Case Study: Open Appendectomy simulator
When we went to the RCSI to visit the Wet lab and talk to leonie Heskin, we were introduced to to the Deltec open appendectomy model that they were currently using to teach students. It is because of this model that inspired Leonie to create the open appendectomy brief, as she feels someone can create a more efficient, cheaper, higher fidelity model that can be used to teach her students.
So, naturally we decided to have a look at the step by step process that this model teaches the students, and pick away at what was going on.
This video on YouTube demonstrates the step by step process of performing the open appendectomy and this is what it says:
- use a grid iron incision to open up the skin in line with the fibres of the external oblique.
- Divide subcutaneous fat, scarpus fascia, and underlying tissue, to expose the upper oblique upperneurosis.
- use scissors to cut through layer
- Upper oblique upper neurosis should be divided by the line of its fibres
- Reposition self retaining retractors to give a better view.
- Deepen the incision to expose fibres of internal oblique
- Reposition retractors
- Cut through internal oblique
- Internal oblique should be split rather than divided by opening mayo scissors in the line of its fibres.
- The split can then be widened using langenback retractors to give you a better view. This displays the muscle underneath
- Widen hole with scissors.
- Cut through transversis abdonomis by splitting the line of its fibres.
- Once this is done the fused transversis fascia should be visible.(and peritoneum)
- Apply 2 masquito forceps to a fold of peritoneum, and ensure onlu peritoneum is held, by pinching the peritoneum with your fingers
- make a small incision in the peritoneum by using a small scissors or knife, and enlarge the hole in-line with the skin incision.
if there is fluid or puss, take a swab or alternatively take a sample with a syringe.
look for any bile stained fluid which may indicate a perforated ulcer.
3) Identifying the appendix
- Identify the cecum via taenie coli and follow these to the base of the appendix.
- It may be possible to find the appendix with a finger sweep.
- In some circumstances the cecum may need to be immobilised in order to deliver the appendix
- View the mesoappendix against the light to locate the appendicular artery which enters from the medial aspect.
- Create a window in the mesoappendix avoiding the vessels and ligate the vessels, between clips using 2/0 vicryl sutures.
- Divide the vessels, then divide the mesoappendix
4) Removing the appendix
- Crush the appendix base with a hemostat and places it distal to the cross segment.
- Doubly ligate the cross segment with 2/0 vicryl sutures
- Divide the appendix, approximal to the hemostat and place these instruments in a dish for contaminated articles.
- Insert a seromuscular purse string suture of 20BDS or similar material on a round bodied needle, encircling the appendix base.
- this is to completely seal off the closed appendix wound and ensure infection doesnt occur in the future.
- Ask your assistant to push the appendix base using non-toothed forcep, while you tighten the purse string to bury the stump
5) Closing Up
- First the peritoneum is closed using a continuous suture of 20BDS. It may help to place clips on the edge of the peritoneum.
- Loose interupted 2/0 vicryl stitches should be used to oppose the muscles of transversis obdonimus and internal oblique.
- External oblique is closed using continuous stitch of 2/0 vicryl
- Scarpus fascia can be closed using interrupted sutures
- A subcirticular suture of 3M monocryl can be used to close the skin incision
Early observations from this case study, indicated to us that the model addresses the incision poorly and locating the anatomy. This is a key insight that we understood from this observation and hope to address this further down our process.
link for video: