1. Introduction

a. Place Veress Needle and Insufflate the Abdomen

b. Insert First Laparoscope Trocar and Sleeve

c. Make Second Incision

d. Insert Second Laparoscope Trocar and Sleeve

e. Make Third Incision

f. Insert Third Laparoscope Trocar and Sleeve

2. Incision and Access to the Abdomen

3. Viewing of Abdominal Organs and Exposure of Appendix

a. Isolate Appendix from Mesoappendix

b. Ligate Appendiceal Artery

c. Cuff the Colon

d. Transection

e. Remove Appendix via Specimen Bag

4. Resection of Appendix with Cecal Wedge

5. Gross Examination of Specimen and Viewing of Polyp

6. Hemostasis

7. Closure

8. Post-op Remarks

This is the case of a 66-year-old man with a history of colon polyps, who undergoes colonoscopy every 3 years for surveillance. During the last colonoscopy, he was found to have a polyp at the appendiceal orifice. The biopsy showed the presence of adenoma. Therefore, the patient underwent a laparoscopic appendectomy with wedge resection of the cecum. The operation went well and took less than an hour. We opened the specimen and found the adenoma within the lumen of the appendix, with at least 1.5 cm of clear margin. The patient was sent home the same day, and resumed regular diet and physical activities the following morning.

<h4>CHAPTER 1</h4>

<p>My name is Dr. Fisichella.
My name is Dr. Levin.
So what are we doing today?
Today we are doing a laparoscopic appendectomy.
This is a 66-year-old gentleman with a history of polyps,
who undergoes colonoscopic surveillance every 3 years.
In a recent colonoscopic surveillance,
he was found to have
an incidental polyp at the appendiceal orifice.
The biopsy showed
adenoma. Therefore, we
are doing a laparoscopic appendectomy
and we will take a portion,
a small portion of the cecum with our procedure.
Our approach is to do an umbilical incision.
A marking pen? Yes.
We will also be placing a subcostal,
doing a subcostal incision
and a left lower quadrant... Suprapubic.
Suprapubic incision for the first one, and most
likely another port here.
And the distance between the ports is usually 5
fingerbreadths from each other.
Otherwise, the instruments will clash together.
In order to gain access
to the abdomen we may put
a Veress trocar here or in the
subcostal margin. That's the reason why
we prepped the entire abdomen.
The patient only had an open -
open cholecystectomy before, so
we don't expect him to have many adhesions.
Can we have two Adsons?
Any questions or concerns?
No, the only prob- concern
was the high blood pressure, but the
anesthesiologist will take care of those.</p>

<h4>CHAPTER 2</h4>

<p>Just make an incision, yes.
Right on the crease.
The crease on top.
Yeah, yeah.
Incision. Nice.
Perfect.
Perfect. Towards you. Okay.
Okay. Let me see...
Can I have a Kocher?
Let go.
S-retractors.
One second.
I need to see the fascia, okay?
Let go. Sorry.
You don't have that Kocher? Kocher.
Let me see.
Perfect. Can you hold this?
Okay. As you can see, this is the fascia.
Okay. Can I have the Veress needle, please?</p>

<p>Can I have the drop test?
Okay, so now the Veress needle
is placed inside the abdomen. The
drop of normal saline goes all the way down.
Now we're going to connect
it to the gas.
Okay.
Can I get gas on high flow?
What's the opening pressure?
Three. Perfect.
So there is a good opening pressure.
There is-it's on high flow.
And no obstruction whatsoever.
So the reason why I'm grasping
the fascia of the abdomen with a Kocher
is so it gives us
at least one inch of distance between
the abdominal contents and the abdominal wall.
That will avoid
puncturing either the abdomen or the major vessels.
Often the vena cava split at the level
of the umbilicus, so one of the
complications of putting the first trocar in, or
complication in placing the Veress needle
right in the umbilicus in
the midline, is to hit the major vessels.
So this is a trick
that we use to avoid that happening.
Okay, the pressure is set to 15.
So that's the maximum that we had.
So I'm going to release the clamp.
There is a good pneumoperitoneum here.
We're going to get- no - yes, this, the camera.
Perfect.</p>

