Minilaparoscopic appendectomy

Needlescopic appendectomy versus conventional laparoscopic appendectomy in young patients

INTRODUCTION

Several studies have reported that needlescopic appendectomy (NA) is a safe and effective procedure for appendicitis because of reduced trocar wounds and tissue trauma. The aim of this study was to evaluate the efficacy of NA in young patients under 40 years of age whose cosmesis matters with appendicitis by comparing it to conventional laparoscopic appendectomy (CLA).

METHODS

We retrospectively reviewed our database looking for patients under 40 years of age diagnosed with appendicitis who underwent NA or CLA from January 2013 to April 2017. Patients were divided into two groups: the NA group, and the CLA group. Data collected from each group included age, gender, body mass index, preoperative C-reactive protein, emergency or non-emergency settings, operative time, postoperative length of stay, postoperative complications, and pathological diagnosis.

RESULTS

Fifty-four patients underwent NA and 53 patients underwent CLA. The groups were similar in terms of demographic features. Pathological diagnoses were divided into the following categories: catarrhalis (n = 35), phlegmonous (n = 37), and gangrenous (n = 35). No significant difference was noted regarding the distribution of the three groups (P = .4). NA resulted in significantly shorter operative times (P = .0005), and reduced lengths of hospital stay (P = .03) as compared to CLA. There was no significant difference in the number of complications between the two groups.

CONCLUSION

NA might be an effective surgical technique when performing a laparoscopic appendectomy in young patients with appendicitis.

Single-Port Needlescopic Appendectomy in Children Using a Mediflex Needle: A New Simplified Technique

Background: Laparoscopic appendectomy is among the most common surgical procedures. Needlescopic appendectomy (NA) is an acceptable, safe technique in children, but with many drawbacks such as a high conversion rate and long operative time. We present a new technique for NA in children using only a single port, Mediflex^® facial closure needle, and vascular access cannula (VAC). Patients and Methods: Single-port NA was attempted in 117 patients (51 boys, 66 girls). Under general anesthesia, a 5-mm camera port was inserted through the umbilicus. Two Mediflex needles and a 14-gauge VAC were introduced. The appendix was grasped and dissected from the surrounding tissues using Mediflex needles. In case of a mobile cecum, the appendix was pulled through the umbilical port, then an extracorporeal appendectomy was performed. In cases with a fixed cecum or severely inflamed appendix, a complete intracorporeal appendectomy was done. The suture was knotted in a sliding reef knot using a single instrument. Results: NA was completed in 117 patients (51 boys, 66 girls) with an average age of 10 years. Thirty patients underwent extracorporeal appendectomy. Eighty seven patients were treated by intracorporeal appendectomy. The mean operative time was 15 ± 3 and 25 ± 4 minutes for extracorporeal and intracorporeal appendectomy respectively. The hospital stay was 1.2 days on average (ranging 8 hours to 2 days). There was no single case of conversion. Family satisfaction was achieved in 97% of cases. Conclusion: The presented unique method for single-port NA using Mediflex^® appears to be a safe, acceptable technique for appendectomy in children that allows for excellent cosmetic results.

Development of a Two Port Laparoscopic Appendectomy Technique at a Rural Hospital

Background

Laparoscopic appendectomy (LA) is most commonly performed using two 5-mm and one 10/12-mm ports. Various attempts to reduce the number and size of ports have been made and new technologies such as single port LA have been introduced. Appendix and mesoappendix are usually divided with a stapler or energy device with electrocautery, clips, and endoloop being cheaper options.

Patients and Methods

This study includes 51 consecutive LAs performed at a rural hospital. Patients were divided into 4 groups: group 1 was the standard technique group (n=12), group 2 served as a “try-out” (n=12), group 3 served as feasibility group (n=12), and group 4 was the final patient cohort in which the optimized technique was preferably used (n=15).

Results

Median age of the study cohort was 35.4 (range: 6.2-80.6) years, and 55% of patients were male. Whereas in G1 all patients had standard port placement (10/12-mm, 2x5-mm), in an increasing number of patients in G2-4 only two 5-mm ports and the 2.3-mm Teleflex minigrasper were inserted. Usage of staplers and/or energy devices was reduced from 100% in G1 to 20% in G4, and in the majority of cases both the appendix and the vascular pedicle were secured with an endoloop. The new technique did not add time to the procedure or total OR time. No stump-leaks or surgical site infections were encountered in this series, and there were no conversions to open surgery. Cost savings when not using a stapler or energy device are approximately 400$ per case; the minigrasper added approximately 200$ to the case.

Discussion

LA with use of two ports and a portless needle grasper is feasible in the majority of cases and was associated with high patient satisfaction and excellent cosmetic results. Avoiding energy devices and staplers is cost saving; the endoloop securely controls appendix and mesoappendix.

Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery

INTRODUCTION:

The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA).

MATERIALS AND METHODS:

All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot.

RESULTS:

A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay.

CONCLUSION:

This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.

Single-Port Laparoscopic Cholecystectomy With the X-Cone: A Feasibility Study in 9 Pigs

Objective: Virtually any port system for single-port laparoscopic surgery is for single usage only. The aim of this study was to trial the novel and completely reusable port X-Cone in order to perform a cholecystectomy by one infraumbilical incision. Methods: Single access cholecystectomies were performed in 9 anesthetized domestic pigs in nonsurvival studies. Only one infraumbilical incision was performed for placing the reusable, multichannel steel port system. A newly developed angulated forceps was used besides regularly used instruments in laparoscopic surgery. Results: The gallbladder was successfully removed in 9 pigs. At postmortem examination, the clips placed on the cystic duct and the cystic artery. No bile leakage was found at the operative field. Conclusion: Single-port cholecystectomy with the reusable X-Cone single-port system is safe and feasible. No additional incisions were needed. The system is ergonomically designed, easy to handle, and the learning curve for cholecystectomy is steep.

True single-port appendectomy: first experience with the "puppeteer technique"

BACKGROUND

Laparoscopic appendectomy is one of the most commonly performed minimally invasive surgeries worldwide. In recent years, successful attempts to reduce the number of the traditionally used three ports have been reported. Specifically, two-port techniques, hybrid approaches, and single-port assisted techniques have been described.

METHODS

In this case series, the author describes for the first time a successful and uncomplicated true single-port appendectomy (TSPA) technique. Between July and December of 2007, 14 consecutive patients were assigned to undergo TSPA for presumed appendicitis at Yale-New Haven Hospital. The novel approach involves an innovative "puppeteer technique," which uses a "pulley" in the form of an intraabdominally placed loop to the abdominal wall as an axle to elevate the appendix with a string. The thread is pulled by the surgeon extracorporeally, similar to a puppeteer moving the limbs of his or her puppets.

RESULTS

Of the 14 patients, 13 (8 women and 5 men) underwent a successful TSPA. One patient was converted to a two-port appendectomy. The average age of the patients was 37.5 years (range, 22-59 years), and the average body mass index (BMI) was 27.4 kg/m(2) (range, 19.4-39 kg/m(2)). The mean operative time was 87.5 min (range, 54-128 min). No major complications were observed. One minor postoperative complication occurred, involving urinary retention, which resolved within 24 h.

CONCLUSIONS

The novel "puppeteer technique" seems to be a safe and easily reproducible alternative to previous laparoscopic appendectomy techniques. It uses only one single 11-mm port without any additional skin incisions or transdermally traversing needles. It is performed entirely intracorporeally, resulting in presumably less postoperative pain and improved cosmesis. Randomized controlled trials are necessary to investigate this novel technique. The TSPA technique, the first of its kind in the treatment of appendicitis, minimizes the minimally invasive approach to a new level.

Feasibility of endoscopic transgastric distal pancreatectomy in a porcine animal model

BACKGROUND

In contrast to laparoscopic tubal ligation, oophorectomy, and appendectomy, laparoscopic distal pancreatectomy is associated with a morbidity rate of more than 50% and a mortality rate of more than 3%.

OBJECTIVE

To develop a minimally invasive, transgastric endoscopic technique for distal pancreatectomy in a nonsurvival series in swine.

DESIGN

Experimental study.

SETTING

Animal trial at a tertiary-care academic hospital.

SUBJECTS

Six healthy Yorkshire swine under general anesthesia.

INTERVENTIONS

A double-channel gastroscope was introduced into the stomach, and a gastric incision was created by using a triple-lumen, 4-mm, cutting-wire needle knife. The peritoneal cavity was accessed. An Endoloop was placed endoscopically around the distal aspect of the pancreas, and the tail of the pancreas was transected by using a diathermic snare. One to 3 hemoclips were placed across the pancreatic duct. The pancreatic specimen was retrieved, and the gastrotomy was closed endoscopically with metal clips. The animals were euthanized after the procedure. The abdominal cavity was examined grossly, and the resected pancreas was examined histologically.

MAIN OUTCOME AND MEASUREMENTS

Feasibility of endoscopic transgastric distal pancreatectomy and rate of complications.

RESULTS

The pancreatic tail was successfully resected via a transgastric endoscopic approach in all animals. The procedure took an average (standard deviation) of 77.3 +/- 18.9 minutes. There was 1 complication, an episode of bleeding from a splenic laceration, which resulted in the loss of 250 mL of blood.

LIMITATIONS

Nonsurvival series, animal study.

CONCLUSIONS

Transgastric endoscopic distal pancreatectomy is technically feasible and can be performed in the porcine animal model.

Peroral transgastric organ resection: a feasibility study in pigs

BACKGROUND

The feasibility of peroral transgastric peritoneoscopy, liver biopsy, and tubal ligation has been demonstrated in prior animal studies. This approach has the potential to reduce postoperative morbidity.

OBJECTIVE

To explore the technical challenges and complications of performing a transgastric organ resection.

DESIGN

Two-week animal survival study.

INTERVENTIONS

Five female Yorkshire pigs underwent peroral transgastric partial hysterectomy. With the animals under general anesthesia, a sterile esophageal overtube was placed and a gastric antibiotic lavage was performed. Subsequently, a needle-knife and through-the-scope dilating balloon were used to make an anterior gastric wall incision through which a therapeutic gastroscope was advanced into the peritoneal cavity. Endoscopes and instruments previously had been disinfected in a 2.4% glutaraldehyde bath or were disposable. An endoloop and polypectomy snare were used to resect a portion of the uterus, which was removed through the mouth. Gastric incision closure was attempted with endoclips. After 2 weeks of observation, necropsy was performed.

RESULTS

Transgastric partial hysterectomy was performed on all 5 animals. One animal became lethargic and febrile, so necropsy was performed on day 4. An incompletely closed gastric incision and suppurative peritonitis were found. A second animal developed a fever; necropsy performed on day 14 revealed a gastric abscess at the incision site and scattered abdominal pus. No complications were encountered in the 3 remaining animals, and necropsy revealed well-healed gastric incisions and no evidence of peritonitis.

CONCLUSION

Endoscopic transgastric partial hysterectomy is technically feasible in a porcine model. Strict sterility seems mandatory but cannot always be assured. Incomplete closure of the gastric incision may lead to significant complications.

Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model

BACKGROUND

Advances in endoscopic equipment have enabled endoluminal techniques to supplant select surgical procedures. Access to extraluminal structures holds the potential to revolutionize flexible endoscopy but, to date, has been limited. The aim of this study was to demonstrate the feasibility of endoscopic transgastric organ resection (oophorectomy and tubectomy) with 2-week survival.

METHODS

Female Yorkshire pigs underwent general anesthesia, and a sterile esophageal overtube was placed. Antibacterial gastric lavage was performed, and a sterile gastroscope was passed through the overtube. Subsequently, a transgastric incision was made with a needle knife. The endoscope then was advanced into the peritoneal cavity, and the ovaries and the fallopian tubes were identified. An endoloop was used to secure the ovary, the fallopian tube, and the mesosalpinx. Snare cautery oophorectomy and tubectomy was performed, and the specimen was retrieved through the gastrotomy. The incision was closed with endoclips, and 2-week survival studies were performed.

OBSERVATIONS

The peritoneal cavity was accessed in all animals (n = 6) without significant complications. The ovaries and the fallopian tubes were easily identified, and unilateral oophorectomy and tubectomy were successfully performed. Postoperative 2-week survival was uneventful in all animals. At necropsy, the gastric incision was seen as a well-healed scar with giant-cell reaction. There was histologic evidence of chronic inflammation at the resection site, without abscess, hematoma, adhesion, or damage to surrounding viscera.

CONCLUSIONS

Endoscopic transgastric oophorectomy and tubectomy with 2-week survival is feasible with meticulous closure of the gastrotomy. This novel technique may extend the applications of flexible endoscopy to include aspects of abdominal surgery.

Mini-laparoscopic appendectomy using a needle loop retractor offers optimal cosmetic results

BACKGROUND

Do conventional laparoscopic appendectomy (LA) techniques provide truly satisfying results for patients and surgeons? We have devised a more advanced technique that improves cosmesis.

