Subinternship Surgery · Year 4 · from Subinternship Surgery

Case 2: First Assist in the Operating Room

Patient Presentation

Demographics: 34-year-old female

Chief Complaint: Right lower quadrant pain for 18 hours

History of Present Illness: Ms. Garcia is scheduled for laparoscopic appendectomy after CT confirmed acute uncomplicated appendicitis. This is your first case as first assist, and the chief resident has asked you to prepare for the OR.

Preoperative Assessment:

  • ASA Class I, no medical problems
  • No prior surgeries
  • Labs: WBC 14,200, otherwise normal
  • CT: Dilated appendix 11mm, periappendiceal fat stranding, no perforation or abscess

Your Pre-OR Responsibilities:

  • Review anatomy and surgical steps
  • Verify consent is signed and correct
  • Confirm NPO status (last ate 16 hours ago)
  • Check if antibiotics have been ordered

Clinical Questions

  1. What anatomy should you review before this case?
  • Blood supply: appendicular artery (branch of ileocolic artery)
  • Location of appendix and McBurney's point
  • Mesoappendix and its relationship to the cecum
  • Port placement for laparoscopic approach
  • Critical view of safety principles
  1. Describe your intraoperative roles during laparoscopic appendectomy:
  • Camera driving: maintain level horizon, center instruments, anticipate dissection direction
  • Retraction: steady, appropriate pressure to maintain exposure
  • Suction: follow the action, keep field clear without obstructing surgeon's view
  • Specimen retrieval bag handling
  • Trocar site closure assistance
  1. The attending asks you to drive the camera. What are key principles?
  • Keep the horizon level
  • Center the area of dissection in the field
  • Use smooth, controlled movements
  • Anticipate where the dissection is heading
  • Keep the lens clean (wipe on gauze or use anti-fog)
  • Communicate if you need to readjust
  1. After the case, what should you do to maximize learning?
  • Thank the team and help with patient transfer
  • Review the pathology when available
  • Read about the procedure, including complications
  • Reflect on what went well and what could improve
  • Ask for feedback from the chief resident

Operative Details for Review

Standard Laparoscopic Appendectomy Steps:

  1. Patient positioning (supine, left arm tucked)
  2. Insufflation via Veress needle or open (Hasson) technique
  3. Port placement (typically 3 ports: umbilical, suprapubic, LLQ)
  4. Identification of appendix and mesoappendix
  5. Creation of window in mesoappendix
  6. Division of mesoappendix (stapler, LigaSure, or clips)
  7. Division of appendix at base (stapler or endoloop)
  8. Specimen retrieval in bag
  9. Irrigation and hemostasis check
  10. Closure of port sites >10mm

Clinical Image

Image: Laparoscopic appendectomy surgical view. Source: Wikimedia Commons. License: Public Domain/CC BY-SA.

Image Attribution: Appendectomy specimen. Available at: https://commons.wikimedia.org/wiki/Category:Appendectomy. Licensed under Creative Commons.

All cases for this lecture as Markdown