SILS Appendectomy by Dr. Nelson Rosen

Welcome to our brief introductory video on single incision laparoscopic appendectomy, more commonly referred to as Syll's appendectomy. You see before you the items necessary for Syll's appendectomy, and they include a specialized 10 millimeter laparoscope with a 5 millimeter working channel, as well as the extra long instruments to go down the working channel. Now we'll show you how to assemble the scope's working port. The end of the port is similar to the top of a trocar. Within this piece fits a dark gray one-way valve. Next comes the black cap. Be careful to screw the threads on correctly without breaking the cap. Finally, a light gray rubber piece covers the top of the cap. Now that the port end has been assembled, it must be attached to the scope. The end of the scope has a mating surface with a notch which corresponds to a mating surface on the port which has a prong. The two mating surfaces fit together, and the prong goes into the notch. When lined up, a locking ring on the port end can be screwed onto the scope, holding everything together. Make sure it is connected well so that it does not become loose during the procedure. The working port. Is where you slide instruments down into the abdomen like you would through a trocar. The eyepiece is standard like all other laparoscopes you are already familiar with and connects to the camera. There is a small valve near where the light cord connects that is used for cleaning the scope and should be kept closed during use. While the scope is described as a 10 millimeter scope, it will only fit through a 12 millimeter trocar. Here you see the fenestrated bowel grasper, also known as the paper clip. The set includes an endoscopic scissors, a Maryland dissector, and another type of a traumatic bowel grasper, often referred to as a gator or the wavy gravy. There's also a hook electrocautery probe and the laparoscopic aspirator probe that fits on the striker suction irrigator set. We start focusing on the right lower quadrant and peel momentum away as needed. Once we have adequate visualization and we can see where the appendix is sitting, we focus on the attachment between the cecum and the retroperitoneum because we're trying to deliver not just the tip of an appendix but the base, so we gently mobilize the cecum bluntly by delicately opening up the peritoneum overlying the attachment between the cecum. And the body wall. Taking care not to injure structures right beneath. Sometimes you can take the tip of the instrument. And gently grasp a bit of peritoneum and sweep towards the liver to make an opening into the retroperitoneum through which you can put the tip of the instrument and then continue to sweep to complete the mobilization. The degree of mobilization varies depending on how mobile the appendix is to start with and how thick the abdominal wall is. If the abdominal wall is substantial and you feel that you might struggle bringing the appendix up, more mobilization might be beneficial. Once we feel we might have full mobilization. We grasp the appendix and see if we can bring it up towards the liver. If the appendix can come up to the liver, then most likely it will be able to be delivered up through the abdominal wall. At this point we'll want to grasp the tip of the appendix with a locking grasper. The key is to get a good squeeze of the tip of the appendix and to be able to have a firm grip to be able to effect the delivery. Once the appendix has been grasped, we bring it up to the level of the trochar and then remove the gas from the trochar and open the valve to start desinflating the abdomen. Once we have that done, we remove the trochar and gently bring the appendix up through the wound, grasping it often with a gauze or an Alice or Babcock clamp. Once you have the appendix mobilized through the abdominal wall, perform an appendectomy. For your reference, here's how Doctor Rosen does it. Once the appendix is up, you can suspend it with an Alice or Babcock clamp and complete your appendectomy. Here the meso appendix is dissected and divided between clamps, and the patient's side is ligated. With a little bit of traction on the appendix we verify if there are any residual bands or meso appendix left that will get in the way of a good low ligation and anything. Remaining is dissected and either ligated or cauterized. Once the appendiceal cecal junction is adequately dissected. It may be ligated. Here we affect the suture ligation of the base of the appendix. The tie is held in the clamp to be able to avoid the stump slipping back intraperitoneally after division. A clamp is placed across the appendix defining the stump, and a scalpel is used to divide it. The stump is cauterized and irrigated before returning to the peritoneal cavity. Once the appendiceal stump has been returned back