Finding appendix

Once adequate access to the peritoneal cavity has been obtained, the appendix is delivered into the wound. Usually, this is achieved by insertion of an index finger laterally along the paracolic gutter, posterior to the caecum. The caecum is hooked and then drawn anteriorly. With the caecum delivered, then the taenia coli are followed distally until they converge at the appendix.

If the appendix is difficult to locate, the following should be considered:

• grasping the caecum, ideally under direct view, with non-toothed forceps
• tilting the patient so that the right side is more inferior
• displacing loops of small bowel medially with a retractor
• dividing the adhesions on the lateral side of the caecum if the appendix is potentially retrocaecal

To prevent prolapse of the appendix back into the wound, it is secured at the first opportunity with Babcock's tissue forceps. However, these should not be used to apply traction to the viscus as this may precipitate peforation.