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Appendicular peritonitis: laparoscopic conversion

WebSurg是個虛擬大學，可在世界各地透過網路取得。我們的目標是提供外科醫師、科學協會及醫學產業第一個腹腔鏡及其最新發展之線上持續醫學教育的平台，包括NOTES和機器人手術。

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Appendicular   peritonitis:   laparoscopic   conversion

作者群
B Navez
關鍵字
urgences,operation
媒體類型
期間
07'00''
刊物
2001-11
普通的
最愛
Favorites Media
音訊
en tw
副標題
en
數位出版
WeBSurg.com, Nov 2001;1(11).
URL: http://www.websurg.com/doi-vd01en1103e_2.htm

Appendicular   peritonitis:   laparoscopic   conversion

1. Script 00'07''
This is the case of a laparoscopic appendectomy being converted from an original McBurney’s incision. This is an 11-year-old child who presented with symptoms of an acute appendicitis. A small McBurney’s incision was made as is the custom of the operating surgeon. Upon exploration of the appendix, a perforation became evident distant to the side of the appendix as seen here. The decision now must be made whether to convert the incision into a larger incision or to do a separate midline incision. The surgeon chose to convert the operation through the original incision into a laparoscopic procedure due to the purulence and the perforation. In order to achieve this, a purse-string suture was placed in the peritoneum at the original incision site. At this original incision, we then introduce a 12mm trocar, which will be used in the operation itself. A suture placed around the peritoneal wall ensures a tight seal around the trocar and enables us to perform a pneumoperitoneum necessary for the laparoscopic procedure. Two other trocars will be subsequently placed one at the umbilicus and one in the left lower quadrant. A 12mm trocar is placed at the original McBurney’s incision site after which a purse-string suture will be tightened to ensure a tight seal. Once the abdominal cavity is explored, it is evident that there is a high amount of purulence underneath the right subphrenic area. The exploration in the abdomen is continued throughout all aspects here in the left subphrenic area as well as and to the colic gutters both on the right and the left, and also in the pelvis itself. The original incision site, which now contains the 12mm trocar, is used to introduce an instrument to hold the appendix itself, which is now dissected free from the surrounding inflamed tissue. As you can see, a very distended an inflamed appendix with a perforation becomes evident. Bipolar coagulation is used to separate the meso-appendix. In this case, the bipolar is a good choice of instrument to avoid damaging surrounding bowel and structures. Sharp dissection is also used after coagulating with the bipolar cautery. We continue dissect the very inflamed tissues around the appendix. An absorbable suture was placed around the base of the appendix before completing dissection between 2 clips. Once completely dissected free, the appendix is removed through a 12mm trocar previously placed. At this point, copious amounts of irrigation are used to irrigate the abdomen. By converting to a laparoscopic procedure, the whole abdomen can be visualized and the irrigation fluid can be placed throughout the whole area of the peritoneum. The irrigation is continued until the fluid clears. This is especially important in the subphrenic area, as we saw earlier, has a high risk of abscess formation. Here we agitate the irrigation fluid so that it spreads evenly throughout the peritoneum. You can see here the turbid color of the irrigation fluid testifies to the perforation and the amount of purulence present, which if left within the abdomen would certainly form an abscess postoperatively. The irrigation remains turbid at this point and will be continued again until the fluid is cleared. It is important to get a good distribution of the fluid throughout the whole abdominal cavity, which can be used as we’ve shown exteriorly by agitating the abdomen anteriorly by placing the drainage and moving bowel away from the area in order to continue to lavage. The advantage with the laparoscope is that all areas including the pelvis can be seen clearly. At this point, a 12 French silicone drain is placed within the pouch of Douglas to drain any postoperative collections. This then concludes our procedure.