Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia and has remained on IV antibiotics. The obese abdomen is widely prepped with DuraPrep and draped. A vertical incision was made in the previous supraumbilical vertical scar, with remarkably thin subcutaneous tissue identifying loose fascia. This is opened, I can palpate adhesions on the right side but none on the left and introduced a 12 mm port with CO2 insufflation and camera introduction. The liver has a somewhat blunted edges and has a regular texture. The stomach is deflated. Pus is evident in the right lower quadrant with obviously inflamed small bowel, omentum adherent to the right lower quadrant. Omental and small bowel adhesions to the infero-umbilical midline and down toward the pelvis. Rotating the camera around the adhesion I find a left suprapubic site and can indent, make a small incision and introduced the 5 mm port under vision. Using grasper and Maryland LigaSure I release the omental adhesions from the anterior abdominal wall, somewhat tediously. I then released the omental adhesions over the ascending colon and find the terminal ileum and inflamed Fat Pad of Treves. The cecum is inflamed, I find the medial tinea in the anterior free tinea and finds inflamed tissue and exudate but no obvious appendix. I then aspirate for cultures and then begin irrigation, freeing the inflamed small bowel and its mesentery from this process retracted to the left, and identifying inflamed fat and inflamed redundant rectum, depressed inferiorly. Then I release the lowest lateral attachments of the cecum and elevate, staying adjacent to the intestine to avoid the inflamed retroperitoneum and course of the right ureter, neither sought nor identified. The exposure of the cecum for definitive dissection now commences, about an hour and 15 minutes of the 2-hour operation was with lysis of adhesions.
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I then follow the two identified tinea to inflamed tissue which has a tubular texture to it and I am able to elevate, with difficulty from exposure, I am able to release until its apparent attachment to the cecum and I amputate with a tan load tri-stapler. This is collected and submitted to the pathologist but returns as probably inflamed and necrotic fat. Dr. department is kind enough to scrub and into the room and begin separately dissecting the fat pad of Treves to clearly identify the introduction medially of the terminal ileum into the a sending colon. He dissects beneath that to clearly identify the medial posterior cecum and absence of inflamed tissue or abscess. More laterally against the lateral sidewall, a superficial dissection is initiated and I commence release of the lateral cecum more thoroughly and then beneath. We now recognized perhaps a tubular structure plastered against the right side of the lower most posterior cecum. That is gently teased, quite tediously with a pulling technique and find separation and feels apparent it can be separated in its midportion. This looks to be normal appendix and probably represents the tip. With more tedious dissection and separation in the inflamed tissues, to avoid injury to the cecum, this can be finally freed. Now it is apparent that the proximal appendix is congested and purple with a small pinpoint opening that may have represented a perforation. By grasping the inflamed fat, which includes the previous staple line of, what is now recognized as, para-appendiceal inflamed fat, I can elevate and circumferentially dissect more to the origin with the cecum. I now introduced a second 45 mm tan load tri-stapler and amputated against the cecum. This is collected in a new specimen retrieval bag. I now complete irrigation in different positioning, and initially head of bed down and then head of bed up to aspirate sequentially the left diaphragmatic area, right diaphragmatic area, right paracolic gutter, right mesentery, right paracolic gutter, and then finally into the pelvis. The irrigant returns clear. There is minimal blood loss during the dissection mostly the lysis of adhesions but total blood loss is perhaps less than 10 or 15 mL’s. Under vision I remove the two 5 mm ports, I find no back bleeding. I now deflate the abdomen and remove the midline port. All sites are irrigated with saline. The midline fascia at the umbilicus is closed with 2 placed 0 Vicryl sutures under direct vision. Each site is irrigated and skin closed loosely with staples with covered arm applied. I had infiltrated a total of 30 mL 0.5% Marcaine with epinephrine distributed at the 3 port sites. She is awakened and extubated, transported to PACU. There were no intraoperative complications and no cardiopulmonary altered vital signs.
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