Laparoscopic appendicectomy: an important skill for the gynaecologist

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1 Laparoscopic appendicectomy: an important skill C. Original LAPARASCOPIC Oxford, Blackwell GENDO Gynaecological 12CALANDRA UK Article Publishing & APPENDICECTOMY Endoscopy I. D. BARABASH Ltd. Ltd, 2003 for the gynaecologist Claude Calandra and Ian D. Barabash Department of Obstetrics and Gynaecology, Western Hospital Sunshine and, Werribee Mercy Hospital, Melbourne, Australia Keywords appendicectomy, appendicitis, laparoscopy. Correspondence C. Calandra, C/ 131 Main Road. West, St. Albans, Victoria, 3021, Australia. Accepted for publication 21 May 2003 ABSTRACT Objective To demonstrate that laparoscopy is an important skill for gynaecologists to acquire. Laparoscopy is now one of the most commonly performed gynaecological procedures, commonly as an investigative tool for acute or chronic pelvic pain. In Australia, thousands of these procedures are performed each year. Methods We outline here the main authors experience and teaching of his trainees, outlining the technique for the performance of this surgery, in three separate clinical entities. Conclusion The performance of laparoscopic appendicectomy is an important facet of gynaecological training and can be performed by all gynaecologists with basic laparoscopic training. INTRODUCTION In Australia, for the year July 1998 to June 1999, there were 8535 diagnostic laparoscopies performed, many for the investigation of pelvic pain. In this same time period there were 1425 laparoscopic appendicectomies performed. 1 With appendicitis, one of the most important differential diagnoses in the investigation of pelvic pain, one has to ask why gynaecologists have not embraced the technique of laparoscopic appendicectomy? Semm, gynaecologist, first described this operation in It is known, however, that very few trainees are exposed to its treatment. In an informal survey of 20 obstetric and gynaecology trainees in levels 2 5, it was found that only three had performed laparoscopic appendicectomy. There is a further complicating issue, in that many obstetric hospitals in Australia are stand alone hospitals and have no surgical services on site, and this can further delay treatment. We outline here three interesting cases as well as a method for performance of laparoscopic appendicectomy. MATERIALS AND METHODS 2 a The main author has performed over 100 laparoscopic appendicectomies since We present three interesting cases that highlight the importance of an understanding and ability to perform this procedure by the gynaecologist. Case 1 A 14-year-old girl with acute on chronic right iliac fossa pain. She had been seen by several paediatricians and was told that she had endometriosis. Confusion occurred in the diagnosis as the onset of pain had occurred with the onset of menarche. She was referred to the main author who performed a diagnostic laparoscopy. No endometriosis was present, but there was clear evidence of acute on chronic appendicitis and laparoscopic appendicectomy was performed. The diagnosis was confirmed on histopathology. Case 2 A 46-year-old woman presented to her general practitioner with a 3-day history of pain in the right iliac fossa. An ultrasound reported the presence of a large 15 cm ovarian cyst. She was referred to the main author who performed a diagnostic laparoscopy with a view to performing ovarian cystectomy. At operation, there was 2002 Blackwell Publishing Ltd Gynaecological Endoscopy 2002, 11,

2 450 C. CALANDRA & I. D. BARABASH Figure 1 (a) Acute non-suppurative appendicitis, bipolar of the mesoappendix. (b) Reaching the base of the appendix. (c) Endoloop tying off the base of the appendix. (d) Appendix being removed through port. no ovarian cyst present; however, a torsion of a mucocele of the appendix was present and this was removed laparoscopically. Case 3 A 26-year-old woman was referred to the main author with a history of dysmenorrhoea and right iliac fossa. pain. A pelvic ultrasound reported a left ovarian cyst. The main author performed a diagnostic laparoscopy and found the presence of stage II endometriosis. However, on inspection, the appendix appeared thick, rigid and the tip had an abnormal vasculature. Making the assumption of dual pathology, the appendix was removed laparoscopically. The histopathology reported a carcinoid tumour at the appendiceal tip. This case highlighted the value to the gynaecologists in familiarizing themselves with the appearance of the normal and abnormal appendix, and then utilizing the skills required to remove the appendix without recourse to secondary referral to a general surgeon intraoperatively. The technique of laparoscopic appendicectomy Essential materials A 10-mm 0 deg telescope, Veress needle, 5-mm cannulas, laporascopic scissors with diathermy, 5-mm toothed graspers, bipolar diathermy, PDS or Chromic endoloops (both Ethicon, Johnson and Johnson Australia, North Ryde, NSW, Australia), 2nd 11 mm (Calandra) cannula on standby (Stortz). 3 Extra instruments (available on standby) A 5 mm camera, bowel retractor, endopouch, reducing sleeve and two needle holders. METHODS For the standard laparoscopic appendicectomy 1 The patient is placed in the semilithotomy position and prepared with betadine and draped in the usual manner. Gynaecological Endoscopy 2002, 11, Blackwell Publishing Ltd

