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Laparoscopic Appendectomy

Dr.S.Navaneethakrishnan MBBS.,MS.,FICS.,FAIS

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Topics

Indications

Indications for Laparoscopic appendicectomy in children are similar to those in adults. Laparoscopic appendicectomy is performed in various stages of acute and chronic appendicitis.

  1. In acute cases acutely suppurative, perforated gangrenous appendicitis
  2. In doubtful cases of appendicitis in young females.
  3. In obese children or over weight child minimally invasive surgery is more advantages than the conventional procedure.

Contra Indication

  1. Children with associated Respiratory and cardiac problems and severe renal disease
  2. In case of coagulatory disorder
  3. In case of appendicular mass and appendicular abscess.

Establishment of pnemo may disrupt the abscess cavity allowing free spill of Pus to the entire peritoneal cavity and the walls of the abscess cavity can be made up of mesentery and bowel and so dissection is unsafe.

Pre-Operative Preparations

Patients are prepared for laparoscopic appendicectomy in children are some as that of Conventional open surgery. The usual preoperative preparation includes a thorough history and physical examination, routine laboratory, radiological and sonographic investigations are obtained as clinically indicated. The patient should be well hydrated and administered appropriate broad-spectrum antibiotics.

Counselling

A thorough discussion is necessary with the parents and their family members regarding the risk and benefits of laparoscopic verses open appendectomy.

Technique

The principles of laparoscopic appendectomy in children are similar to those in adults.

Special care is required when applying the Technology to children when compared with adults. All the patients are placed under GA with endotrachial intubation and muscle relaxants to allow for controlled ventilation. Stomach and Bladder are decompressed with appropriate cathetrisation in order to prevent trocar injury during cannula insertion and to provide adequate exposure of the operative field. The abdomen is prepared widely.

Place the patient in supine in the operation table with trendelenbergh Position and little tilt to the left. Usually three trocars are placed – sub umbilical 10 mm for telescope and camera. All Secondary trocar are placed under vision. 5 mm supra pubic in the midline and 3 mm secondary trocar on the left iliac region lateral to the rectus muscle. We don’t place the trocar directly over the appendix or in the right iliac region because we feel that makes video endoscopic eye hand co-ordination more difficult. Since the abdominal surface and cavity ratio in children is reduced compared to adults, more attention is required regarding the placement of cannulas. It must be emphasized that an appropriate working angles are maintained by placing the cannulas in proper position.The abdominal wall in these small patients is very pliable compared with adults. So when inserting the cannulas with their accompanying trocars, it is very important to direct the sharp stylette away from the underlying Intra abdominal organs to prevent injury with forceful insertion of the trocars and cannulas.


FAIS Professor of Surgery, Rajah Muthiah Medical College, Annamalai Nagar, Chidambaram

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