Two-port laparoscopic appendectomy as transition to laparoendoscopic single site surgery

Laparoscopic appendicectomy without the use of disposable materials - a low-cost alternative - 1,552 cases operated in 20 years

INTRODUCTION

Laparoscopic appendectomy does not have a single protocol on its technical systematization, access routes, and use of energy and staplers. The cost of disposable materials can prevent its widespread use. Alternatives to decrease cost can help disseminate the laparoscopic access to appendectomy.

OBJECTIVE

to introduce a low-cost laparoscopic appendectomy method with good aesthetic results through the location of incisions; to show its viability through its application in 1,552 cases of laparoscopic appendectomy operated between 2000 and 2019 with three portals and very low-cost regarding materials used.

METHODS

we applied three punctures - an umbilical one for the camera (5 or 10mm in diameter), a 10mm puncture in the right iliac fossa, and one 5mm puncture in the left iliac fossa. The materials used were permanent use trocars, grasping forceps, hook, scissors, and needle holder, without the need for any disposable device.

RESULTS

1.552 patients were operated between 2000 and 2019, 56.2% being female, mean age 32.66 years (9-93), average hospital stay of 1.74 days (1-10), and median of 1.2 days.

CONCLUSION

the technique we describe uses three metallic trocars and four permanent instruments, in addition to a single cotton suture. It is, therefore, a very low-cost laparoscopic procedure. Its application has shown good results and low morbidity, which may become the preferred indication for laparoscopic surgery in the treatment of acute appendicitis.

Combined laparoscopic ovariectomy and laparoscopic-assisted gastropexy utilizing a 2-port technique in 10 dogs

A case series was selected retrospectively to evaluate the technique, outcome, and short-term complications associated with a combined laparoscopic ovariectomy (Lap OVX) and laparoscopic-assisted gastropexy (LAG) using a 2-port technique, and to compare it with previously published combined laparoscopic techniques for Lap OVX and LAG in dogs. Medical records of dogs undergoing elective, combined Lap OVX and LAG performed using a 2-port technique between 2017 and 2019 were reviewed. Total surgical time was compared to previously published combined Lap OVX and LAG techniques in dogs. Intraoperative and short-term complications were recorded. Ten dogs [median weight: 29.4 kg (range: 11.4 to 84.1 kg); mean: 37.4] met the inclusion criteria. Median surgical time to complete both the Lap OVX and LAG was 72.5 minutes (range: 47.0 to 120.0 minutes; mean: 77.4 minutes), which was not significantly different than that described in previous studies of combined Lap OVX and LAG (weighted mean average: 67.3 minutes; 95% confidence interval: 46.9 to 87.7, P = 0.3). No intraoperative or postoperative complications were reported. It is concluded that a 2-port technique for combined Lap OVX and LAG is feasible, has few complications, and requires similar time to perform compared to other previously published laparoscopic techniques.

Single-Incision, Two-Port Laparoscopic Appendectomy as an Alternative to Transumbilical Single-Port Laparoscopic Appendectomy

Purpose

We designed a modified technique to perform an advanced procedure using conventional instruments and did not employ specialized single-incision laparoscopic surgery (SILS) port equipment. We compared postoperative results for transumbilical, single-port laparoscopic appendectomy (TUSPLA) and single-incision, 2-port laparoscopic appendectomy (SITPLA).

Methods

This retrospective study enrolled 77 patients who underwent TUSPLA or SITPLA to provide more minimally invasive surgery between May 2017 and April 2018. TUSPLA was performed in 39 patients and 38 underwent SITPLA. In the SITPLA group, two 5-mm trocars were inserted through the umbilicus and an extra puncture site was used for a left-handed instrument. Demographic characteristics, operative data, and postoperative outcomes were collected and compared between the groups.

Results

The mean total operative time in the SITPLA group was shorter than in the TUSPLA group (p=0.003). The mean laparoscopic instrumental time was also shorter (p<0.001) in the SITPLA. The number of postoperative analgesics in the SITPLA group was less than in the TUSPLA group (p=0.002). The length of hospital day after surgery was shorter in the SITPLA group than in the TUSPLA group (p=0.008). There were no other significant differences between the groups.

Conclusion

SITPLA had a shorter operative time, required less pain management, and had a similar cosmetic outcome when compared with TUSPLA.

