# Laparoscopy/adhesions/laparotomy/appendectomy/lavage



## bda23054 (Nov 28, 2012)

NAME OF OPERATION
1.  Laparoscopy with adhesiolysis and purulent drainage suctioning.
2.  Laparotomy with appendectomy and abdominal cavity lavage.

SPECIMEN
Appendix with surrounding inflammatory tissue.

FINDINGS 
Upon establishment of pneumoperitoneum, the patient was noted to have thickened inflamed peritoneum throughout the abdomen.  He had some inflammatory adhesions, small bowel loops to the anterior abdominal wall as well as mostly to the right colic gutter and along the right pelvic brim.  There was significant amount of purulent drainage in the pelvis as well as right gutter.  There was what appeared to be an organized abscess near the base of the cecum in the colic gutter.  The appendix was found to be retroperitoneal and essentially distal half of it obliterated in inflammatory tissue within the retroperitoneum lateral to the duodenum.  The small bowel did not have any isolated lesions or perforations appreciated.  The colon did not appear to be acutely inflamed itself.  The appendix base was essentially normal, not inflamed, again the rest of the appendix was essentially obliterated in inflammatory tissue consistent with perforation.  Appendicolith was found within the abscess cavity and a little bit of stool with it.  The stomach and duodenum did not appear injured or have any perforations.  
DESCRIPTION OF OPERATION
The procedure as well as indications, benefits and potential risks were explained to the patient.  All questions were answered.  With consent obtained, the patient was taken to the Operative Suite, placed in the supine position and general anesthesia initiated.  Foley catheter was then placed.  The   anterior abdominal wall was then prepped and draped in the usual sterile fashion.  A 5-mm incision was made at the inferior edge of the umbilicus and Veress needle was inserted into the intraabdominal cavity with negative aspiration and positive free fluid of saline.  CO@ gas was insufflated to establish pneumoperitoneum.  Once adequate pneumoperitoneum was established, a 5-mm port was placed at this site using Visiport method.  No injury to the intraabdominal structures appreciated with insertion of 5-mm 0-degree scope.  The above findings were appreciated.  The scope was changed to a 30-degree scope and a 12-mm port was placed in the suprapubic area as well as a 5-mm accessory port in the right upper quadrant.  These were placed under direct visualization with no injury to intraabdominal structures.  The small bowel loops were then carefully taken down from the anterior abdominal wall and I did take some down along the right colic gutter with the inflammatory adhesions easily peeling down.   The right colic gutter had some inflammation that was taken down taking care not to injure the bowel and purulent drainage was suctioned up with suction.  With the base of the cecum identified and the appendix found to have organized abscess and inflammatory tissue around it, essentially fused to the retroperitoneum, I opted at this point to abandon laparoscopy and convert to a hand-assisted laparoscopy.  I placed a hand port around the umbilicus, extending the incision from 5-mm port with electrocautery.  With the hand port inserted, I then placed a 5-mm port in the left upper quadrant for the 30-degree scope.  I then carefully took down the rest of the inflammatory adhesions between loops of small bowel, pulled the loops of small bowel up to break up any loculations or developing abscesses from the ligament of Treitz down to the ileocecal valve.  The colic gutter was then opened into the retroperitoneum, where the inflammatory mass of the appendix was, taking care not to injure any retroperitoneal structures, though anatomy was difficult to establish.  The ureter was not visualized and though I stay up fairly high on the wall of the abdomen.  Up near the hepatic flexure, the duodenum was able to be identified with some difficulty due to the thickening of the peritoneum and its appearance in relationship to bowel.  With the duodenum protected the inflammatory mass in the retroperitoneum was appreciated.  Again, with difficulty of seeing landmarks and the technical difficulty of protecting the duodenum, I did opt after medializing the right colon somewhat and being unable to dissect the appendix off of it safely, I opted to extend the incision into a laparotomy and this was done with electrocautery.  Pneumoperitoneum was released.  The accessory ports were removed, and with the right colon medialized I then was able to easily identify the base of the appendix and carefully dissect out the inflammatory mass in the retroperitoneum and the colic gutter that was lateral to the duodenum that appeared to have surrounded the obliterated tip of the appendix.  The appendix and its surrounding inflammatory attachments were taken down with LigaSure device for hemostasis and the base of the appendix was fired across with Echelon 60 blue load stapling device.  No serosal injuries or perforation of the bowel was appreciated.  The intraabdominal cavity was then irrigated with 3 liters of sterile saline.  The drainage returned without any active bleeding appreciated.  A 19-Blake drain was placed through the right upper quadrant 5-mm accessory port site and 19 round Blake drain was placed through the left upper quadrant, 5-mm port site, both of which were secured to the skin with a 2-0 nylon suture.  These were placed in the colic gutters down towards the pelvis and placed to grenade suction.  The midline fascia was closed with an antibiotic-impregnated double strand 0-PDS with figure-of-eight #1 PDS every fourth throw of the suture.  The continuous sutures went from caudad and cephalad and tied just above the umbilicus.  The subcutaneous tissues then irrigated with a liter of sterile saline followed by a liter of Polymyxin/Bacitracin normal saline and electrocautery was used to control skin edge bleeding.  Skin was staples were then placed, also to close the 12-mm port in the suprapubic area.  The Provena incision V.A.C. was then placed over the midline port and incision.  Silvercel was placed around the 2 drain sites and occlusive dressing applied over these to secure them in place.  The Foley catheter was left in place.  The patient was awakened and taken to the Recovery Room in stable and satisfactory condition, with NG-tube in place that was placed during the procedure and placement confirmed by palpation of the gastric lumen.


----------

