, please? Thank you. I think I'm above you. Here, again. Okay. Needle back. I'll have the knife. Knife back. I am gonna try to take down some of these adhesions. Can you look up at the umbo port? Can we have these overhead lights off and out of the way? Thank you. So I wanna take these adhesions off from the umbilical, or from like the abdominal wall. Soula, can you grab that light that's overhead and push it out of the way? I thought you wanted a spotlight on you. Yeah. It's like too much. It's too much light in the field. If I can just take this off, that would be great. Can you look down at the colon just for a second? At the colon? Yeah, 'cause I think this is just the omentum. Okay. Now look up. Yeah, just let me make sure it's out of the way. All right, so I'll do a lysis of adhesions. I want to try to do this without putting another port in. Hey, how are you? Good. How are you? Lemme just moved some of this. Yeah. This is not set up to do this, but it's okay. All right. Come back. All right. Do you have another 5? Just look over here. I think it's gonna be easier if we just take it out. Can I get another 5 port, please? Yep. Here, I'll just keep doing this until they give us a 5. So, because this is gonna be like struggle the whole time because I can't get past this leg. All right, great. You wanna go to do some head up? No, I don't think the head up will help. I just think that we need to take, because we don't take these adhesions down. Like you're not gonna be able to, it's like... Yeah, the head up would get the adhesions down because the legs won't be in the way. No, it's, it's always, this port is always like this. Okay, lemme just come here. Okay. Okay, let's do this. I'll just look a little backwards, but it'll be all right. Okay. Look up at the abdominal wall. And do you have a... Want me to go through here? You could try. I just have to…

CHAPTER 3

This is... Can you show me the other side? Is that possible? That's what I was thinking we could do, but with the port we can only come like this. That's all I got. All right. It's just that this, but it's because that suprapubic port is designed just for the appendix. Yeah. It doesn't actually work for this other stuff that we're doing. Okay. It's okay. All right. So now around the port. And once we drop this off of the port, then, it's funny how we went exactly through it. 'Cause if I had gone through his umbo or infraumbilically, we would've avoided this. Right? Like we were trying to avoid it and we still went into it. Want me just to take that port out? And blast through it all and then we'll put it back in? Maybe I should do that. I can pull it back a little bit so that it's not so in there. Hold on, let me switch this to this port here. If I just come here. Yeah, there'll be a plane right there. Good thinking. Let's do that. Pull up a little. Okay. All righty. Now we can do the operation.

CHAPTER 4

Do you mind if we rotate a little bit this way, Helen, or...? Yeah, yeah. You can, you position... If you want, you can roll towards me before I do the next one. Thank you. Yep. Position the table however you need. Is that it? Yeah, it's under there somewhere. It looks kind of purple. It's probably it. I just have to sweep. Yeah, just have to sweep the stuff off. Looks kind of inflamed and there's like a little bit of murky stuff around it. Yeah. You might need to, if it's not exposing, maybe to sweep some of that bowel off. Like probably up to the left upper quadrant area. Yeah. Okay. It's a serious appendix. Yep. There's cecum behind it. Yeah, because the cecum is here, base of appendix there, and then the appendix is going up and over. So the base actually looks pretty healthy. Base right here? Yeah. So actually pretty good. Trying to focus the camera right up here. Trying to see this thing. Yeah, that'll peel just right off. That's good. It's very purple and angry looking. Very angry. All right. Can we see the tip? Can you find the tip for me? Yeah, just come in with the camera. Yeah. We're gonna find that tip so we can free it and pop it up and then we can start from there. Nice. All right. Where's the tip, Soula? The tip of the appendix? Yeah. That's it, right there. Yeah. Yeah. Alright, so come back, now I'm looking for a good spot to grab. Grab the appendix, which looks like this because... Yeah, that's just like cecal fat over there. Alright, so the base here... I wonder if we can make the picture a little bit better. Just... Like the focus, or...? Like either focus or... I think this is one of those times where we might actually take the base of the appendix first and then ligature the rest of the mesentery. I've turned to, I've turned to, here. Let's, let me work on this. Take this out for a second. Probably maybe grab like up here. And see if you can see this space. I think you need to grab, I think, don't grab the cecum with your Maryland. 'Cause it leaves, like, we're just gonna injure it. Just grab a little higher with your left hand there and see if you can come around it like it's the, you know, cystic duct. Yeah. Don't do it from that side. It should come, let me come over here. I wanna come down from, I just wanna show. No, I wanna show you what we wanna do and just, 'cause you see the crotch right here? I think you can more easily use your right hand and get into that crotch around, but... You want me to come from the other side? I want you to come from the right side of the screen. A little higher and then- You want me to come here? Like, and try to come a little higher 'cause I don't wanna be in the cecum. Up here? Yeah, let's just do that for now. We can always come closer. Alright, so... Okay. Lemme see if I can help you. Bowel grasper?