Conventional laparoscopic appendectomy versus double-incision, three-port laparoscopic appendectomy: A 1-year randomized controlled trial

INTRODUCTION

Management of appendicitis has evolved dramatically in the last 120 years, from McBurney's large incision to minimally invasive laparoscopic appendectomy to hardly noticeable incisions with SILS. As a bridge between conventional laparoscopic surgery and SILS, double-incision laparoscopic surgery further minimizes the invasiveness of laparoscopic surgery by reducing the number of incisions. This study aimed to establish the efficacy of double-incision, three-port laparoscopic appendectomy (DILA) as an alternative to conventional three-port laparoscopic appendectomy.

METHODS

A total of 60 patients were divided randomly into two groups: the conventional laparoscopic appendectomy (CLA) group and the DILA appendectomy group. Demographics, diagnostic history, additional intraoperative findings, and duration of operation were recorded. Postoperative pain after 6 h and 24 h and cosmetic outcome after the surgery were also evaluated. Statistical analysis was done using Fisher's exact test, χ² test, and Student's t-test.

RESULTS

No significant difference was observed in demographic and clinical characteristics in either group (P > 0.05). No significant difference in mean postoperative pain was observed between the two groups at 6 h (P = 0.62) or 24 h (P = 0.484). However, patients in the DILA group were more satisfied with their cosmetic outcomes than those in the CLA group (P = 0.04). The mean operative time was 26.4 min in the CLA group and 27.6 min in the DILA group (P = 0.62).

CONCLUSION

DILA can be performed with operative outcomes that are equivalent to CLA but with superior cosmetic outcomes.

Two-port laparoscopic appendectomy assisted with needle grasper comparison with conventional laparoscopic appendectomy

Purpose

The 2-port laparoscopic appendectomy technique (TLA) is between the conventional 3-port and single-port laparoscopic appendectomy surgeries. We compared postoperative pain and cosmetic results after TLA with conventional laparoscopic appendectomy (CLA) by a 3-port device.

Methods

Patients undergoing TLA were matched with patients undergoing CLA between February 2015 and November 2015 at the same institution. Thirty-two patients underwent TLA with a needle grasper. The appendix was secured by a percutaneous organ-holding device (needle grasper), then removed through a puncture at McBurney's point. Another 38 patients underwent CLA. Patient demographics, operative details, and postoperative outcomes were collected and evaluated.

Results

One patient in the TLA group developed a wound infection and 1 patient in the CLA group developed a postoperative intra-abdominal abscess and 3 wound infections. There was no significant difference between the groups when comparing the length of hospital stay, time until oral intake, and other complications. The pain score in the first 12 hours after surgery was significanly higher in CLA group than the TLA group (P < 0.001). Operative time was significantly shorter in the CLA group compared to the TLA group (P < 0.001).

Conclusion

TLA using a needle grasper was associated with a significantly lower pain score 12 hours after surgery, better cosmetic results, and lower cost, than the CLA 3-port procedure because of the fewer number of ports.

Two-port laparoscopic appendectomy with the help of a needle grasper: better cosmetic results and fewer trocars than conventional laparoscopic appendectomy

INTRODUCTION

The two-port laparoscopic appendectomy technique (TPLA) lays between the conventional three-port trocar procedure and single-port laparoscopic appendectomy surgery. During TPLA, the appendix is suspended with stitches, resulting in perforation risk and difficulty in exploration.

AIM

We used a needle grasper in TPLA to hang and manipulate the appendix.

MATERIAL AND METHODS

Thirty-four patients (10 female, 24 male) who underwent TPLA between February 2015 and November 2015 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. The needle grasper was inserted at the right under the abdominal quadrant (McBurney point) without an incision to hang and manipulate the appendix.

RESULTS

The mean age was 25.19 ±8.464 years; the mean body mass index (BMI) was 23.50 ±3.246 kg/m(2). ASA scores were 1 and 2. The operations were completed without any additional trocar in 34 patients. The mean operation time was 57.03 ±3.814 min. There were no intraoperative complications in any patients. Three patients required a drain; all were discharged after drain removal. Thirty-one patients were discharged on the 1(st) postoperative day; three patients with drains were discharged on the 2(nd) day. The mean hospital stay period was 1.18 ±0.535 days.

CONCLUSIONS

Using the needle grasper, the appendix was held and suspended and the mesoappendix was cauterized and skeletonized successfully in TPLA. Inserting a needle grasper into the abdominal cavity at the McBurney point to manipulate the appendix helps and does not leave a visible scar.

Efficacy and safety of a new single-port model for appendectomy: Experimental study on swine

CONTEXT:

With the cooperation of surgeons and the engineering division of the company Bhio supply^© (Esteio-RS, Brazil), a permanent single port was developed.

