# Lap drainage of abscess w resection of appendiceal stump



## ksb0211 (Apr 2, 2013)

I'm not quite sure which direction to head with this one.  The patient had undergone a laparoscopic appendectomy for a ruptured appendix on 02/12.  He presented to the ER on 03/05 with abdominal pain which revealed multiple abscesses.  This is the surgery that followed.  Not quite sure how to bill this one.

POSTOPERATIVE DIAGNOSES
Intraperitoneal abscess with residual appendiceal stump.

OPERATIONS PERFORMED
Laparoscopic drainage of abscess x3 with resection of appendiceal stump.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR after induction of adequate general anesthesia, the patient was prepped with DuraPrep and draped sterilely.  Perioperative antibiotics had been administered.  The initial incision was made in the infraumbilical region with a #15 blade and carried down through the subcutaneous tissues.  The Veress needle was introduced.  The abdomen was insufflated to 15 mmHg pressure with CO2.  Once this was done, the 5 mm port was passed without difficulty.  Following this, a 5 mm port was placed in the epigastric area and 1 in the right lower quadrant.  The 10-12 port was placed in the Infraumbilical site.  With all this completed, the patient was noted to have adhesions of omentum and fibrous adhesions of liver to the diaphragm.  These were taken down with primarily bluntly.  The liver was quite friable and some capsule tears were noted without significant bleeding.  Ultimately, I was able to trace the liver edge up to the region of the most cephalad abscess.  It was actually fairly lateral.  Once this was done, the abscess was opened and irrigated.  A fecalith was identified and this was ultimately caught in an EndoCatch bag.  Cultures were taken of the purulent fluid.  It was well irrigated.  Once this was done, attention was then turned to the abscess in the region of the hepatic flexure.  The liver and the flexure were mobilized somewhat.  Ultimately, I was able to get into a abscess cavity.  Again, a fecalith was identified and the area was well irrigated.  With all this completed, the right gutter was mobilized somewhat and again ____ irrigated with antibiotic solution.  With decreased inflammatory response relative to the time of the initial surgery, the cecum was better visualized and there appeared to be a significant residual appendiceal stump.  This was mobilized and the Endo-GIA with blue load was passed.  The fecaliths and the appendiceal stump were then retrieved with the EndoCatch bag.  The abdomen was thoroughly irrigated with antibiotic solution.  A 10 mm Jackson-Pratt drain was placed via the right inferior port site.  The drain was secured in place with 3-0 nylon, fascia of the midline infraumbilical incision was reapproximated with figure-of-8 of 0 Monocryl.  Wounds were injected with 0.5% Marcaine and closed with 4-0 Vicryl subcuticular stitch.  Steri-Strips and Tegaderm applied.  The patient tolerated the procedure.  Cultures are pending.


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