A Study of Three-port Laparoscopic Appendectomy with Alternative Port Placement Technique

INTRODUCTION

Acute appendicitis is one of the most common gastrointestinal conditions encountered by general surgeons in emergency practice.¹ Although there are various researches into its conservative management, the most commonly accepted course of management remains to be appendectomy.²

Laparoscopic appendectomy is currently the most preferred method for appendectomy owing to better cosmesis, decreased surgical trauma, and complications, especially in obese patients.³ Various modifications have been developed and proposed by various authors for laparoscopic appendectomy with respect to number of ports used, port placement, dissection method, and retrieval of the appendicular specimen.

Conventional laparoscopic appendectomy involves placement of three ports, one umbilical 10-mm port and two 5-mm ports in the suprapubic region and left lower quadrant.⁴ While performing routine conventional laparoscopic appendectomy, the retrocecal position of the appendix could not be approached with ergonomic efficiency. In this study, we have described our experience with alternate port placement, as described below, practiced in 50 cases in pursuit of gaining better ergonomic advantage and cosmesis.

MATERIALS AND METHODS

A total of 50 patients underwent laparoscopic appendectomy with this technique of port placement in the Surgical Department at Sheth LG General Hospital, AMC MET Medical College, from July 2021 to July 2022.

All patients were explained about the procedure and possibility of conversion to open. Informed and written valid consent was taken. Acute, subacute, and recurrent appendicitis patients were preferred, whereas patients with appendicular lumps were excluded. All appendicitis patients included in this study were categorized on the basis of age, duration of illness, and history of recurrence of pain. Intraoperative time, ergonomic advantage, and requirement of conversion to open as well as postoperative recovery, cosmesis, and complications were noted. Patients were followed up after discharge on an outpatient basis for a period of 21 days.

TECHNIQUE

All patients underwent laparoscopic appendectomy under general anesthesia in the Trendelenburg position with the left arm tucked alongside the body. Catheterization was done in the selected patients. A single monitor was placed on the right side of the table and surgeon, with one assistant positioned on the left side. After sterile preparation of the abdomen exposed from the epigastrium to the pubis, pneumoperitoneum was created by insufflation of carbon dioxide at 12 mm Hg via Verres needle technique through the umbilicus. A 10-mm Trocar was inserted through the umbilicus, and a 0° laparoscope was introduced. Under visualization, two 5-mm working ports were created in LIF and RIF approximately 2 cm below the level of ASIS and just lateral to inferior epigastric vessels, as shown in Figure 1. The appendix was identified and lifted through the RIF port, and the mesoappendix was dissected up to the base of the appendix with monopolar cautery. Adequate hemostasis was achieved from the mesoappendix. The base of the appendix was then transfixed with a 2-0 polyglactin 910 (Vicryl) suture. The appendix was cut just distal to transfixation and delivered out through an umbilical 10-mm port by rail-roading technique.

RESULTS

A total of 50 patients were operated on for laparoscopic appendectomy using the described port placement technique. From 50 patients, 28 patients (56%) were male of mean age 24.33 (±3.25) years and 22 patients were female (44%) with mean age 27.05 (±4.25) years. Two patients were converted to open appendectomy due to limited working space in one pediatric patient having dense intra-abdominal inflammatory adhesions with the presence of pus and dilated bowel loops and in another one, there were dense omental adhesions in LIF in case of situs inversus. Mean operative time was 25.6 minutes (±6.2) minutes. None of the patients developed any significant postoperative complications. All patients were satisfied with the cosmetic results on follow-up postop day 14.

DISCUSSION

The appendix was first described by Berengario da Carpi in 1522, and the first successful appendectomy was performed by Claudius Amyand in 1735.³ Since then, various incisions of open appendectomy have been described by various authors, the most commonly practiced being oblique muscle splitting incision in RIF described by Charles McBurney in 1893.⁵ However, open appendectomy scars had to be carried throughout life, especially in young patients, particularly of the adolescent age group. That is why the introduction of laparoscopic appendectomy by Kurt Semm for the first time in 1980⁶ opened many possibilities of minimally invasive approaches to appendectomy. From traditional three-port laparoscopic appendectomy (TPLA), we now have single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) appendectomy. However, considering limited facilities and technical expertise, SILS and NOTES appendectomy have not been able to replace TPLA in India yet.

While performing conventional TPLA, which involves one umbilical 10-mm port and two ports in the suprapubic region and LIF, we faced limited space and working angle between instruments through the suprapubic port and LIF port, especially in thin and lean patients and in pediatric patients. Due to limited working space, instrumental swording was commonly encountered in those patients.

In order to achieve better ergonomics, we decided to place working ports in LIF and RIF, which provided a wider working angle and better instrumentation as shown in Figure 2. During dissection of the mesoappendix facing the lateral wall, as in the retrocecal appendix, chances of injury to the cecum and bowel loops from electrocoagulation were more through the LIF port. In those cases, we were able to interchange working hands allowing us to use RIF for dissection of the mesoappendix while lifting the appendix through the LIF port. However, in prolonged operations as in difficult cases or when the surgeon is performing multiple surgeries in the same session, shoulder fatigue happens due to the crossing of arms from the left side of patient’s midline.⁷

In conventional TPLA, the base of the appendix can easily be ligated using Roeder’s knot, but when we wanted to transfix the base of the appendix, those ports did not provide good ergonomics. Consequently, in our study with alternative port placement, LIF and RIF ports gave better instrumental mobility for suturing, as shown in Figure 3. For removal of appendicular specimens, delivery through a 10-mm umbilical port could easily be performed.

However, in cases where the cecum and appendix were situated more caudally in the pelvis, we faced difficulty in retraction with Babcock’s forceps via the RIF port. In those cases, after identifying the location of the cecum, omentum, and bowel, they were displaced cranially using Atraumatic Bowel Grasper from the LIF port allowing better retraction of the appendix with Babcock’s forceps from the RIF port.

In our study, peak incidence of appendicitis was found in young patients of 20–29 years age group, so cosmesis was important. Upon observing cosmesis up to day 21, patients were satisfied with the cosmesis achieved as 5-mm scars were found to be minimal and could be easily hidden by clothing.

Our technique described above is simple and does not require any additional training than basic laparoscopic skills. Moreover, it can be performed at any hospital without the requirement of any additional instrument other than the basic instruments required in conventional TPLA. It can be used for any age group at any stage of appendicitis and even in perforated appendicitis, especially in females who require any additional pelvic procedure coexisting with the presence of appendicitis.

CONCLUSION

The laparoscopic appendectomy technique with LIF and RIF working ports is reproducible and provides an effective working position to surgeons by allowing better triangulation as shown in Figure 2. Instrumentation aiding in transfixation of the base of the appendix without compromising safety while achieving good cosmetic results is another advantage, as shown in Figure 3. However, a comparative study and randomized controlled trial would be required to confirm our findings.

REFERENCES

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