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Laparoscopic appendectomy following transparietal drainage of an abscess

Patients presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. This video shows the case of a 48-year-old female patient operated upon previously for a collection at the rectouterine (Douglas') pouch following a suspected acute appendicitis. A laparoscopic exploration was performed along with a laparoscopic drainage of the collection, but the appendix had not been identified. Fifteen days later and the patient presents with a 15cm residual collection for which we performed a puncture under CT-scan guidance. Following a 3-month interval, the patient is admitted to our Department to perform an appendectomy.

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Laparoscopic appendectomy following transparietal drainage of an abscess

作者群

F Costantino, J Marescaux

摘要

Patients presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. This video shows the case of a 48-year-old female patient operated upon previously for a collection at the rectouterine (Douglas') pouch following a suspected acute appendicitis. A laparoscopic exploration was performed along with a laparoscopic drainage of the collection, but the appendix had not been identified. Fifteen days later and the patient presents with a 15cm residual collection for which we performed a puncture under CT-scan guidance. Following a 3-month interval, the patient is admitted to our Department to perform an appendectomy.

分類

clinical cases

關鍵字

Laparoscopic appendectomy, transparietal drainage, abscess

媒體類型

手術影片

期間

04'05''

刊物

2009-11

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2738.htm

Laparoscopic appendectomy following transparietal drainage of an abscess

1. Clinical case presentation 00'20''

This is the case of a 48-year-old female patient operated upon previously for a collection at the Douglas’ pouch following a suspected acute appendicitis. A laparoscopic exploration was performed along with a laparoscopic drainage of the collection, but the appendix had not been identified. 15 days later and the patient presents with a 15cm residual collection for which we performed a puncture under CT-scan guidance. Following a 3 month interval, the patient is admitted to perform an appendectomy. The CT-scan performed 3 months after the percutaneous treatment can be seen on this picture.

2. Trocar positioning 01'00''

We perform a laparoscopic appendectomy using the routine technique with the placement of a 12mm optical trocar at the level of the umbilicus and two 5mm trocars are introduced, one supra-umbilically and one in the left flank.

3. Freeing of adhesions 01'15''

The dissection begins with the freeing of the adhesions at the level of the colon and of the last ileal loop, which indicate a previous inflammatory process. The freeing is performed with cold scissors and a very low voltage of monopolar cautery.

4. Identification of a retrocaecal appendix 01'46''

Once the caecum has been identified, we can observe that the appendix is in a retrocaecal position.

5. Dissection of meso-appendix 01'59''

We perform the dissection and control of the appendicular meso from its caudal to cranial end. This control is performed with monopolar coagulation and scissors, but we also use alternating bipolar coagulations on the last branches of the appendicular artery. The last adhesions are taken down with cold scissors and low voltage monopolar coagulation, allowing us to free the appendix entirely, first with control of its appendicular meso, then with the complete freeing of the latter’s posterior adhesions. We then apply some absorbable Vicryl sutures extracorporeally at the base of the appendix. An extraction bag is introduced and a plastic wound protector is placed to protect the abdominal wall. The appendicular specimen is placed in the bag and a stitch is placed 1cm cephalad from the base of the appendix.

6. Division of appendix 03'30''

The division is performed using cold scissors and without the use of electrocautery. We perform the coagulation of the appendicular mucosa with a bipolar grasper at the level of the stump and extract the operative specimen in a retrieval bag.