SILS Appendectomy by Dr. Nelson Rosen

The specialized laparoscope is described as a 10mm scope but will only fit through a 12mm trocar.

The degree of cecal mobilization varies depending on how mobile the appendix is initially and how thick the abdominal wall is.

If the appendix can come up to the liver laparoscopically, it will most likely be able to be delivered up through the abdominal wall.

The key to successful delivery is to get a good squeeze of the tip of the appendix with a locking grasper to have a firm grip.

Early in performing this procedure, it is beneficial to get a good intracorporeal view of the base ligature to ensure adequate flush ligation onto the cecum without leaving a segment of appendix.

When deciding between 1 or 3 port approach, factor in patient body habitus, duration of illness, and appendix size if imaging was obtained.

Obese or extremely muscular patients can have thick abdominal walls that make it difficult to deliver even a mildly inflamed appendix.

The challenge of delivery is compounded when the appendix is very thick and friable.

It is reasonable to start with the SILS approach even if not confident of finishing that way, using a 5-minute timer and reassessing progress.

If after 10 minutes of attempting SILS there is no significant forward progress, do not hesitate to convert to traditional intracorporeal approach with two additional trocars.

A 12mm trocar placed through the umbilicus by Veress needle technique will make an opening that in thin, small patients will be large enough to work through for appendectomy.

When the abdominal wall is thick or the appendix is thick and friable, the fascial opening may need to be enlarged to safely deliver the appendix.

If placing a trocar by open technique, it is helpful to start with a skin and fascial incision as large as possible while still concealing it within the umbilicus to avoid needing to enlarge the incision after failing initial delivery.

If gas is leaking around a large fascial incision, set insufflator flow on high; special trocars with a balloon on the tip can also be used to maintain a seal.

The suction irrigator should not be opened in routine cases, nor is it necessary if only suction is needed.

When ligating the mesoappendix, consider taking precaution against losing the divided end into the abdomen before the tie is set by flashing and reclamping the mesentery until the tie is complete.

When the appendiceal base is deep in the wound and hard to ligate by usual means, consider using endo loops to get the tie down into position.

If uncertain whether at the true appendiceal base when working through a small incision in a thick patient, ligate where the base is thought to be, leave the suture long on an external clamp, return the appendix to the abdomen, and re-explore laparoscopically to verify adequate ligation before completing appendectomy.