Single incision laparoscopic appendectomy technique and instrumentation

SILS appendectomy requires a specialized 10mm laparoscope with a 5mm working channel and extra long instruments to go down the working channel.

The 10mm scope will only fit through a 12mm trocar.

Cecal mobilization is performed by gently opening the peritoneum overlying the attachment between the cecum and body wall, taking care not to injure structures beneath.

The degree of cecal mobilization varies depending on how mobile the appendix is initially and how thick the abdominal wall is.

If the appendix can come up to the liver laparoscopically, then most likely it will be able to be delivered up through the abdominal wall.

Early in performing SILS appendectomy, it is beneficial to get a good intracorporeal view of the base ligature to ensure adequate ligation flush to the cecum without leaving a segment of appendix.

When deciding between one or three port approach, patient body habitus, duration of illness, and appendix size if imaging was obtained should be factored in.

Obese or extremely muscular patients can have thick abdominal walls that make it difficult to deliver even a mildly inflamed appendix.

The challenge of appendix delivery is compounded when the appendix is very thick and friable.

A five-minute timer approach is reasonable when attempting SILS, and if not making significant progress after 10 minutes, conversion to traditional three-port laparoscopy should be considered.

A 12mm trocar placed through the umbilicus by Veress needle technique will make an opening that in thin small patients will be large enough 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.

When placing a trocar by open technique, starting with the skin and fascial incision as large as possible while still concealing it within the umbilicus helps avoid failing to deliver the appendix initially.

A large fascial incision can make it hard for the trocar to stay in, which can be addressed by securing the trocar with a towel clip or suture.

If gas is leaking around the trocar, the insufflator flow should be set on high.

The suction irrigator should not be opened in routine SILS appendectomy cases, nor is it necessary if only suction is needed.

For aspirating small amounts of fluid, the suction probe can be inserted through the port with the outside end covered with a lap pad, using thumb pressure to alternately press and relax on the gauze to allow positive pressure from insufflation to push fluid out.

In cases of advanced or perforated appendicitis, the suction irrigator should be opened.

With a thick abdominal wall, placing a small Weitlaner retractor in the wound with downward pressure can help expose the appendiceal base.

When ligating the mesoappendix, flashing and reclamping the mesentery as the tie is cinched down can prevent losing the divided end into the abdomen before the tie is set.

When the appendiceal base is deep in the wound and hard to ligate by usual means, endoloops can be used to get the tie down into position.

If uncertain about ligation at the true appendiceal base, the appendix can be ligated with a long suture held externally, returned to the abdomen for laparoscopic verification, and if inadequate, further dissection can be performed before completing appendectomy.