Video Transcript: A Video on Appendectomy in Gynecologic Surgery
A video on appendectomy in gynecologic surgery. Our objectives are to provide an overview of laparoscopic appendectomy in the context of gynecologic surgery, as well as discuss indications for appendectomy in gynecology. We will demonstrate the surgical technique, as well as present two relevant clinical scenarios.
Appendectomy is one of the most common surgical procedures performed globally. Indications for removal include acute inflammation, related pathology, chronic pelvic pain or abnormal appearance during non-related abdominal or pelvic surgery. We propose that appendiceal assessment be part of the routine gynecologic survey and that performing an appendectomy become part of surgical training in gynecology. We will present two clinical cases to illustrate the importance of this skill.
A number of considerations are important to help select appropriate patients for appendectomy. The appendix is identified in every case to rule out abnormalities. All abnormal-appearing appendixes are removed at the time of surgery, even if appendectomy is not related to the primary surgery being performed. The appendix is removed if indicated by primary pathology. And finally, all patients with severe endometriosis or chronic pelvic pain provide written consent for possible appendectomy.
The operative setup is for routine gynecologic surgery. The patient is in a dorsal lithotomy position, and Trendelenburg is applied as necessary. A leftward tilt may be considered to facilitate exposure of the appendix. All patients should receive peri-operative antibiotic prophylaxis in the form of a first-generation cephalosporin and aminoglycoside or metronidazole.
The surgical approach to laparoscopic appendectomy can be divided into five simple steps.
Step 1: Isolate the Appendiceal Base
The mesoappendix is isolated and separated close to the base of the appendix using bipolar electrosurgery forceps and monopolar scissors or laparoscopic ultrasonic shears. The mesoappendix is carefully desiccated here with bipolar energy and subsequently transected. The eventual goal here is to isolate the appendiceal base.
Step 2: Secure the Base of the Appendix
The base of the appendix is secured with two 0 PDS Endoloops placed on the proximal portion of the appendix. It’s important to place the first Endoloop as close to the appendiceal base as possible. The second Endoloop is then placed 2mm to 3mm distal to the first one.
Step 3: Endoloop
A third 0 PDS Endoloop is placed on the specimen side, approximately 5mm distal from the second Endoloop.
Step 4: Transect the Appendix
The appendix is transected between the second and third Endoloops using laparoscopic scissors. We recommend avoiding the use of energy here to avoid damaging the suture.
Step 5: Remove the Appendix
The appendix is removed from the abdomen using a laparoscopic retrieval bag.
We will now present two clinical scenarios to demonstrate the clinical importance of routine appendiceal assessment, as well as comfort with performing an appendectomy in gynecologic surgery. In this first clinical scenario, a 38-year-old multiparous woman presented to us for further management of a misplaced intrauterine device. Perforation of the uterus was suspected at the time of IUD placement in the preceding days and confirmed on pelvic ultrasound. Intraoperatively, the IUD was noted in the left lower quadrant, with no associated injury to nearby organs or visible uterine perforation.
Routine inspection of the appendix, however, revealed a sizeable growth at the appendiceal tip. The patient went on to undergo a laparoscopic removal of a misplaced IUD, as well as a diagnostic hysteroscopy and placement of a Mirena IUD under direct vision. She also underwent an appendectomy. The pathology report suggested a carcinoid tumour with extension into the peri appendiceal fat and mesoappendix. Consultation with general surgery was requested, and a full metastatic work-up was performed. The patient subsequently underwent a laparoscopic right hemicolectomy and has done well to date.
In the second clinical scenario, a 34-year-old nulliparous woman presented with abdominal pain and a clinical diagnosis of left ovarian torsion. A pelvic ultrasound revealed an 8cm by 9cm complex left ovarian cyst with vascular septations. Her Ca 125 was normal at 11, and the patient subsequently underwent a laparoscopic left salpingo-oophorectomy. Intraoperative findings included a 10cm complex left ovarian cyst with multiple septations and serous content. The ovary was torted twice about its stalk.
The appendix was inspected as part of our routine gynecologic survey, and a note was made of vesicular lesions at the appendiceal base and over the cecum near the appendix. In addition to describing a mucinous cystadenoma of the left ovary, the pathology report confirmed a carcinoid tumour of the appendix. This was described as a swell differentiated, with negative surgical margins. However, focal extension into the peri appendiceal fat and mesoappendix was documented. The patient thus underwent a hemicolectomy with negative surgical margins and is doing well to date.
In conclusion, it’s crucial to include appendiceal assessment as part of a routine gynecologic survey. In addition, appendectomy should be part of gynecologic surgical training. As demonstrated in this video, the appendix should be removed if it appears abnormal at the time of surgery or if it’s indicated by primary pathology. Finally, appendectomy should be considered and written consent should be obtained in patients with chronic pelvic pain or severe endometriosis.