Laparoscopic Appendicectomy

Laparoscopic Appendicectomy

Pneumoperitoneum Created Through Umbilical Port

                    

Port Positions for Lap Appendicectomy

   

Port sites, after closure-Lap Appendicectomy

                                       

Laparoscopic Appendicectomy is now becoming the standard of care for Acute or Chronic appendicitis.

Port positions are :-

One 10 mm Port- Umbilicus

One 5mm Port- Infra umbilical in midline

One 5mm Port-Left iliac fossa

Procedure:-

Pneumo peritoneum is created to through the umbilical port. It is used as the camera port.

Two 5mm working ports are placed; one in the infra umbilical area in the midline and another in the left iliac fossa.

Appendix is visualized. Meso appendix is cauterized. Base of the appendix delineated.

Two  ligatures are placed with 2 O vicryl at the base of the appendix at a distance of 1cm apart.

Appendix is divided between two ligatures and removed through one 5mm port.

Port sites are closed.

Femoral Hernia

Femoral Hernia

A Case of Femoral Hernia- Note the Typical Position

Inguinal Incision for Femoral Hernia Repair

Femoral Hernial Sac

Omentum as the content of Femoral Hernial sac

A femoral hernia descends through the femoral ring, traverses the femoral canal and comes out through the Saphenous opening.

Hence a femoral hernia  is seen typically below the inguinal ligament.

Femoral hernia is more common in females. It is because of the anatomical tilt of the female pelvis. But the commonest hernia in a female patient is the inguinal hernia.

Inguinal Operation for Femoral Hernia Repair

Incision-Oblique incision just above and parallel to the line of attachment of the inguinal ligament.

Position of the patient-Supine

Anesthesia-GA/ SA

Steps of Surgery

External Oblique Aponeurosis is defined and is split opened along the direction of its fibers.

Fascia transeversalis is opened and the sac is identified. Sac is opened and the viability of the contents is checked.

Contents are reduced back and the peritoneal sac is closed.

Femoral ring is obliterated by approximating Inguinal ligament and Pectineal ligament.

Posterior wall of the inguinal canal is reinforced with a Poly Propelene Mesh.

Wound is closed in layers after achieving hemostasis.

Surgical Procedures available for Femoral Hernia

High Operation of Mc Evedy

Low Operation of Lockwood

Inguinal Operation of Lotheissen’s

 

Surgical Repair of Indirect Inguinal Hernia

Surgical Repair of Indirect Inguinal Hernia

External Oblique Aponeurosis

External Oblique Aponeurosis Opened

Inguial Ligament

Conjoint Tendon



Inferior Epigastric Vessels



Indirect Sac Protruding out within the Spermatic Cord

Indirect Sac Opened

After Mesh Placement

Hernia is a Latin word which means a  tear or rupture.

Hernia is defined as protrusion of viscous in a part or whole through an abnormal opening in the walls of its containing cavity.

Inguinal Hernias Form 75% of the total abdominal wall hernias.

Anaesthesia

o Depends on personal  preference of surgeon.

o Laparoscopic Herniorrhaphy-G.A mandated by the pneumoperitonium.

o Otherwise G.A,epidural,spinal ,local or regional anaesthesia can be used.

Position of the patient – Supine

Incision-Oblique  incision 1.25 cm above and parallel to the inguinal ligament covering the medial two third. Inguinal ligament is attached to Anterior superior iliac spine to Pubic Tubercle.

Steps of Surgery

Step 1. External Oblique Aponeurosis  is defined -The First Landmark

Step 2. External Oblique Aponeurosis  is opened along the direction of its fibers and Inguinal Ligament and Conjoint Tendon are defined.

Step 3. Spermatic cord is hooked out from the medial end and is defined up to the deep ring where the inferior epigastric vessels are found.

Step 4. Spermatic cord  opened and Hernial Sac dissected out. In indirect hernia, the sac is found inside the spermatic sord.

Step 5. Indirect hernia sac is opened laterally, to prevent injury to the contents of the hernia sac like Urinary bladder.

Step 6. Herniotomy and  trans fixation of the sac is done at the level of the deep inguinal ring.

Step 7. Poly propylene  mesh is placed in the plane of conjoint tendon and the inguinal ligament

Step 8. Spermatic Cord is placed over the Mesh .

Step 9. External Oblique Aponeurosis is closed

Step 10. Skin and subcutaneous layer closure

Appendicectomy

Lanz Incision for Open Appendicectomy

Lanz incision is a Horizontal Incision at the level of Anterior Superior Iliac Spine..It is a cosmetic Incision as it can be masked by the under garments.

  Indications for Appendicectomy

                  Acute Appendicitis

                  Recurrent Appendicitis

                  Carcinoid Tumour <2cm in diameter

                  Mucocele of Appendix

 Operative surgery Steps for Open Appendicectomy

—  Anesthesia: Spinal Anesthesia

—  Position of the Patient: Supine

—  Incision

Gridiron Incision   (Muscle Splitting)

Rutherford Morrison Incision   (Muscle Cutting)

Lanz Incision   (Muscle Splitting)

 Steps of Operation

—  Step 1. Incision deepened through Superficial fascia (Fascia Camper & Fascia Scarpa).

—  Step 2. External oblique Aponeurosis opened along the direction of its fibers.

—  Step 3. Internal oblique & Transversus abdominis split opened along the line of their fibers.

—  Step 4. Peritoneum opened, Caecum delivered, the Appendix is hooked out and held with a Babcock’s forceps.

—  Step 5. Mesoappendix ligated and divided.

—  Step 6. Purse string sutures applied around the appendicular base.

—  Step 7. Appendicular base crushed and ligated.

—  Step 8. Appendix removed and the  stump cauterized ( with Povidone Iodine ) and invaginated  by tightening the purse string sutures.

The purpose of invaginating the stump is to prevent inflammatory adhesions. The disadvantage of invaginating the appendicular stump is that it can act as a pathological lead point for intussusception later in life.

—  Step 9. Search for Meckel’s diverticulum.

—  Step 10. Haemostasis achieved and the  wound is closed in 4 layers.

What is Retrograde Appendicectomy ?

If the tip of the appendix is not visible  Appendicectomy  can be done in a retrograde manner – the base is first ligated and divided – tip is traced distally and the procedure is completed. Such type of appendicectomy  is called Retrograde Appendicectomy.

Causes of Fever in a Post Operative Patient

Causes of Fever in a Post Operative Patient

Causes of Fever in a Post Operative Patient can be abbreviated as 5 Ws

1.     W- Wound:- Wound Infection

2.     W-Wind:-Respiratory Tract Infection / Atelectasis of Lung

3.     W-Water:-Urinary Tract Infection

4.     W-Waste:-Pseudo Membranous Colitis-Diarrhea

5.     W-Wonder Drug:-Drug Induced Fever