AIMS:

An experimental study assessed the safety and efficacy of the device using a swine laparoscopic appendectomy model (right salpingo-oophorectomy).

SETTINGS AND DESIGN:

Experimental randomised study.

MATERIALS AND METHODS:

A total of 20 pigs were randomised for the conventional laparoscopic (CL) three-trocar technique or the single Centry port (CPort) with two working channels, aided by a transparietal thread. Operative times, surgical complications, CO₂ use, and pneumoperitoneal pressure were checked. Pressure and chromopertubation tests assessed the ligatures.

STATISTICAL ANALYSIS USED:

For quantitative outcomes, the Fisher's exact test analysed the samples to compare the surgeons in each group, the ANOVA test for parametric data (volume and pressure) and the Student's t-test for analysis of the fascial incision length. The binaries and isolated occurrence events were described in percentages.

RESULTS:

For all cases, pneumoperitoneum was maintained. The CPort group, however, resulted in higher CO₂ use (26.18 l; standard deviation [SD] ± 11.09) than CL group (5.69 l; SD ± 2.44) (P < 0.01). The mean pressure in CPort group (6.604 mmHg, SD ± 1.793) was comparatively lower than in CL group (7.382 mmHg, SD ± 1.833) (P = 0.363). There was no statistical difference between operative times, ligature safety or adverse surgical events between the different groups and surgeons.

CONCLUSION:

The surgical technique used with the single port showed no differences in safety and efficacy. Though it does require more CO₂ use, its working dynamics did not lead to increased operative times. The results were similar between the two surgeons in the study, suggesting that they can be reproduced.

One-trocar versus multiport hybrid laparoscopic appendectomy: What's the best option for children with acute appendicitis? Results of an international multicentric study

BACKGROUND

One-trocar laparoscopic appendectomy (OTA) is routinely adopted in children with acute appendicitis. In case of a difficult appendectomy, it is necessary to add additional trocar/s to safely complete the procedure. This technique is called multiport hybrid laparoscopic appendectomy (HLA). We aimed to compare the outcome of multiport HLA versus OTA.

METHODS

We retrospectively reviewed the data of 1,092 patients underwent LA in 5 European centers of pediatric surgery in the last 5 years. We compared 2 groups: G1 of 575 patients (52.6 %) (average age 10 years) underwent OTA and G2 of 517 patients (47.4 %) (average age 8.2 years) underwent multiport HLA.

RESULTS

No intra-operative complications occurred in both groups. An additional pathology was treated in 12 cases (8 Meckel's diverticulum, 2 carcinoids, 2 ovarian cysts) in G2. Operative time was significantly shorter in G2 compared to G1 (47.8 vs 58.6 min; p < .001). The average analgesic requirement was significantly shorter in G2 compared to G1 (44 vs 56 h; p < .001). As for postoperative complications, the incidence of port-site infections was similar between the two groups, while the incidence of postoperative abdominal abscesses (PAA) was significantly higher in G1 compared to G2 (4.7 vs 0.2 %; p < .001). The cosmetic outcome was excellent in all patients of both groups. A subgroup analysis between complicated and uncomplicated appendicitis showed that only in complicated cases, the average operative time, the average VAS pain score, the average analgesic requirements and the incidence of PAA were significantly higher in OTA group compared to multiport HLA group (p < .001).

CONCLUSIONS

Our results suggest that OTA is a valid and safe procedure for the uncomplicated cases, while additional trocars are required in case of complicated appendicitis. Multiport HLA significantly reduces the operative time, the incidence of abdominal abscesses and the analgesic requirements compared to OTA.

Three port laparoscopic appendectomy technique with low cost and aesthetic advantage

INTRODUCTION

Despite dating more than 30 years after the first laparoscopic appendectomy, ileocecal appendix resection is still performed by laparotomy in more than 90% of cases, in our country.

AIM

To describe a technique for laparoscopic removal of the ileocecal appendix with three portals, at low cost and very good aesthetic appearance.

TECHNIQUE

Three incisions, one umbilical and two suprapubic are made; permanent material used comprises: grasping forceps, hook, scissors, needle holders, three metal trocars and four other usual instruments, and a single strand of cotton. There is no need to use of operative extractors bags, clips, endoloops, staples or bipolar or harmonic energy instruments. Allows triangulation and instrumentation in the conventional manner.

CONCLUSION

The proposed technique is safe and reproducible, easily teachable, at very low cost and can be applied in general hospitals with conventional laparoscopic equipment.