Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy

Figure 1 Port placement and laparoscopic view. A-C: If the left lateral port is set for laparoscope, a wider angle of working forceps can be made. However, a stab scar of 5 mm remains visible; D-F: Port placements for LA using an endostaple with the best cosmesis are shown. LA: Laparoscopic appendectomy.

Figure 2 Major techniques during laparoscopic appendectomy. A: A suprapubic port (5 mm) for a flexible laparoscope is placed within the area of pubic hair (dotted blue line) to hide the postoperative stab scar. A left lateral port (3 mm) is placed as low as possible, to enable an adequate angle for the working forceps and to hide the postoperative stab scar by underwear; B: The bladder wall (red arrows), the dome of the bladder (dotted blue line), and the central umbilical fold should be recognized. Although the suprapubic peritoneum easily extends during port insertion, a suprapubic port should be placed without bladder injury; C: Any injury of the left inferior epigastric vessels should be avoided; D: Countertraction of the mesoappendix (red arrow) should be made without obstruction of the abdominal wall. Gripping and rotating forces of 3-mm forceps are sufficient. The appendix can be shortened in a rolled-in fashion (blue arrow) to avoid any disturbance by the abdominal wall.

Figure 3 Key techniques during laparoscopic appendectomy. A: Appendiceal vessels should be clearly dissected and be sealed without a clip for subsequent use of an endostaple; B: Total resection of the appendiceal root should be made (red solid arrow). A flexible endostaple has an advantage in extended resection to the cecum (red dotted arrow); C: The ileocecal valve should be recognized before an endostaple is placed (red arrow). Any involvement of this valve should be avoided; D: The externally-inverted staple line should be carefully checked. If there is any concern about a stump, a couple of interrupted seromuscular sutures can be added. Unrelated and spilled staples (blue arrow) should be removed.