Thank you for agreeing to this interview Dr . Williams . Let ’ s get right into it . Are appendix and gall bladder removals something that you see fairly often ?
They are extremely common . Gall bladders and hernias are my top two most seen surgical procedures preformed .
Could you talk about the difference between an open surgery and a laparoscopic ( minimally invasive ) surgery for these procedures ?
For both surgeries , the common way of doing things is laparoscopic . That ’ s what most surgeons would do first . Laparoscopic surgery has smaller incisions , and leads to moderately less pain .
Pain is all related to the incision size . Gall bladder removal used to take a pretty good size incision , but laparoscopic surgery has made it significantly smaller . Appendix removal incisions used to be a little bit larger before laparoscopic procedures as well . So , that has become the standard . It ’ s reduced recovery time and overall pain .
Are there special cases , for instance if the gall bladder or appendix is too inflamed , that you should go back to an open procedure ?
Right . If you get in there and there ’ s too much inflammation , then you may need to proceed with an open procedure . That ’ s also the case if the anatomy is different somehow . For example , there may be something in the body that deviates from the norm and that may push you to opening so you can get your hands in there and potentially sort it out .
Early on , surgeons used to worry about the patient having scar tissue from too many prior surgeries and how that might affect a laparoscopic procedure . But , these days you can free up scar tissue laparoscopically just as if you had your hands in there . It ’ s just surgical technique .
Can you lead me through a laparoscopic procedure for appendix removal ?
With an appendix , let ’ s say the appendicitis has been going on for a week . It is so inflamed that you can ’ t make heads or tails of the structure . I may have to get my hand in there to free things up and identify structures . With an appendectomy , you have limited exposure to the area . The surgeon drops down right on top of where the appendix is , and if there ’ s a lot of inflammation , you ’ re going to have to make the incision bigger . Typically though , you ’ re going to start out with a laparoscopic procedure for both of those .
Are the incisions you make the same with both procedures ?
It ’ s a little different . Gall bladder is below the belly button . That ’ s where I go in . I don ’ t use the same device that I use for the appendix . Sometimes there are big gall stones and you have to extend the incision . You don ’ t usually have to do so with the appendix . Also , the size and location of the incisions can change from surgeon to surgeon . Some people put them at slightly different locations , but each incision is usually less than a centimeter in size .
Let ’ s talk about each procedure individually . When you approach an appendectomy , what are you looking for to make sure the procedure is a success ?
If you ’ re happy with your diagnosis of appendicitis and you have a good idea of what ’ s going on , it ’ s pretty simple . Sometimes you ’ re not so sure when you look at the scan . It ’ s not always straightforward . Sometimes the patient has pain in the area , but appendicitis is questionable .
Some patients you may watch over a short interval , because appendicitis will typically get worse over time . Other patients may have tenderness right where the appendix is , the scan looks like appendicitis , and the diagnosis is easy to make .
Other times , you find things such as Crohn ’ s Disease , colonic diverticulitis , an STD or a foreign body . These could be causing problems . So , you may have to alternate what you do based the findings .
Most of the time , appendectomies are going to be straightforward . You put your trocars in . ( Editor ’ s note – a trocar is an instrument used to create an opening in the body .) There ’ s your appendicitis . You divide the blood vessels going to the appendix with your cautery instrument or stapler . Then you fire your stapler across the base of the little bag , pull it out and that ’ s it .
I understand the appendix can burst or abscess if it reaches a certain point ?
Well , its more that the appendix is obstructed . It gets swollen , the blood supply gets cut off and it starts to disintegrate . It starts leaking . Appendicitis is more of a slow and steady process . There are cases where the appendix ruptures , but most of the time it ’ s an evolving thing .
And surgery is still the best option in those cases ?
Yes . Occasionally someone will come in after the appendix has ruptured and there ’ s a well formed abscess where the appendix used to be . You could probably do a percutaneous drainage , put them on antibiotics and let things resolve , then go back later to do an interval appendectomy . There ’ s a good chance appendicitis can recur if you don ’ t . So , sometimes we let it all settle down and then take out the appendix after six to eight weeks .
VITAL SIGNS Volume 12 • Issue 2 3