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Laparoscopic retrocaecal appendectomy and disseminated peritonitis

This video demonstrates the laparoscopic treatment of a retrocaecal appendicitis with disseminated peritonitis. This is the case of a 45-year-old patient presenting with an appendicular peritonitis. The patient, who had no previous medical history, was referred to emergencies with a pain syndrome of the right iliac fossa, fever, tachycardia and hyperleukocytosis. The CT-scan identified a retrocaecal infiltration and a voluminous appendicitis. The appendicitis, situated in a retrocaecal position, was going towards a suprahepatic position.

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Laparoscopic retrocaecal appendectomy and disseminated peritonitis

作者群

F Costantino, J Marescaux

摘要

This video demonstrates the laparoscopic treatment of a retrocaecal appendicitis with disseminated peritonitis. This is the case of a 45-year-old patient presenting with an appendicular peritonitis. The patient, who had no previous medical history, was referred to emergencies with a pain syndrome of the right iliac fossa, fever, tachycardia and hyperleukocytosis. The CT-scan identified a retrocaecal infiltration and a voluminous appendicitis. The appendicitis, situated in a retrocaecal position, was going towards a suprahepatic position.

分類

basic techniques

關鍵字

Laparoscopic retrocaecal appendectomy, disseminated peritonitis

媒體類型

手術影片

期間

09'43''

刊物

2009-12

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Dec 2009;9(12).
URL: http://www.websurg.com/doi-vd01en2676.htm

Laparoscopic retrocaecal appendectomy and disseminated peritonitis

1. Clinical case presentation 00'10''

This is the case of a 45-year-old patient presenting with an appendicular peritonitis. The patient, who had no previous medical history, was referred to emergencies with a pain syndrome of the right iliac fossa, fever, tachycardia and hyperleukocytosis. The CT-scan identified a retrocaecal infiltration and a voluminous appendicitis. The appendicitis, situated in a retrocaecal position, was going towards a suprahepatic position. The exploration of the abdominal cavity demonstrates the presence of a diffuse peritonitis. This diffuse peritonitis renders the identification of the caecal appendix difficult.

2. Appendix identification 01'04''

By taking our preoperative work-up into account, we will look for the appendix suprahepatically behind the caecum. This will allow us to identify our caecal appendix easily at that level.

3. Dissection of adhesions 01'28''

The dissection of the adhesions and inflammatory tissues secondary to the peritonitis turns out to be difficult and is performed step by step with monopolar and bipolar coagulation. This dissection aims at freeing the appendix of the adhesions caused by the inflammatory process. We can observe the presence of inflammatory tissues at the cranial extremity of the appendix.

4. Identification of perforation 02'35''

At this level, a perforation of the extremity can be seen, explaining the disseminated peritonitis. The freeing is performed with monopolar and bipolar coagulation. The suprahepatic dissection is difficult to perform due to the inflammatory tissue.

5. Exposure and dissection of appendicular meso 02'55''

The freeing continues and it is at that moment that we can observe the appendicular meso that will be coagulated with monopolar and bipolar cautery and will allow us to perform a step by step freeing of the caecal appendix with a vascular control of the appendicular artery by monopolar cautery at the level of the meso. Once the freeing has been completed, we can obtain a new exposure at the level of the appendicular base.

6. Stapling of appendix 03'32''

In these cases in which the base of the appendix is fragile, we decide to perform a division of the latter with the application of a 60mm blue cartridge Endo-GIA linear stapler introduced through the trocar in the left iliac flank. This Endo-GIA stapler allows for a reassuring division. The appendix is placed in a plastic extraction bag before it is extracted later on.

7. Bacteriological samples 04'24''

Once the appendectomy has been performed, we extract a few bacteriological samples of pseudo-membrane for antibiogram.

8. Lavage of peritoneal cavity 04'46''

To perform the abdominal cavity’s lavage, we introduce a gauze that will allow us to obtain exposure on one side and use our aspiration/irrigation freely on the other side without having the intestine and greater omentum obstruct the field. We begin by irrigating the Douglas’ pouch with physiological liquid. This lavage is performed at the level of the 4 abdominal quadrants. On average, we use 6 litres of physiological liquid. This aims at diminishing the concentration of purulent liquid to then increase the effectiveness of the antibiotics postoperatively. The lavage does not diminish the number of intra-abdominal abscesses, but we hope to diminish the concentration of bacteria intra-abdominally. As you can see here, this lavage is performed at the left and right parietocolic spaces, the left and right flanks, the left and right hypochondriums, and in the space between each loop. It is at that moment that the gauze becomes indispensable for the aspiration and irrigation of the fluids.

9. Insertion of drains 07'07''

We then place the gauze in an extraction bag before introducing two drains through the trocar in the left iliac fossa. These drains will drain the right parietocolic space and the Douglas’ pouch. The patient resumed food intake on postoperative day 3 and was discharged home on postoperative day 5 with no complications.