"Touch Surgery" Open Appendectomy

Recently came across this app called "Touch surgery". Its an interact software that teaches the user the step by step process of performing certain surgical procedures. So naturally, I decided to give it a go with the open appendectomy and understand the steps. Heres out it went.



so as you can see from the above screenshot, the app uses 3d visuals and short step by step descriptions to guide you through the process.

Section 1 Patient Prep:

1) Patient is placed supine on the operating table

2) tuck patients arms by his/her side

3) apply compression stockings

4) shave abdomen

5) prep the patient with 2% chlorhexidine

6) Drape the patient and ensure the appropriate antibiotics are given

Section 2 Identify Anatomy:

1) Anterior superior iliac spine, umbilicus and mcburneys point are used to locate the point of incision

Section 3 Approach to the appendix

1) Make an oblique incision in the skin crease over mcburneys point.

tip: an oblique incision allows easy extension laterally for difficult case.
      also incising along a skin crease improves the cosmetic appearance of the scar.

2) Diathermy any bleeding vessels

3) Using diathermy incise and subcutaneous fat.

4) Incise through the campers fascia

5) Incise through scarpias fascia

6) Apply self retaining retractor

7) Make small incision in the external oblique muscle in line with its fibers.

8) Lift the edges of external oblique using small artery clips

9) Release external oblique from its underlying layers medially using dissecting scissors.

10) Repeat this laterally using the dissecting scissors.

11) Using the dissecting scissors now extend the opening laterally in line with the fibers of the external oblique.

12) Repeat this medially

13) Reposition the self retaining retractor to open up the external oblique. The fleshy internal oblique muscle with its perpendicular fibers is exposed.

14) using scissors, split the internal oblique muscles in line with its fibers.

tip: muscle splitting is less painful for the patient.

15) Using 2 retractors seperate the muscle transversely in line with the skin incision.

16) Reposition the self retaining retractor to include the muscle layer. Transversalis fascia with underlying peritoneum is exposed.

17) Pick up the final layers with 2 artery clips.

18) Lift the 2 clips up to take the peritoneum away from the underlying bowel.

19) Cut between the clips with the dissecting scissors.

20) Take a swab sample and send it to microbiology.

Section 4 Exposure of Appendix.

1) Extend the incision using scissors.

2) Feel for the anatomy inside the peritoneum - Identify caecum, terminal ileum, and the appendix. Remember that 75% of appendixes are retro- caecal and 20% are pelvic.

tip: follow the taenia coli muscles along the caecum as they converge at the root of the appendix.

3) Deliver the appendix into the wound with the manual traction and/or carefully placed babcocks forceps. This is made easier if the caecal pole is delivered into the wound.

Section 5 Ligation of appendicular artery.

1) Carefully hold the appendix with babcocks forceps.

2) Dissect a window in the meso appendix, at the appendix base using a small artery clip. This isolates the appendicular artery.

3) Place 2 artery clips across the appendicular vessels in the meso-apendix.

4) Cut between these 2 clips.

5) Tie off the distal appendicular artery stump and remove the distal clip.

6) Tie off the proximal appendicular artery stump and remove the proximal clip.

Section 6 Appendectomy

1) Take a heavy artery clip such as sawtell, frasers or roberts and crush the base of the appendix.

2) Place the clip just above the crushed base.

3) Transfix the base of the appendix below this clip with a 2/0 vicryl suture.

4) Cut the appendix between the suture and clip

5) Hand the specimen to your nurse to be placed in formalin and sent to histopathology.

Section 7 Restting of Caecum

1) Trim the sutures

2) Apply a 3/0 lubricated vicryl purse string around the appendix stump.

3) bury the appendix stump

4) tighten and tie the purse strings

5) Place the caecum back into the peritoneal cavity.

Section 8 Closure:

1) Carry out a careful washout of the operative field, pelvis and paracolic gutter. If there has been significant contamination, consider leaving a robinsons drain.

2) Close the peritoneum and transversalis fascia layer with a continuous 3/0 vicryl stitch

3) Use interrupted 2/0 vicryl stitch to appose the internal oblique layer.
Tip: do not tie these too tight, to avoid muscle ischaemia.

4) Close the external oblique layer with a continuous 2/0 vicryl.

5) Close the fat layer with interrupted sutures.

6) Close the skin with clips ( or monofilimant suture such as 3/0 vicryl if minimum contamination.

7) Inject subcutaneous with local anaesthetic and suitable dressing.

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