<p>So this one here is an Optiview trocar
that has a clear tip
that will allow us to see exactly the
layers of the abdominal wall under direct vision.
So there are different kinds of trocars.
This one here is splitting. So if
I touch, I don't cut myself.
The way it works is that by twisting
left and right, the muscles are spread
or a cut is made
into fascial structures.
That's the fascia of the
abdominal wall, right there.
See we are spreading and spreading.
That's preperitoneal fat.
That's some of the muscles.
Okay and this one here, we are inside the abdomen.
And as you can see,
when there is black, black
means that there is always air, so
we are safe right there.
You can see the edge of the peritoneum.
We're going to go back again in.
I'm going to take it out.
And that's the inside of the abdominal cavity.
Perfect. As you can see there is
no intra-abdominal injuries and then we're going
to put the -
the next trocar right here.</p>

<p>This one here is the bladder.
Can I have a local, please?
So, this one here is that I want
to see exactly...
Can you hold this?
Okay. Can I have a knife, please?
Let me do this.</p>

<p>Can I have a trocar?
Okay, the reason why I want
to put it myself is just I want to
make sure that I don't go into the bladder,
because this one here,
this structure here is the bladder.
Okay, so we're far away but in the
middle, in the midline. Okay.
Okay, so the appendix is going to be there.
Can you put the patient right-side up, please?
So we're gonna put the -
we put the patient in right-side up,
so the gravity
can help us, mobilizing the small
bowel and give us exposure.
Like this.
A good way to
understand the anatomy here is-
these are - that's the right colon.
These are the teniae. If you follow
the teniae down, you will see the appendix and...
Let me see.
So this loop here is the
last loop of the small bowel. The terminal
ileum that attaches there -
onto the colon, right there.</p>

<p>Okay, let's see if we can put the other trocar.
Can I have the local again?
Perfect.
Knife.</p>

<p>Thank you.
Okay, let's go back.
Yes. And the other good bowel grasper.</p>

<h4>CHAPTER 3</h4>

<p>That's the terminal ileum over here.
This is the teniae. Follow down
the teniae, there should be the appendix.
Can you put the patient -
a little bit more right-side -
up?
I'm gonna move the bed.
Yeah.
Stop. Stop, stop.
Okay, and
foot down. Head up.
Okay, thank you. Stop.
Can you put the patient head down, head up, more?
More head up? Head up.
I'm gonna move the bed. Yeah.
Okay, stop.
Okay, can you put it in, head down, again?
Like it was in a flat position. Flat.
Gonna move the bed. Yes, thank you.
Thank you.
Oh man.</p>

<h4>CHAPTER 4</h4>

<p>Okay, let's try it with a Bovie.
Closer.
Okay.
Okay. Let me get the Hunter.
Okay.
We may need to have that thing open now.
The suction-irrigator open, yeah.
Yeah, no, let open.
Open, yeah. On the field, yes.
One second.
One second. Yes.
Do you want one or three liters of saline?
Three.
So this is the appendix, it looks like,
and I'm trying to go behind
to see - so it's the only place. It is stuck somewhere
near the small bowel. Maybe here,
the previous appendicitis. That I cannot tell.
Thank you. Hold this, please?
Back up the camera.
Okay.
So this one here,
looks like an artery that comes from behind.
Yep.
Oh, let me tell you.
So, we follow the teniae and the teniae
took us to the appendix.
That's the base of the appendix.
This one here is the
posterior portion of the mesentery.
This one here is the mesentery. Okay?
And the artery is somewhere there, it's a little bit, you know,
oozy, but that's fine.</p>

<p>So can we have the LigaSure in the -
in the room?
The LigaSure is in the room. Would you like it opened?
Yeah, open.
And the reason why - the LigaSure is going to give
us the hemostasis to take out the artery.
Usually, what we do is to put -
make a hole here and take this portion with -
you see that's the artery
right there -
with a -
with a stapler.
But in this case the LigaSure may be much better.
Perfect. This one here is the base of the appendix.
Okay, this one
here is the colon that is attached
to the abdominal wall right here.
That's the right colic gutter.
That's our appendix, here.
Okay.</p>

