SILS Appendectomy by Dr. Nelson Rosen

The specialized laparoscope for SILS appendectomy is described as 10mm but requires a 12mm trocar for insertion.

The degree of cecal mobilization needed varies depending on baseline appendix mobility and abdominal wall thickness.

If the appendix can be brought up to the liver laparoscopically, it will most likely be deliverable through the abdominal wall.

Patient body habitus, duration of illness, and appendix size on imaging should be factored into the decision between 1-port or 3-port approach.

Obese or extremely muscular patients have thick abdominal walls that make it difficult to deliver even mildly inflamed appendices high enough for safe appendectomy.

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

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

If after 10 minutes of attempting SILS there is no significant forward progress, conversion to traditional multi-port technique with two additional trocars should be performed.

A 12mm trocar placed through the umbilicus by Veress needle technique creates an opening large enough for transumbilical appendectomy in thin, small patients.

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

When placing trocar by open technique, starting with a skin and fascial incision as large as possible while still concealed in the umbilicus helps avoid needing to enlarge the incision after failed initial delivery attempt.

A large fascial incision can make trocar retention difficult; the trocar can be secured with towel clip or suture, and insufflator flow should be set on high if gas is leaking.

The suction irrigator should not be opened in routine SILS appendectomy cases.

For aspirating small amounts of fluid, the suction tip can be inserted through the port with the outside end covered by a lap pad, using thumb pressure to alternately press and relax on gauze to allow positive insufflation pressure to push fluid out.

When ligating mesoappendix, a precaution against losing the divided end into the abdomen is to flash and reclamp the mesentery as the tie is cinched down until the tie is complete.

When the appendiceal base is deep in the wound and hard to ligate by usual means, endo-loops can be used to position the tie.

If uncertain whether ligation is at the true appendiceal base, the appendix can be ligated with a long suture held externally, returned to abdomen for laparoscopic inspection, and if inadequate, further dissection performed before completing appendectomy.