3 LAPARASCOPIC APPENDICECTOMY 451 Figure 2 (a) Suppurative appendix with thick mesoappendix. (b) Appendix entering endoloop. (c) Appendix being placed in endobag. 2 A 11-mm sheath is introduced via a subumbilical incision, following establishment of a pneumoperitoneum. 3 A 5-mm sheath is introduced suprapubically in the midline under direct vision. 4 An 11-mm Calandra sheath (Storz) is then introduced 5 cm right lateral to the midline suprapubic port. This sheath has a rotating 10 mm/5 mm port incorporated in its head (Calandra trocar). 5 Using 5-mm toothed locking graspers inserted into the R lateral sheath, the tip of the appendix is grasped and placed on tension. 6 Bipolar diathermy forceps are introduced in the midline suprapubic port and the mesoappendix is diathermied and then cut up to the caecum, where there is a window. Care must be taken that heat transmission, using the bipolar diathermy does not reach the caecum. 7 An endoloop, either PDS or Chromic, is introduced through the 5-mm midline port and the base of the appendix is ligated. It is important here not to leave too large a stump of the appendix, but equally so not to ligate the appendix flush with the caecum. The suture is then cut. 8 The graspers are now placed over the stump of the appendix 1 cm away from the suture. 9 Through the 5-mm port the stump is cut flush with the graspers and the appendix removed through the 11-mm sheath. 10 With the use of the Calandra sheath (Storz), containing the rotating 5 mm/10 mm head, virtually all appendices can be removed without the use of an endopouch or reducing sleeves. 11 For all techniques, haemostasis is assessed, the ports are then removed and the port-sites are sutured using either a 3 0 prolene or a 3 0 vicryl suture (undyed). The technique of laparoscopic appendicectomy for acute suppurative appendicitis 1 Where abscess formation involves adhesions to small bowel, omentum, tube, or ovary, all adhesions must be divided and anatomy restored Blackwell Publishing Ltd Gynaecological Endoscopy 2002, 11,

4 452 C. CALANDRA & I. D. BARABASH Figure 3 (a) Retrocaecal appendix. (b) Retrocaecal dissection with hole for suture. (c) Bipolar cutting from appendix tip. (d) Cutting diathermy using scissors. 2 The mesoappendix is always oedematous. 3 Using the same ports as previously discussed, two endoloops are introduced consecutively through the midline 5-mm port and the base of the swollen appendix is ligated. 4 The appendix is held by grasping forceps and cut between the two ligatures. 5 In the case where the appendix is extremely swollen, there are two alternative techniques for removal of the appendix. The 10-mm telescope is introduced through the lateral 11-mm sheath, and the endobag ( Johnson and Johnson Australia), is introduced through the subumbilical sheath. This is often required if the appendix is too swollen to be removed through the 10-mm port. The appendix is placed in the endobag, which is then sealed and the appendix removed. The alternative is in the situation when the appendix is too large to fit through the 10-mm sheath. The umbilical scar can be extended using the knife to allow the bag to be removed. 6 The closure of the wound is then completed as above. The technique of laparoscopic appendicectomy for the retrocaecal appendix 1 All ports are as described in the technique for the standard laparoscopic appendicectomy. 2 The graspers are used to grasp the base of the appendix at the caecum. 3 A 2 0 monocryl needle is inserted and the base of the appendix is ligated with the suture. 4 An intra- or extracorporeal knot is thrown and the base of the appendix is cut. 5 The graspers are used to place the appendix on tension and then, with either a slimline bipolar, or diathermy hook, the mesoappendix is divided, and the appendix is removed through the 11-mm port. 6 An alternative technique here is to identify the tip of the appendix and grasp it using the toothed graspers. Then dissecting it back to the caecum, thus freeing it, so that it can be ligated and removed as in the technique for standard laparoscopic appendicectomy. DISCUSSION In 1983, Semm, a German gynaecologist, published the first article 2 outlining the performance of laparoscopic appendicectomy, adapting the techniques already available for gynaecological pelviscopy. He demonstrated that the success and recovery from this form of surgery was comparable to open techniques. Since this time there have been great advances in the equipment available to Gynaecological Endoscopy 2002, 11, Blackwell Publishing Ltd

5 LAPARASCOPIC APPENDICECTOMY 453 perform such procedures. These include bipolar diathermy, laparoscopic scissors with diathermy attachments, as well as suturing apparatus and endobag for appendix removal. 4 There have also been numerous articles that have outlined other techniques suitable for both acute and chronic appendicitis; 5 however, this article presents a technique adapted from other commonly performed laparoscopic gynaecological procedures. There have been articles outlining that up to 20% of all appendices removed were non-inflamed; 6 however, in 1978, Grossman published a retrospective report on 20 patients with right lower quadrant pain. Of these, 13 had some form of appendiceal problem and 17 of the patients had complete relief of symptoms following open appendicectomy. 5 In the light of these findings and the frequency that laparoscopy is performed by gynaecologists in the investigation of women with pelvic pain, we feel that gynaecologists should learn to recognize appendiceal pathology and gain competency in dealing with the pathology, i.e. performing laparoscopic appendicectomy. The process of learning laparoscopic appendicectomy should begin in the training programme of gynaecological registrars. REFERENCES 1 Health Insurance Commission Statistics. Health Insurance Commission (Australia) Annual Report Semm K. Endoscopic appendicectomy. Endoscopy 1983; 15: Storz Catalogue Laparoscopy, 3rd edn. ref. No 30103RLC. Tuttlingen, Germany: Karl Storz GMBH and Co., Popp LW. Gynaecologically indicated single-endoloop laparoscopic appendicectomy. Journal of the American Association of Gynecological Laparoscopy 1998; 5: Grossman EB. Chronic appendicitis. Surgery, Gynaecology and Obstetrics 1978; 146: McCaughan BC, May J. Appendicectomy audit. Australia and New Zealand Journal of Surgery 1983; 53: Blackwell Publishing Ltd Gynaecological Endoscopy 2002, 11,