CHAPTER 5

I think at this point you can probably actually start taking the mesentery that way. I think you might have the second one up there, somewhere. Yeah, let's do this. I'll take the LigaSure. Then just LigaSure the meso since we already made a small window, it actually looks like it's gonna give it to us. And then go a little higher for your liggy if possible. Higher, which direction? Like, towards the appendix. Right over there? Yep. Nice. That's good. Just burn the mesoappendix twice. Let me give this back to you, Soula. You can take it. Here's the... Tail to 9 o'clock. There's just one band. Let's see. We just have a little bit more mesentery. You have to go under yourself, and your right hand should go under. Then like... Want me to take this way? I would take it closer because we're trying to - can you spread next to the base of the appendix to try to clear that stuff up a little bit? Need the Marylands. So then turn the tips. Yeah, like that. Yes. Right there. Yeah. Yeah, and then take that with your LigaSure and then we can staple. There's like a little - once you take that actually there's a spot of bleeding on the mesentery. I just want to take that also. Okay. And just like burn it so it doesn't bleed. And then a little more. Yeah. I think the appendiceal artery is in that blob, right there. You guys have the stapler?

CHAPTER 6

What stapler do you want? Can we have a 45 purple? Purple. Show me the base of the appendix again. And then Soula, can you look around it? Try to show the left side. Spin left. Yeah. Okay. Stapler is ready. Here, let me help. Lemme take this from you, Soula. Can I have this? All right, let me articulate first. Yep. Roll it up. Is it open or...? Yep, it's open. Go again. Gonna do more right there. Can you put it all the way in the crotch so we have the whole staple line. I like where you are. You want right there? A tiny bit lower if you can. Pull up with your left hand if possible. Yeah. The appendix is about to rupture. Okay. All right. Just grab it and then we'll just take it here. A tiny bit higher. Like come down like this? Yeah, just be - right there. Push in a tiny bit. Good? That's all the way it goes. Yep, good, good. Perfect. Good. Here? Take it. Yep. All right. Can we take the Endo Catch bag next? Straighten it out? Yep.

