Video: GLLS Appendicectomies

Appendicectomy is the most common abdominal operation performed as an emergency. Appendix is a tubular structure at the ileo-cecal junction. The inflammation of the appendix causes Appendicitis. There are several types of appendicitis of which the obstructive type is the most dangerous. Obstruction by a fecolith can cause peritonitis either by rupture of the appendix or by the appendix becoming gangrenous. The catarrhal type of inflammation causes appendicitis that resolves with treatment with antibiotics. The subacute type can cause vague symptoms and is the most difficult to diagnose as the classical symptoms are absent. There could be lot of Fibrosis and adhesions.

Although the diagnostic protocols might differ in the west and at medical college setting the diagnosis still remains clinical in rural areas. Most of the senior surgeons go by the guarding and rigidity in the right iliac fossa due to inflammation of the appendix. Several clinical signs have been described.

The following clinical signs are from an old video from a small mission hospital in Northeast and this is to let you know that the clinical signs have not changed for several decades. Simple laboratory tests like total and differential count and urine microscopy could add value to clinical diagnosis.

We would like to primarily discuss about the minimally invasive procedures. Although there are no questions about the need for surgical procedure for acute appendicitis we had several interesting exchanges with editors of international journals regarding so called elective surgeries.

The final consensus was that in remote and rural areas elective surgeries still has a significant place. The logic is simple. When patients have to travel very long distances to access surgical care there is significant morbidity and mortality due to delay. The chance of repeat attack of appendicitis is much higher that the chance in general population.

Minimally invasive surgeries have lot of advantages over open surgeries because they help with confirmation of diagnosis. Sometimes there are surprises like this one where the actual pathology would be hidden under the retractors of the open surgery and Appendicectomy does not help. In rural areas showing the pathology to the patient and relatives help with their accepting the surgical procedures.

Before we had the laparoscopic surgical equipment we used the cystoscope to help with minimally invasive surgery. For elective appendicectomies we made a small incision at the McBurney’s point and after introducing the cystoscope we either used towel clip or purse string suture to hold the tissues tight around the scope. For air insufflation we used either the BP cuff or the pathfinder that we use for URS.

Having the patient in head down position with the right side up helps in visualization of the appendix. The appendix is then grasped with cystoscope grasper and pulled out of the incision. Appendicectomy is carried out like in open surgery and the stump is then pushed inside.

The gas less or GLLS apparatus offers the most comfortable way of carrying out Appendicectomy under spinal anesthesia. The umbilical incision offers the most cosmetically attractive scar and laparoscopic diagnosis is possible for the surgery.

It is important to make sure that shoulder braces are in position and a sand bag under the right gluteal region is helpful.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
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