Steps

1. Insertion of ports

   Camera is introduced through the periumbilical port.

• • This port is placed using a Hassan technique or direct cut down method.
  • A diagnostic laparoscopy is performed.
  • A 5mm port is introduced in the right lower quadrant under vision.
  • A non traumatic grasper is introduced through this port to identify the appendix.

1. Exposure of the Appendix

   At this point the small is lifted out of the pelvis exposing the inflamed appendix. Careful manipulation is essential without directly grasping it to avoid bowel injury.

• • A 10mm port is introduced in a suprapubic site.
  • The appendix is grasped with the left hand instrument exposing the mesoappendix. This is adherent to the small bowel mesentery & requires careful sharp dissection with scissors & diathermy.

1. Isolation of Mesoappendicular Artery

• • We then commence scoring the mesentery with scissors & diathermy
  • A Maryland grasper is introduced and a window is created in the mesentery to isolate the appendicular artery.

1. Clipping & Dividing of the Artery

• • Three clips are applied to the isolation vessel. The vessel is divided between clips leaving two clips on the patient side.
  • We the use diathermy to divide the rest of the mesentery.

1. Application of 3x Endoloops

• • An endo-loop is introduced and placed at the base of the appendix. It is critically important to visualise the knot of the endo-loop because if this is outside the field of view it can snag onto other structures. The attached thread is divided with scissors. The two remaining endo-loops are placed and the appendix is divided between the second & third endo-loop leaving two endo-loops on the patient side.

1. Division of the Appendix

• • At this point we assess the appendix stump and divided vessel to ensure haemostasis.

1. Retrieval of the Appendix in an Endobag

• • The appendix is the grasped. the camera is switched to the suprapublic port. An endo-bag is introduced through the periumbilical port & the appendix is retrieved in this.
  • The balloon is deflated & the specimen is retrieved.
  • The ramining port is removed under vision.
  • The 5mm port is closed with monocryl.
  • The fascia of the 10mm sites is closed with vicryl.
  • The skin is close with monocryl.
  • Local anaesthetic is injected into the incisions & dressings are applied.