CHAPTER 7

I'll give this to you. Thank you. All right, just put the bag somewhere else, so that we can... Take a look at the appendix. Here. Then we wanna look at just - I just wanna look at the stump a little bit. Do you have any clips over there? You can get like a 10 millimeter maybe. I have 10-millimeter clip, is that okay? Yeah, that's fine. Is this... Oh, I don't need it just yet. Is the irrigation on? Yes. Nothing's coming out. It's not working. Can you squeeze the bag for me? You shouldn't have to, the pump should take care of that. Yeah, I know. I hear the pump, I don't know why it's not working. It's okay. Maybe try unplugging the... No, I mean it seems okay now. Maybe the pump is too close to the bag... Yeah. All right. I actually wanna put some clips on here. Do you want me to undo it or is it working? No, it's working now. It's working. Jason, I'm gonna go to the other side and I'm gonna hold this blob of fat up so that you can put a clip or two on that staple line. All right? All right, Soula, you take this camera back. Want me to clip the next one? No, I mean, Jason's gonna clip it from this side, but there's a piece of fat that I need to hold out of the way. So I'll just need a bowel grasper for that part. But I think I have 'em all here. All right. Okay. And then put one more next to it. It looks good. Looks perfect. All right. And then can you irrigate one more time? We're just gonna hold it back for us so we can look, and Soula, come with the camera so we can look at our staple line. 'Cause it was a little bit bloody before. All right. Looks pretty good. And Jason suction, and then we'll take one more look at the mesentery. Show us the mesentery, like irrigate it so we can see if it's bleeding. Yep. Come in and see if there's any ooze. I don't see anything bleeding. Yeah, just this looks red here so I just wanna make sure it's nothing. Can you look down? Look down with the camera please. Yeah, sorry I was just... Just irrigate right there. Okay. It's this side that I was... Okay. Let's suck out the pelvis and then we can flatten the table. All right, just look down here. Lemme get that bowel grasper again. Let's try from this port. Great. Okay. We can flatten the table out. So now for this part, we'll put all this back here. All right. Yep. And just pull the port out and then pull the appendix out right after. Pull it like you mean it. Now you pull that out. Relax for a second because this bag tends to break, so... Nice. All right. Tell her specimen is out. All right. Specimen, appendix. His temp is still 38.4. All right. Well, we gave him some antibiotics and the angry appendix is out. Can you have him actually a little bit right side up just 'cause he's tilted a bit.

CHAPTER 8

And then Jason will take the white insert for the Carter-Thomason. And then now I want you to put the post down and look up at the abdominal wall because he's going to close that hole. Carter-Thomason. I'll take a Maryland. Yep. You wanna look at the tip? Yeah. 'Cause you wanna look at the - now pull back. Yeah. So you wanna look at the tip of that so that we can... Okay. I need the camera centered on my tongs. All right, great. Is this sufficient or you do a figure-of-eight? No, we do a figure-of-eight after it. I just, I found it easier to close the peritoneum with like one simple first. Yeah. And then... Yeah, I'll need another stitch. Can I have scissors, please? I'll take that second Carter-Thomason. Just make sure we get the anterior fascia. When we pull up, that should stop bleeding. But if it doesn't, we'll put another stitch in it. Just pull up. Yeah. Make it tight so it doesn't bleed. Are you all set with this? Yes. Thank you. All right. I like to watch this port come out. Here, let me come from this side. Turn the gas off. That's great. Gas is off. That's good. Alright. Great. Room light's on. Yep. And then the gas off and lights on. Okay, there we go. Some local there. Is that all of the local? Yes. Okay. Bring the table up a little bit please. Here, we'll do this. Up him, please. Thank you. That's good. Thank you. Not yet, they called and I guess... Do you have scissors? Okay. I just see a few button holes over here. Yeah, you can come through. Alright, good. Helen, you're okay if I remove the instrument? Yes. That's okay. Alright. And now you can hold that with your right hand and let go with your left hand. So you can hold - if you're holding the needle with your right hand... Yep. Sorry, could you... So you know how you turn your wrist and come through, you can then let go with your left hand at that time and then you're still holding the needle with your right so you can grab your needle. Oh, I see. Right. And that way you have a little more control of it. Okay. And then make sure you're both on the same side. 'Cause I think one stitch is... Yes. Dermabond please. Yeah, just make sure they're on the same side. That's all. It looks like it. See like when you come too close in the dermis, that's how you get that little dimple. Okay. Can I have one dry sponge for the Dermabond portion? All right, it's gonna be amazing. All right. Okay, go for it. Here, you dry for him. Dry for him? Yeah. And that, that guy and this guy. And dry this 'cause it's wet. Remember it has to be dry.

CHAPTER 9

In terms of postoperative care, the most important thing is not to lift anything more than 10 pounds for about six weeks. I also tell patients not to go tub bathing or swimming or submerge underwater for about one month. And then the final thing that's very important is that they should follow up on what the pathology is. So we usually talk to them about that at the postoperative visit. Usually the appendix is a regular inflamed appendix, but in very, very rare circumstances it can hide a malignancy. So that's the reason why I want the patients to know what their pathology is.