with Dr. César Ginestà
A 40-year-old male patient with relevant medical record was brought to the emergency room suffering from abdominal pain, vomiting and fever. In the physical examination he had stated that he was in pain and had rebound tenderness at the right iliac fossa.
There were leukocytosis and high levels of CRP and an abdominal ultrasound was carried out showing a thickened cecal appendix with surrounding inflammatory changes and a 6-cm abscess that could not be drained by the radiologist.
Surgical treatment was performed with the patient in the supine position, and the surgeons located to the left of the patient. A total of three trocars were used: a 12mm trocar at the umbilicus for a 30° scope, a 12mm trocar at the right flank, and a 5mm trocar in the suprapubic position.
The goal of the procedure was to drain the abscess and evaluate the possibility of removing the appendix. Examination of the abdominal cavity revealed a plastron composed of the sigmoid colon, the terminal ileum, the appendix and the cecum.
Blunt dissection was performed in order to individualize the terminal ileum from the appendix. During this manoeuvre the abscess was drained, the separation plane became more evident. There was edema from the inflammatory process and tissues tend to bleed more easily.
The sigmoid colon was detached from the plastron. Traction was performed against the pelvic wall. An evolved appendicitis made the surrounding organs rigid. Step by step the individualization was completed.
The appendix was identified, its mesentery was also thickened and fused, the left hand of the surgeon performed countertraction and suction was used for blunt dissection, the correct plane was hard to identify. The peritoneum was accidentally detached during the mobilization of the appendix.
Appendix assessment was performed to decide the best strategy to section it. The mesentery was thickened. Its division was performed with clips and the hook, there was bleeding from the appendicular artery despite the scaled section. It was controlled using clips.
The appendicular base was prepared for section. The attached peritoneum was separated with the hook, now the appendicular base was released. An EndoGIA™ was used to improve a secure section appendix.
The surgical specimen was removed in a bag. The surgeon performed revision for bleeding and lavage with iodine solution. A drain was placed for postoperative surveillance.
The surgery took 120 minutes. The patient presented a mild ileum. Oral intake started on the third postoperative day and the patient left the hospital five days after the procedure. The pathological evaluation ruled out malignancy.
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