to the abdominal cavity, we often put the trochar back in and reinsert the laparoscope to take a look. Early in performing this procedure, it's nice to get a good intracorporeal view of the base ligature to make sure that you've gotten flush enough onto the cecum and are not leaving a segment of appendix. We reinspect to make sure we have good hemostasis. Any irrigation or aspiration can be done at this time, and once we're satisfied that everything is fine intraperineally, the scope is removed and wound closure finishes the surgery. This quick and simple procedure utilizes many of the basic surgical skills you are already familiar with. There are a few differences though, and appreciating them will make your transition to the new technique much easier, as well as increase the likelihood you will succeed with the technique when deciding between a 1 or 3 port approach, factor in patient body habitus, duration of illness, and appendix size if imaging was obtained. Obese or extremely muscular patients can have thick abdominal walls that make it difficult to deliver even a mildly inflamed appendix up enough to perform appendectomy with confidence. The challenge is compounded when the appendix is very thick and friable. It is reasonable to start with the sill's approach, even if you're not confident you'll be able to finish that way. Give yourself a 5 minute timer and when that time passes, if you have yet to succeed, ask yourself if you're making significant progress. If so, persist for another 5 minutes. If after 10 minutes you feel that you're not really making forward progress, do not hesitate to ask for the standard length 5 millimeter instrument tray, a 5 millimeter 30 degree scope, and place two additional trocars. Complete the surgery in a traditional intracorporeal fashion. If you find that with two hands you can safely mobilize and then wish to complete the appendectomy transumbilically, that's fine as well. A 12 millimeter trochar placed through the umbilicus by various needle technique will make an opening that in thin, small patients will be large enough for you to work through for appendectomy. When the abdominal wall is thick or the appendix is thick and friable, the fascial opening may need to be enlarged to safely deliver the appendix. If placing a trochar by open technique, it is usually helpful to start with a skin and fascial incision as large as you can make while still concealing it within the umbilicus. This helps avoid failing to deliver the appendix initially and having to enlarge the incision before a second try. Sometimes a large fascial incision makes it hard for the trochar to stay in. You can secure the trochar with a towel clip or suture. If gas is leaking, set insufflator flow on high. We also have special trocars with a balloon on the tip to secure it and maintain a seal. The seal's equipment tray has a 45 centimeter suction irrigator tip that fits on the end of the striker suction irrigator, but you should not open the suction irrigator in routine cases, nor is it necessary if you only need suction. If you wish to aspirate some fluid, insert the suction tip through the port and cover the outside end with a lap pad. Hold the suction probe by the end and use a thumb to alternately press and relax on the gauze to allow positive pressure from the insufflation to build up and push the fluid up and out the suction tip into the gauze. If you have a moderate amount of fluid, regular suction tubing can be applied over the tips end to facilitate suctioning. If you encounter advanced or perforated appendicitis, open a suction irrigator with a thick abdominal wall. It can be helpful to place a small wheat liner retractor in the wound and apply downward pressure. This can help expose the base. When ligating the meso appendix, consider taking a precaution against losing the divided end into the abdomen before the tie is set. When the clamp is loosened as the tie is cinched down tightly, flash the clamp and reclamp the mesentery until the tie is complete. When the appendiceal base is deep in the wound and hard to ligate by usual means, consider using endo loops to get the tie down into position. Sometimes when working through a small incision in a thick patient, it can be challenging to know if you're truly at the appendiceal base. If you are not 100% certain, you can ligate the appendix where you think the base is and leave the suture long and held on an external clamp. Return the appendix back into the abdomen and re-explore laparoscopically. If you ligated low enough, deliver the appendix and complete the appendectomy, but if not, dissect further. This video was made possible by the efforts of our entire Syll's appendectomy research team, with a special thanks to Doctors Rachel Hanky and Alex Cassar for their time and effort in filming, editing, and producing this video.