Transvaginal Appendectomy Technique

Updated: Jun 22, 2016
  • Author: Kurt E Roberts, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Technique

Transvaginal Appendectomy

After a surgical timeout, the patient is positioned, prepared, and draped (see Periprocedural Care). Once the patient is in a steep Trendelenburg position, a weighted speculum is introduced into the vagina, allowing visualization of the cervix and exposure of the posterior vaginal fornix.

The fornix is grasped with a single-toothed tenaculum on the posterior cervical lip; this brings the posterior vaginal fornix into the operative field. Access to the peritoneum may be achieved with electrocautery and then sharp dissection (see the image below).

Transvaginal appendectomy. Culdotomy. Transvaginal appendectomy. Culdotomy.

Once successful access to the peritoneum is established and confirmed, the single-incision laparoscopic surgery (SILS) port with two 5-mm ports and one 12-mm port is introduced. Pneumoperitoneum up to 15 mm Hg is achieved. A feasible and safe modification of transvaginal appendectomy with gasless laparoscopy has also been reported. [13]  

The right lower quadrant of the abdomen is inspected and the appendix identified (see the image below).

Transvaginal appendectomy. Identification of appen Transvaginal appendectomy. Identification of appendix.

The flexible endoscopic grasper may be used to elevate the appendix medially and superiorly, so that the mesoappendix and base can be adequately visualized (see the image below).

Transvaginal appendectomy. Identification of mesoa Transvaginal appendectomy. Identification of mesoappendix.

The Maryland dissector is passed through the port and used to dissect the appendix at its base of the mesoappendix (see the image below).

Transvaginal appendectomy. Dissection of appendix. Transvaginal appendectomy. Dissection of appendix.

The mesoappendix is divided with either a LigaSure (Covidien, North Haven, CT) device or a stapler. The appendix is divided at the cecoappendiceal junction with a stapler (see the image below).

Transvaginal appendectomy. View of cecoappendiceal Transvaginal appendectomy. View of cecoappendiceal junction.
Transvaginal appendectomy. Stapling of appendix. Transvaginal appendectomy. Stapling of appendix.

Good hemostasis and the absence of spillage are confirmed (see the image below).

Transvaginal appendectomy. Inspection of staple li Transvaginal appendectomy. Inspection of staple line.

The appendix is placed in a retrieval bag and removed (see the image below).

Transvaginal appendectomy. Appendix being placed i Transvaginal appendectomy. Appendix being placed into endoscopic retrieval bag.

The culdotomy is closed with a running absorbable suture (see the image below).

Transvaginal appendectomy. Closure of culdotomy. Transvaginal appendectomy. Closure of culdotomy.
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Complications

Potential complications of this procedure may be extrapolated from the complications of culdoscopy (accessing the abdominal cavity through the posterior fornix, which is performed as an office procedure for the evaluation of infertility, for treatment of polycystic ovarian disease, or for harvest of oocytes) described in the gynecology literature. One potential complication described in the culdoscopy literature is bowel or rectal injury, which occurs in approximately 0.25% of cases. [14]

Other potential adverse effects from a gynecologic perspective include the formation of adhesions and spread of preexisting endometriosis.

Although the potential for infertility or dyspareunia was once a concern, the uterus is only passed by and uninjured on the way to the posterior fornix, so any effect on potential childbearing is unlikely.

Also extrapolated from the gynecologic literature, preservation of sexual function with transvaginal access for hysterectomy is similar to that associated with transabdominal access. [15] However, patients are recommended to refrain from sexual intercourse for a period of 2 weeks, as recommended by the gynecologists in the authors’ institution.

Antibiotic prophylaxis may be employed for reducing the incidence of infectious complications (eg, intra-abdominal abscess) after the procedure. [16]

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