<p>Okay, so that's the base of the appendix.
Now remember we are to take a cuff.
Most likely we are to go across from
here to here without damaging
the ileocecal valve.
Okay, so the ileocecal valve is right there.
Perfect. That's the base of the appendix.
And that's the lumen, right there, okay.
So that's the ileocecal valve, right there.
Okay, so we are to go take a cuff,
making sure that we don't bust.
Okay, do you have -
open Ray-Tec?
Grasper.
Hold this.
Okay, put the trocar in.
Thank you.
Perfect.
So this one here is going to make sure
there is some hemostasis there,
okay, in the meantime,
this is going to clean also the blood.
So we can -
do a better operation.
Okay.
So the polyp is somewhere inside here, okay, at this level.
So we have to make sure that we
transect this, making sure that there is no -
we don't make any more trouble.
Okay.
Actually maybe you can see the polyp right here.
That's where the polyp is.
Look at this. Yeah.
You see?
That's where the polyp is.
You can see really good.
Okay.</p>

<p>Again, this is terminal ileum, the ileocecal fat pad,
the cecum with the teniae.
Following down the teniae, there is -
following down the teniae here,
you'll see the appendix.
The appendix is free from the mesentery. We're going
to pull it up and then
transect the base.
Okay, come closer. No.
I'm going to try to take this thing off.
Perfect. Thank you.
Okay, so what do we think?
Okay, so one second. Make sure...
Let's go on the other side here.
Okay, perfect. We're not taking anything bad.
Okay?
Here, we are not taking -
the valve, okay?
Ready? Okay.
Let's check again.
We're not taking -
I need to see the valve, my friend. Right here.
Perfect.
There's no stricture in the valve,
which is there. Put it like this.
Okay.
Perfect.
We're not taking the valve.
And that's a little bit up thing and then maybe
the thing is right there.
The polyp is right there.
Okay.
Maybe. Let me see.
Come closer.
Scissors.
Sure.
That's going to bleed.
Come closer.
Yeah.
Okay. Do you have the bag?</p>

<p>Yes.
Right here.
Ten introducer.
No, the other one.
Okay.</p>

<h4>CHAPTER 5</h4>

<p>Can I open this thing?
I need...
A towel? A towel, yes.
You have, 4-by-4?
This one here is the appendix. Okay? Very short.
This is our staple line.
Take it out. I need your help, here.
Do you have a Hudson?
Okay.
I don't know.
Can I have some water in here?
Water, a small little cup.
And sure enough, here is the polyp.
Ta-da!
So, it was like this.
Okay, that's the base of the rec-
of the cecum.
This is the line of transection.
Open it up, and in the lumen
there is a polyp.
With its...
With a base. That's the base of the polyp.
Okay?
Yes, formalin.
So next step, we're going to
check the hemostasis on the staple
line, making sure that the ileocecal valve
is not being compromised.</p>

<h4>CHAPTER 6</h4>

<p>We need 2-0, Vicryl.
No, sorry, 0-Ethibond.
Can you give me a 10-mm scope, please?
10-30.
We took out the appendix with the base.
We found the polyp.
We are checking hemostasis. And close.
I like the thirty,
here, because its a better quality
of image than the five.
If we have the
luxury of using it, we will use it.
Do you have two bowel graspers?
Don't worry. Cut the needle away.
Come closer, there.
Okay, so come closer,
closer, closer, so we can see the staple line.
Staple line is okay. It's not bleeding, okay?
And we go below here.
Slowly.
It's kind of really dry.
Let me see what's going on there.
That's some
irrigation.
Okay.
Go in.
It's mostly clear, okay? There's no bleeding.
Okay.
Perfect.
There's no problem there.
No problem there.
I see the ileocecal valve,
which has not been compromised.
Okay?
Okay.
Now we need the 5-mm scope, please.
Let's go around here and see if
we have any problem.
That's okay. Right there.
Okay. It's okay there.
Okay, those are the adhesions
from his previous cholecystectomy.
Okay.</p>

