Laparoscopic Appendicectomy - Operative Surgery - Steps.

1. PORTS:

1. 10mm - Umbilicus

2. 5mm - Suprapubic (Risk of bladder injury, so catheterise the patient) & another port Close to ASIS

2. POSITION: Trendelenberg ( So that small bowel moves into Upper Abdomen )

3. INSPECTION: 

1. Obviously inflamed appendix - Proceed with Appendicectomy

2. Appendix Looks Normal - Look for any other pathology in abdomen, if any other pathology found - then leave appendix in situ. Else proceed with Appendicectomy. 

4. DISSECTION:

1. Gently peel away adherent omentum & loops of small bowel from appendix using closed forceps. (Avoid holding bowel with graspers)

2. Use diathermy to release adhesion between appendix & lateral abdominal wall.

3. For Retrocecal appendix - Release peritoneum lateral to cecum » Deliver the appendix » Retract cecum upwards to expose base of appendix » pickup base of appendix. 

5. MESOAPPENDIX DISSECTION:

1. Create a window in the mesoappendix close to base.

2. Appendix and Mesoappendix is divided using diathermy.

6. LIGATION:

1. A tissue grasper is passed through noose of pre tied suture to hold the appendix.

2. Appendix is delivered through the noose and the noose is then guided to the base of the appendix and tightened.

3. Repeat step 6a and 6b

7. Cut appendix between the  ligatures. 

8. SPECIMEN RETRIEVAL: To avoid port site contamination, use specimen bag.

9. Fascia closure to all 10mm ports to prevent port site hernia and then skin closure.