Mini lap appy

This video demonstrates a mini laparoscopic appendectomy using the 5 millimeter just right surgical stapler. The patient is a 16-year-old female presented with a 24 hour history of increasing right lower quadrant pain. Here you see the room set up. Two ports are placed through a 1 centimeter umbilical incision, and a single 3 millimeter incision is made in the suprapubic area for the left hand retracting port. Here you see the abdomen, uh, and being prepped and then draped. The child weighs 65 kg and so it's possible to use this technique in patients up to 100 kg, if necessary. After the abdomen is uh adequately prepped and draped, the inferior umbilical ring is infiltrated with lidocaine to avert it. A 1 centimeter incision is then made within the umbilicus so that the scar will not be visible postoperatively. A V needle is then inserted and the abdomen is insufflated to a pressure of 15. We use primarily this closed. Technique In all of our cases. A 4 millimeter trochar is then inserted for a 4 millimeter 30 degree scope. Uh, in larger patients, we will often use a 5 millimeter 30 degree scope. A second trochar is inserted through the same incision but through a separate fascial defect, and this is for the 5 millimeter Maryland and 5 millimeter hook cautery and eventually the 5 millimeter stapler. A tiny 3 millimeter incision is made just above the. Pubic bone, uh, below the pubic hairline. And this is for a 3 millimeter Babcock which provides right angle retraction, allowing for safe dissection and manipulation of the appendix. Here you see the inside view. This is a, uh, just a mildly inflamed appendix, uh. And we're using a hook cautery to take the appendiceal mesentery. You can see there is a significant amount of energy spread and smoke using this, but because we're not concerned about injury to the appendix itself, it is being removed, uh, we use monopolar cautery in this case. This can of course be done using. Uh, either a 3 millimeter sealer or other energy devices, uh, but in general, a reusable hook cay is adequate. The mesentery is divided down to the base of the appendix. It is important to not. Leave the appendiceal artery, uh. Patent next to the appendix if you're using the 5 millimeter stapler. Uh, as sometimes the vessel is so small, uh, the staples do not adequately capture it. Patients with a thicker mesentery, you can use the staple load for the mesentery, although this technique works quite well. With the appendiceal mesentery taken, the base of the appendix is then grasped and compressed to ensure that it is not too thick for the 5 millimeter stapler. The 5 millimeter stapler is then inserted and compressed. Checking to make sure there is excellent alignment of the two ends. If necessary, the stapler can be reapplied, and here you see an excellent staple line. There's an occasionally some very mild oozing at the staple line, and this is insignificant. Uh, with the appendix free, um, the 5 millimeter trocar is removed. And the currently available 5 millimeter endoscopic bag is inserted. Uh, through the fascial defect. It is placed into the abdominal cavity where it is opened and the appendix is placed within it. Again, you can see that the uh surgical staple line of the appendiceal stump is uh intact and that there's no significant bleeding. The bag is then removed through the umbilicus. Camera port is removed and if necessary, the fascial defect is widened or the two fascial defects are joined using a Kelly clap. But the patient remains with a 1 centimeter skin incision.