“The easiest operation I’ve ever done is an appendicectomy. The most difficult operation I’ve ever done is an appendicectomy. They can bite” – Mr. Mark Taylor FRCS (Consultant HPB Surgeon, Mater Hospital, Belfast).
Inferior Epigastric Artery
The inferior epigastric artery arises from the external iliac artery, just proximal to the inguinal ligament in the mid-clavicular line.
It then courses superiorly and slightly medially, usually running between the midline and mid-clavicular-line.
This area should be avoided during port insertion (it can sometimes be seen from inside on the anterior abdominal wall).
The appendix lies at the junction of the taenia coli of the caecum. A good way of finding it therefore is to find one of the taenia and trace it backwards.
The appendicular artery is a branch of the ileo-colic artery and runs up in the free edge of the meso-appendix, giving off branches as it goes.
The patient should be positioned flat initially for laparoscopic access, then slightly head-down and right side up, as this helps move the small bowel out of the way to aid visualisation.
Most surgeons will use a three port-technique, with a port in the umbilicus, a supra-pubic port and one in the left iliac fossa (although the right upper quadrant can also be a useful location if the appendix is high). The key is place the ports in such that you get good triangulation on the appendix.
If the LIF port is below the arcuate line, a 5mm port should ideally be used to reduce the risk of port-site hernias, although early on in a surgeon’s experience, a 10mm port is easier and allows rapid insertion of a clip-applier to help control bleeding.
- Identify the appendix. The suction irrigator is useful for this if the appendix is particularly stuck down or there is an abscess.
- Perform a full laparoscopy, looking in particular at the following areas:
- Both ovaries and fallopian tubes for torted or ruptured cysts / pyosalpinx
- The terminal ileum for an inflamed Meckel’s diverticulum (classically 2 feet (60cm) from the ileo-caecal valve) or evidence of Crohn’s disease (typically presents as “fat-wrapping”, whereby the mesenteric fat wraps around the small bowel).
- Remove the appendix as appropriate (several strategies can be used here)
- A favoured strategy involves dissecting across the meso-appendix at the tip (where the appendicular artery is small) with the hook or Maryland’s forceps, then dissecting down the plane between the appendix and meso-appendix to the base.
- Another strategy is to make a window at the base of the appendix, clipping the appendicular artery low down in the free edge of the meso-appendix and dividing across it with diathermy.
- Secure the base, typically by lassoing it with endoloops; if the base is friable it can be oversewn laparoscopically (if you have the skill set). Divide the appendix and remove it in a bag via the umbilical port and check the base is secure and dry.
If there has been contamination, ensure a thorough and focused wash-out is done with several litres of warmed fluid. Consider placing a tube drain in these patients (although the need for this is pretty rare, between 2-5% of patients) and close the 12mm port-sites.
- Be careful to avoid the inferior epigastric artery with the LIF port.
- Before dissecting the appendix in female patients, double check that it is the appendix and not the fallopian tube.
- If you’re failing to progress laparoscopically, do not panic or struggle – either call for help or convert. Access via a traditional right iliac fossa incision is time-consuming and gives a poor view, so have a low threshold for a lower midline incision in these circumstances.
- When dissecting the meso-appendix, be careful about two things:
- Pushing a hot instrument towards the terminal ileum or caecum – this risks iatrogenic injury to the caecum or small bowel if you slip
- “Getting carried away” and dissecting beyond the meso-appendix and damaging the caecum
The ‘Normal Appendix’
What to do with the macroscopically normal appendix is one of the great unresolved controversies of general surgery and there are many firmly held (and frequently opposing) opinions.
One school of thought is that ~30% of patients with a macroscopically normal appendix have microscopic inflammation. Given that the patient has already been subjected to a laparoscopy, then in patients with acute right iliac fossa pain then this justifies removing the appendix (and a proportion of patients who in whom the appendix was left will certainly return with similar pains, which then poses a diagnostic dilemma in a patient who may well be unhappy that the appendix wasn’t removed the first time).
Against this is the fact that the clinical significance of these microscopic changes is unknown and that the UK National Appendicectomy Audit showed that the complication rate of removing a histologically normal appendix was the same as the complication rate of removing an appendix that was inflamed. Removing a “normal appendix” is therefore certainly not without risk.
Remember that laparoscopy is a test and that like all tests, the likelihood of it being positive depends on the pre-test probability of disease. Therefore a patient with a typical history of migratory right iliac fossa pain, focal tenderness, high temperature, raised White Cell Count / CRP probably has appendicitis whatever the appendix looks like and removing the appendix would be sensible. Conversely, a patient without any of these factors probably has another cause for their pain and appendicectomy is probably not justified.
Many surgeons favour a compromise therefore and remove the macroscopically normal appendix if there is no other obvious cause for the pain (such as a ruptured cyst or apparent Crohn’s disease). There is, however, still no consensus.