Currently, most transvaginal appendectomies are performed using the pure transvaginal technique or the hybrid transvaginal technique with either flexible or rigid instruments.

Access to the peritoneal cavity during pure transvaginal appendectomy is obtained by incising the mucosa of the posterior fornix of the vagina with entry into the peritoneum in the cul-de-sac, with or without assistance from a gynecologist depending on the comfort level of the general surgeon with transvaginal anatomy. A weighted speculum is introduced to the vagina, and a uterine retractor is used to lift the uterus anteriorly to expose the posterior vaginal fornix. The cervix is grasped with a single-toothed tenaculum and retracted anteriorly. The colpotomy is created transversely in the posterior fornix using electrocautery or, alternatively, using scissors. Specific landmarks have been described to identify “the triangle of safety” within the posterior fornix [13], using the base of the cervix and the rectovaginal fold (Figs. 18.2 and 18.3).

The pure rigid laparoscopic appendectomy technique employs the use of a SILS™ port (Covidien, Mansfield, MA) that is inserted into the colpotomy site (Fig. 18.4) [14]. Two 5-mm ports and one 12-mm port are used. The right lower quadrant of the abdomen is inspected, and the appendix is identified (Fig. 18.5). A flexible endograsper may be used to elevate the appendix medially and superiorly, so that the mesoappendix and base can be adequately visualized. A Maryland dissector is passed through the port and used to dissect the appendix at its base of the mesoappendix. The appendix is divided at the ceco-appendiceal junction with a stapler (Fig. 18.6). The mesoappendix is divided using an ultrasonic dissector, a ligating cautery device, or a stapler (Fig. 18.7). Then, the appendix is placed in a retrieval bag and removed (Fig. 18.8). The staple lines are inspected for completeness and hemostasis (Fig. 18.9).

A single-channel endoscope (gastroscope or colonoscope) is introduced after the colpotomy is made. Carbon dioxide insufflation can be achieved through the endoscope, or alternatively, a Veress needle introduced at the umbilicus can be used. Endoscopic instruments passed through the working endoscope channels are used for dissection of the appendix. The endoscopic needle-knife cautery is used to dissect the mesoappendix. An endoloop, introduced through the channel, is used for ligation of the base of the appendix. A second endoloop is placed slightly distal to the first, and the appendix is sharply transected between the endoloops with endoscopic scissors or needle-knife cautery. Grasping the free end of the endoloop with an endoscopic grasper, the appendix can be retrieved from the abdominal cavity [10, 11].

In hybrid transvaginal appendectomy, access to the peritoneal cavity is first obtained transumbilically with a Veress needle. Capnoperitoneum is established to a pressure of 15 mm Hg, and a 5-mm trocar is placed through the umbilical incision. The patient is placed in steep Trendelenburg position, and the pelvis is inspected for adhesions that obliterate the pouch of Douglas. In the absence of these findings, the uterus is elevated with a uterine retractor (Humi retractor). Once the “triangle of safety” is exposed, the colpotomy is performed with simultaneous direct laparoscopic visualization of the cul-de-sac by penetrating the posterior fornix of the vagina with a trocar. Alternatively, scissors or electrocautery may be used.

Knuth et al. [5] placed a transvaginal 5-mm trocar followed by an adjacent 13-mm trocar for the camera and stapler. Standard, rigid laparoscopic instruments are used. The laparoscope can alternate between the transvaginal or transumbilical port as needed for optimal visualization. A transvaginal, rigid, curved, grasper forceps is introduced to retract the appendix. The mesoappendix can be divided with a stapler, coagulation, clips, or a combination of these. The specimen is retrieved transvaginally through the 13-mm port.

The working ports of the transvaginal endoscope are used to proceed with appendiceal dissection similar to the pure endoscopic approach described above. The umbilical port acts as an added working port for a grasper to retract the appendix. Endoscopic coagulation forceps are used to dissect the mesoappendix, and the appendiceal artery is coagulated [15, 16]. Alternatively, the endoscopic graspers are used to retract or lift the tip of appendix, and the mesoappendix is dissected free using an ultrasonic dissector introduced through the umbilical port [17]. Endoscopic graspers retract the appendix, and a laparoscopic snaring device is introduced via the umbilical port to ligate the base of the appendix. Transection of the appendix is made with laparoscopic scissors or the ultrasonic scalpel. The specimen is recovered transvaginally.