Laparoscopic Appendectomy

Acute appendicitis is the most common acute abdomen in children. Because the pig's appendix wall is thin, the perforation rate is high; the abdominal cavity has poor ability to limit infection. Once perforation often causes diffuse peritonitis; at the same time, children are often unable to treat early due to diagnosis delay, so the clinical appendicitis is more serious. Therefore, once the diagnosis of appendicitis in children, surgery should be treated immediately. In the 1930s, due to the use of antibiotics, some appendicitis was also improved by antibiotic treatment. However, due to the residual inflammation of the appendix, there is still a recurrence. Therefore, the best treatment for recurrent appendicitis is still appendectomy. Laparoscopic appendectomy (LA) is a new surgical procedure that has emerged with the development of laparoscopic techniques. In 1983, Semm reported the first laparoscopic resection of non-acute inflammation of the appendix, 4 years earlier than laparoscopic cholecystectomy. The appendectomy for laparoscopic acute appendicitis was first reported by Semm in 1987. Subsequent laparoscopic appendectomy has been reported in both adults and children, but it is far less common than laparoscopic cholecystectomy, and there are controversies about the pros and cons of LA. A large number of prospective, randomized, controlled trials have demonstrated that laparoscopic appendectomy is superior to conventional appendectomy (CA) in that hospital stay is short, postoperative complications are low, and recovery is rapid. For cases that cannot be diagnosed before surgery, intraoperative exploration is broader than open surgery, and the superiority of retroperitoneal and subhepatic ectopic appendix is more suitable. Obese patients are more suitable. It is a safe and reliable minimally invasive surgical procedure. Treating diseases: appendicitis Indication 1. The diagnosis of acute appendicitis was established. 2. Except for acute appendicitis, there are indications for surgical exploration. Contraindications 1. The incidence of acute appendicitis in children over 48h, the lower right abdomen touched the mass, considering the formation of appendix abscess, temporarily not surgery, active anti-infective treatment and close observation of changes in the condition. 2. Have a history of lower abdominal surgery, it is estimated that the establishment of pneumoperitoneum. Preoperative preparation 1. The sick child is in good general condition and can be operated immediately. When the sick child is seriously poisoned and dehydrated, it should be prepared for several hours, including intravenous infusion, antibacterial application, high heat and temperature reduction, etc., which can make anesthesia and surgery safer. 2. Place the stomach tube if necessary before surgery. 3. It is possible to transfer to the family to open the open surgery. Surgical procedure Place the catheter After the anesthesia is successful, the catheter is routinely placed to prevent the pubic bone from puncturing the bladder. 2. Establish a belly Cut the skin about 0.5-1.0cm on the umbilicus or the lower arc. Use two cloth tongs to clamp the sides of the incision and lift the skin of the abdominal wall. Veress pneumoperitoneum is slowly puncture through the umbilical incision, and there is a feeling of falling into the abdominal cavity. Then connect the air belly machine and inject CO2 gas. The gas pressure is 10 mmHg under 7 years old and 12 mmHg (1.33 to 1.60 kPa) over 7 years old. Pull out the pneumoperitoneum needle and insert a 10mm diameter trocar from the umbilical incision. There is a feeling of falling out. After the gas is discharged, the cone core is removed and a 30° laparoscope is placed. 3. Place the casing After laparoscopic implantation, the upper abdomen, right lower abdomen, left lower abdomen and pelvic cavity were sequentially observed, with or without secondary injury, inflammation around the abdominal cavity and appendix. Under laparoscopic monitoring, a 5 mm or 2 mm diameter cannula was placed on the cecum of the right iliac crest and placed in a non-invasive grasping forceps. A 5 mm diameter cannula was placed over the top of the bladder above the pubic symphysis, which placed the grasping forceps, electrocoagulation hooks, aspirator and micromirror. If the appendix is located in the posterior cecum, the surgical exposure is difficult, and a 5 mm cannula can be placed on the left side of the pubic symphysis puncture point. 4. Cut off the tail (1) appendix treatment: insert the non-invasive grasping forceps from the right upper abdomen, find the appendix along the colonic band, separate the surrounding adhesions, use the grasping forceps to clamp the tip of the appendix or its mesangium, and pull the appendix to the upper right to make the appendix The membrane "expands like a sail." The appendix is treated close to the appendix to facilitate the removal of the appendix. The treatment of the appendix can be performed by a variety of methods, such as bipolar coagulation, titanium clip clamping, and in vivo or in vitro suture. (2) Root treatment of the appendix: If the root of the appendix is not thick, the inflammation is not heavy, and two titanium clips can be sandwiched at the root. The appendix is cut between the two titanium clips, and the stump is electrocoagulated and burned. If the root of the appendix is thicker, the root of the appendix can be ligated with a Roeder knot, and the distal end of the appendage can be ligated once again. The appendix is cut between the two ligatures and the stump is electrocauterized. (3) Check for active bleeding, whether the ligature or titanium clip is firm, absorb the peritoneal exudate, and wash with local saline if necessary. Adjust the position to the head-high right tilt position before rinsing. If drainage indications are placed, the abdominal drainage tube can be placed in the right colonic sulcus to the pelvic direction. (4) Remove the appendix from the 10mm casing. If the appendix is heavy or perforated, it should not be taken out directly. Put it into the take-up case and take it out. When taking the appendix, it should be operated under the microscope. complication Iris artery bleeding The main reason is that the appendix is inflamed and edematous, and the mesangium is thickened and curled, and it is not easy to flatten it. Intravascular coagulation is not complete, and the appendix artery bleeding occurs when the mesentery is cut. The precautionary measure is to dissect the appendix mesenteric to flatten it, using a bipolar electrocoagulation forceps, the internal coagulation time is 30 seconds/time, and the general internal coagulation is 2 to 3 times. Close to the cecal area should be banded to stop bleeding, to prevent electrocoagulation and cecum. 2. Intraperitoneal infection Due to the inflammation of the appendix, the stump was improperly treated, the distal ligation line of the appendix fell off, and the contents spilled and contaminated the abdominal cavity. 3. Puncture infection This kind of infection occurs mostly in the puncture hole of the appendix, which is caused by the contamination of the appendix. The prevention method is to prevent the dirt in the appendix cavity from overflowing into the abdominal cavity, and the heavier appendix can be taken out in the take-up case. 4. Puncture hole Generally occurs in the umbilical incision, the content is usually the omentum, the reasons are: 1 umbilical puncture hole is large and straight; 2 due to anatomical reasons after pulling out the cannula, the abdominal wall can not be tightened quickly; 3 deflation rate is too fast, The abdominal pressure drops rapidly, causing some of the retina to poke. The precautionary measure is to slowly remove the pneumoperitoneum and suture the subcutaneous fascia of the umbilical puncture hole for 1 stitch. 5. Subcutaneous and omental emphysema Subcutaneous emphysema can be absorbed by itself without treatment. Omental emphysema is caused by pneumoperitoneum needle penetration into the greater omentum. From the mirror, there is a membrane of vascular network on the surface of the liver. The real liver is not seen. It is proved that the omental air sac is formed and should be puncture from the left lower abdomen. Hole, placed into the vascular clamp, piercing the omental cyst. It is only after seeing the liver that it proves to enter the free abdominal cavity.