General

Appendicectomy (Laparoscopic) (Variant)

OPERATION: Appendicectomy (Laparoscopic)
ANAESTHETIC: General anaesthesia
ANTIBIOTICS: Broad-spectrum IV antibiotic with anaerobic and gram-negative coverage administered at induction
POSITION: Supine. Urinary catheter inserted. Left arm tucked. Table capable of Trendelenburg and left lateral tilt.

INDICATION:
Acute appendicitis confirmed on clinical assessment / CT / USS.

PROCEDURE:
WHO Checklist performed. Abdomen prepared and draped.

ACCESS AND PORT PLACEMENT:
Umbilical access via Veress needle / open Hasson technique. Pneumoperitoneum CO2 to 12-15 mmHg. 5 or 10/12 mm camera port at umbilicus. 30 degree laparoscope. Initial laparoscopic survey performed. Two further working ports inserted under direct vision: one suprapubic (10/12 mm) and one right upper quadrant or left lower quadrant (5 mm). Table placed in Trendelenburg with left-side-down tilt to displace small bowel from the right lower quadrant.

IDENTIFICATION OF APPENDIX:
Right lower quadrant visualised. Free fluid or purulence suctioned and sent for MC+S. Caecum identified. Taenia coli followed to their confluence at the appendix base. [Retrocecal appendix: lateral caecal attachments divided, allowing inferior and medial mobilisation of the caecum to display the appendix.] Appendix identified and grasped atraumatically.

DIVISION:
Mesoappendix elevated. Window created at the appendix base. Mesoappendix divided with a vascular load on the linear endoscopic stapler / sequential laparoscopic clips / energy device down to the appendix base. Appendiceal artery secured and divided.

Appendix transected at its base using a gastrointestinal load on the linear stapler / doubly ligated with pre-tied absorbable endoloops and divided between ligatures. [Necrosis extending to caecal base — partial cecectomy performed with stapler.]

Staple lines / ligatures inspected for haemostasis and security. [Closed-suction pelvic drain placed if perforated or gangrenous appendicitis.]

SPECIMEN RETRIEVAL:
Appendix placed in endoscopic retrieval bag and removed through the 10/12 mm port. Abdominal cavity copiously irrigated and aspirated, particularly the right lower quadrant and pelvis.

CLOSURE:
Pneumoperitoneum reduced to confirm haemostasis under reduced pressure. Ports removed under direct vision. Fascia of 10/12 mm port closed with absorbable suture. Skin closed with subcuticular absorbable suture / tissue adhesive.

FINDINGS:
[Acutely inflamed / gangrenous / perforated] appendix. [Free purulence / localised pus / no free fluid]. Appendix base [viable and suitable for stapling / requiring partial cecectomy].

SPECIMEN: Appendix to histopathology. Peritoneal fluid to microbiology if purulence present.
EBL: Minimal. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Eat and drink as tolerated. IV antibiotics continued 24-72 hours if perforated or gangrenous appendicitis. Mobilise early. VTE prophylaxis as per protocol.