<h4>CHAPTER 7</h4>

<p>The last thing that we're going to do now that
hemostasis is done, we're going to
close the 11-mm port.
Okay, do you have the Carter-Thomason?
Yes, the full length. Yes. Hold this.
It's a figure-of-eight. Look at this.
Okay?
Okay. Now what we do, take everything out.
Gas off.
Is it off?
Gas off.
Okay. We're going to deflate the abdomen. Like this.
Is the patient flat?
The patient is flat.
Yes.
Scissors, please.
Let me see.
Okay.
Do you have something to clean? Like water?
Okay, go on the other side.
No, stay here, Scott.
We need two Adsons.
We used them on the appendix. They are off the field.
No problem - something - yes, they're fine.
You and I have to make the hemostasis here, okay?
I don't know where it's coming, just go deeper.
Nice. Let go.
Good. So we'll just come in from the skin, then.
Here we got to do the same.
Let go. See what happens.
One second, let me do this.
Now stick it in there.
Can you close this? Yes.
Okay.</p>

<h4>CHAPTER 8</h4>

<p>So the first case was a patient with an adenoma
of the appendiceal orifice.
This was discovered by routine colonoscopy.
Because it was quite difficult to
excise the adenoma
with endoscopy, we
decided to take the patient to the operating room
and take
the appendix out together with the adenoma.
The challenging fact in this
case was that it was very difficult for us
to understand where was
the location, the correct location
of the adenoma. We didn't
know if it was within
the lumen of the appendix or if it was
right at the appendiceal orifice.
And this is important because
what we have done during the operation was
to take the base
of the appendix together with
at least one centimeter of the wall
of the cecum.
At the same time that exposed us to the danger
of stapling the cecum too close
to the ileocecal valve.
So the challenging portion was trying
to achieve a good resection of the appendix
together with the adenoma, but
at the same time,
being mindful of not taking down or
narrowing the ileocecal valve.
In this case the patient was relatively healthy.
He only had hypertension that
was very well controlled with antihypertensive medication.
And we chose
the laparoscopic approach
because the patient did not have an appendicitis before,
so the amount of adhesions
and the anatomy would have been
particularly prone to the laparoscopic approach.
We discharge the patient right
after the operation.
Another thing that was
challenging was finding the appendix.
When the appendix is inflamed,
it's usually swollen with a big diameter.
In some cases the appendix
is very long, but in this case, the appendix was
less than a centimeter in diameter
and it was also very short.
So, we found the colon first. And to find the colon we
put the patient with a left lateral decubitus,
which means the right side
was placed up, and the left side was placed down.
So we swept the small bowel
to the most dependent portion to
expose the cecum and the right colon.
Once we saw the cecum, we
identified one of the teniae,
and by following it down we
were able to identify both the
ileocecal valve and the appendix.
So, the first thing
I did after I saw the appendix,
we grasp it and traction, apply traction.
The appendix was
very densely adherent to the ileocecal valve,
so we took the mesentery down
from the ileocecal valve using the cautery.
The appendiceal artery
was taken down with a LigaSure,
which is this instrument that
coagulates the vessels and cuts
them at the same time, providing hemostasis.
And then, we went
all the way down to the
base of the appendix to make sure that
we were able to pull
at least a centimeter of the
cecal wall in order to make sure
that we could
get the adenoma
within the specimen.
The operation went well.
The staple line was free of any bleeding,
and the operation took about an hour.
The patient will be sent home later today,
and he will resume a general
diet and all the physical activities tomorrow morning.
And we will see him back
in clinic in a week.
Once we took out the specimen,
we opened it on
table and we were able to find that
the adenoma was within
the lumen of the appendix,
and there was at least one and a half
centimeter of margin clear from the adenoma,
compared to the staple line.</p>


Watch this full-length, narrated surgical video of a laparoscopic cecal wedge resection appanedectomy.

DOI
Publication Date	2023/10/13
Article ID	207
Production ID	0207
Volume	2023
Issue	207
https://doi.org/10.24296/jomi/207

Laparoscopic Cecal Wedge Resection Appendectomy

Procedure Outline

Table of Contents