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General Surgery Specialty
General Surgery (General) Subspecialty
UCSF Health
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Past Notes
(upbeat lighthearted music)
<v ->Hi, I am Jonathan Carter.</v>
I'm a professor of clinical surgery
here at UCSF in San Francisco,
and today, we're gonna do a laparoscopic appendectomy.
(upbeat music)
The patient is a guy that came in
with a right psoas abscess a couple months ago.
That was managed with a percutaneous drain and antibiotics.
The cultures were polymicrobial.
We believe that was caused from appendicitis.
He has completely recovered,
now he's coming electively to get his appendix out.
(upbeat lighthearted music)
The main challenge today might be adhesive disease.
The patient has a history
of a laparoscopic lysis of adhesion
and a small bowel resection for adhesive disease.
He's got a periumbilical small midline laparotomy
and so, I think,
the trick is gonna be to see how bad his adhesions are
and whether we can sneak around them
to get back to the appendix and get the appendix out.
It's gonna be good, here we go.
(upbeat music)
We're gonna do a laparoscopic appendectomy today,
and I wanna talk a little bit
about how we set up the case.
And these are general principles of laparoscopic surgery.
The first principle is we wanna set up a line,
and the line goes from surgeon to camera,
to target organ, to monitor.
So, you can see all four points are in a line.
And so, in this patient's case,
we're gonna put on our laparoscope here.
The target organ is about here, in the right lower quadrant.
I'm gonna stand here, and you can see,
I got my monitor straight across from me,
not in the right upper quadrant.
The second principle
is you always wanna set your laparoscope
between your right and left hand.
So, once I've decided
that my laparoscope is gonna go here,
I wanna set my left hand somewhere to the left of that,
and in this case, we'll just do suprapubic midline,
and then, my right hand, periumbilical, like this.
And you wanna set up your working port
so that the angle that they meet,
when they hit the target organ,
varies between 60 and 90 degrees.
If you do it that way,
you'll find that really, it's ergonomical and easy.
If you're too far back,
you get kinda this coaxial difficulty manipulating organs,
and if you're too close, you get more like this.
The other rule is, if you just hold your hand like this
and make an arc, and you put your pinky on the target organ,
all of your ports should be on the arc, basically.
We're gonna get in with Palmer's point.
So, Palmer's point is midclavicular line,
just below the costal margin, which is about here.
Let's go ahead and get in.
Incision.
And the Veress needle, how do you safely do this?
What I do is, every time there's a pop,
I jiggle it in and out, and I can tell
that the the tip of this is still against a membrane.
So, I'll insert a little more.
There we go.
So, now we're free.
So, I know that I'm in the peritoneal cavity now,
'cause the tip's free.
Now, this patient, I'm a little worried.
He has a history of small bowel obstruction,
probably from a congenital adhesion
that required a lysis of adhesion
and a small bowel resection.
So, I don't know what the adhesion burden is gonna be.
I usually put my 12 millimeter port
pretty close to the umbilicus, but in this patient,
we're gonna cheat it up into the left upper quadrant a bit.
At this point, we've delivered 3.4 liters
and his pressure is six.
So, we'll probably take another liter or so.
And end tidal, dropped a little bit, we're at 36,
but pressure is good, sat's good, heart rate's good.
Okay.
So, we're gonna put a 12-port on my right hand.
I'm gonna use that to staple, and it needs to be a 12,
'cause that's what the stapler goes through.
Okay, so I can see anterior rectus sheath,
there's rectus muscle, posterior sheath,
peritoneal cavity, and we're in.
All right, come on in Owen,
let's take a look at that Veress needle.
So, you'll notice I haven't withdrawn the Veress needle yet.
Visceral perforations with the Veress needle
occur about, maybe, one in 500 to one in 1,000,
and the only way you're gonna make the diagnosis
is you're gonna see the needle
actually penetrating through the colon.
And so, I make a point not to withdraw this needle
until I've gone in and inspected.
So, the Veress needle looks clean,
and you can see the underlying colon looks clean,
and there's no injury to the viscera.
Okay.
Okay, so our goal is to get the appendix out,
so I'm not really interested in doing a lot of lysis,
if we can avoid it.
For the suprapubic 5-port,
you just wanna avoid the dome of the bladder.
In the left midabdominal port,
you wanna avoid the inferior epigastrics.
(machine beeping)
Okay, so we're just gonna do a little lysis.
Let's drive our scope around here,
and we're gonna work down in here now.
I'm gonna switch to the LigaSure.
Okay, so we're just gonna sneak around, ninja-like,
around these adhesions,
and just really focus on getting his appendix out,
which is our goal.
He has not had any clinical signs
of small bowel obstruction,
so I don't feel like a lysis is indicated.
I wanna make sure there's no bowel or anything.
Look down just a little.
Yeah, looks fine.
<v Owen>It's just this round ligament.</v>
<v Jonathan>Round ligament, yeah.</v>
So, I'll sneak right under that.
(LigaSure clicking) (machine beeping)
Great, this looks like gallbladder.
(LigaSure clicking)
And we'll just finish lysing these
and then we'll focus down on the right lower quadrant.
(LigaSure clicking)
Great.
So, this patient presented originally with a psoas abscess,
so we can go stem up, straight up.
Our first goal is to just identify the cecum,
and I think this is cecum.
This looks like small bowel.
This looks like cecum, here.
Okay, and there is the base of the appendix.
I'll take another grasper.
<v Owen>That's here.</v>
<v Jonathan>Okay.</v>
The way to find the appendix
is if you just follow the taeniae coli down,
it will always run into the appendix.
So, here is the appendix here.
(machine beeping)
We'll see how well.
Looks like there's some few little adhesions down here.
Looks like the small bowel is a little bit stuck
to the base.
So, we can disconnect those.
(LigaSure clicks)
You know, there's many ways to do an appendectomy.
I like using the LigaSure as my cutting, sealing device,
'cause it produces a nice seal,
and I feel like that protects you from post-op bleeding.
The other thing
is you don't have to spend a lot of time making a window,
it's whatever presents to you first,
whether it's the base of the appendix or the tip,
you can just staple it off.
Different people use different things
to divide the cecum and the appendix.
I think the stapler works the best.
(stapler clicking)
We just divided this base,
and now, we're just gonna work on the tip,
and our main trick
is to get this loop of small bowel off here
without hurting the small bowel.
So, we'll just keep working on teasing that off,
and as we come down here,
we'll sequentially be taking down the mesoappendix.
(LigaSure clicking)
Slowly getting there.
Looks like we got the whole thing.
There is the tip.
<v Owen>Uh-huh.</v>
(LigaSure clicking)
<v Jonathan>Divide between those staples.</v>
Okay, take the Endo Catch bag.
Okay.
And then we'll just pull this up,
and then, we're just gonna look for hemostasis.
I'll take a grasper.
Looks nice and dry.
You can see the base of the appendix is well closed.
Staples are well formed.
So, we're done.
Okay, so, to close,
all we gotta do is pull out our specimen,
so I'm gonna pull out my 12-port,
and then I'm gonna pull out the appendix, the specimen.
And then I'll take the large cone,
Carter-Thomasson, No. 1 Vicryl.
Now, I put all my ports through muscle
'cause I believe that you have less hernias.
(lighthearted music)
So, this port actually goes through his rectus muscle.
You saw that on the entry point.
Great.
So, we're done.
(upbeat music)
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