METHODS

A 2-mm scope is inserted at the umbilicus, and a 12-mm working trocar is inserted through a suprapubic incision placed below the line of pubic hair. A needle loop retractor (NLR) is inserted to hold the appendix in the lower right abdomen. In this NLR, a stainless steel wire is placed within a needle having a diameter of 2 mm. From the suprapubic trocar, a bipolar coagulator is inserted to transect the appendiceal mesentery. A series of 30 patients underwent this procedure.

RESULTS

There were no conversions to laparotomy and no intra- or postoperative complications.

CONCLUSIONS

Laparoscopic appendectomy using a 2-mm scope, suprapubic trocar, and an NLR yields optimal cosmetic results. For surgeons, the NLR allows the appendix to be held more firmly than then a 5- or 2-mm grasping forceps is used.

An "all 5-mm ports" selective approach to laparoscopic cholecystectomy, appendectomy, and anti-reflux surgery

Laparoscopic appendectomy, cholecystectomy, or anti-reflux procedures are conventionally performed with the use of one and often two 10/12-mm ports. While needlescopic or micropuncture laparoscopic procedures reduce postoperative pain, they invariably involve the use of one 10/12-mm port and the instruments applied have their ergo-dynamic shortcomings. Between September 2002 and March 2003, we have attempted an "all 5-mm ports" approach in 49 laparoscopic procedures, which included 18 of 59 laparoscopic cholecystectomies (31%), 26 diagnostic laparoscopies for suspected appendicitis (of which we proceeded to a laparoscopic appendectomy in 17 patients), and in the last 5 of 9 laparoscopic Nissen fundoplications. Conversion of one of the 5-mm ports to a 10-mm port was required in 5 of the 18 (28%) laparoscopic cholecystectomies and in 6 of the 17 (35%) laparoscopic appendectomies to facilitate organ retrieval in patients with large gallstones (>5 mm in diameter) and in obese patients with fatty mesoappendix. There were no conversions to open surgery. No significant differences in the operating time between the laparoscopic procedures performed by the all 5-mm ports approach or the conventional approach were observed. No intraoperative or postoperative complications occurred in this series. The "all 5-mm ports" approach to laparoscopic cholecystectomy and appendectomy in selected patients and to laparoscopic fundoplication appears feasible and safe. A randomised comparison between this approach and the conventional laparoscopic approach to elective cholecystectomy and fundoplication in which two of the ports employed are of the 10-mm diameter is warranted.

Needlescopic appendectomy

BACKGROUND

In this paper, we compare our experience with the techniques of needlescopic appendectomy (NA) (2-mm instruments) for the treatment of acute appendicitis with the more conventional approach of a laparoscopic appendectomy (LA).

METHODS

We did a retrospective review of patients who underwent NA for the diagnosis of acute appendicitis between August 1996 and January 2002. Variables including operative time, blood loss, postoperative time to discharge, intra- and postoperative complications were analyzed and compared to data from control patients who had undergone an LA for acute appendicitis.

RESULTS

The NA group had a longer average operating time (54.5 +/- l3 vs. 42.5 +/- 12.6 min, p = 0.0001) and a longer postoperative hospital stay (2.1 +/- 1.4 vs. 1.3 +/- 1.1 days, p = 0.01). Blood loss was similar for the two groups.

CONCLUSIONS

With the exception of superior cosmesis, NA appears to have little advantage over the better-established LA; moreover, it has some disadvantages. A clearer benefit of this procedure over LA, as well as improvements in instrumentation, needs to be shown before it can be widely accepted.

Laparoscopic appendectomy: a gynecological approach

The removal of surgical specimen at operative laparoscopy through an incision of the posterior fornix is frequently performed for the removal of pelvic masses of the internal genital tract. We present a technique for the removal of the appendix through a laparoscopic colpotomy. Eight patients who underwent laparoscopy for a suspected pelvic or adnexal disease and intraoperatively found to be affected by an appendicular disease were included in the present series. After intrabdominal dissection, the appendix was removed from the abdomen transvaginally through a laparoscopic colpotomy. The median range of the operation was 45 minutes (range 25-95). There were no intraoperative complications. The postoperative hospitalization period ranged from 2 to 7 days. Vaginal spotting was present in one case and lasted 24 hours. At follow-up visit, no patients complained of pelvic pain or dyspareunia. Vaginal wall induration was not found in any of the patients at pelvic examination. The removal of the appendix through a posterior colpotomy after laparoscopic appendectomy is simple, safe, feasible, well tolerated, and can be considered a valid alternative to other methods.