BACKGROUND
Laparoscopic surgery for the treatment of appendicitis and hernia repair have gained wide clinical acceptance. Trocar-site herniation can occur if a 10-mm trocar is used.1 Herniation through a 5-mm port site is, however, rare.2 The underlying fascia is closed when using trocars of 10-mm or more, but also when extensive manipulation is performed through a 5-mm trocar port, causing extension of the incision. Conventionally, a 10-mm port is required for the camera, whilst a second 10-mm port is needed to retrieve a large appendix during an appendicectomy3 or for the insertion of a 20 cm × 20 cm mesh during hernia repair. We describe a method that avoids the need of a second 10-mm port in both of these cases.
TECHNIQUE
A standard 10-mm umbilical port is used for insertion of the camera. This is followed by two 5-mm ports to allow mobilisation of the appendix and its ligation. Conventionally, one of the 5-mm ports would then be converted to a 10-mm port to allow retrieval of the appendix. We describe a method to avoid this. The appendix is held at one end with a grasper (via the 5-mm port) and passed into the 10-mm trocar (intra-abdominally, under constant vision) following the tip of the camera whilst the camera is reversed out of the 10-mm trocar (Fig. 1). Similarly, when inserting the mesh for hernia repair, a 5-mm port allows the passage of a 15 cm × 15 cm mesh but needs to be converted to a 10-mm port to allow a larger mesh to be passed through (as the trocar is too narrow). Instead, the grasper, which is through the 5-mm port, is passed into the 10-mm trocar (intra-abdominally) following the camera tip as it is reversed out of the trocar (Fig. 1). Once, the grasper is through the 10-mm trocar, the trocar is removed leaving the grasper pointing out of the abdomen. A mesh is placed in the grasper which is then pulled back into the abdominal cavity.
Figure 1.
Demonstrating the grasper (via 5-mm trocar) entering the mouth of the 10-mm trocar following the tip of the camera.
DISCUSSION
We have successfully performed this technique on numerous occasions. It avoids the need of a second 10-mm port (and the need to close it). This facilitates safe and efficient removal of an appendix during an appendicectomy or insertion of a mesh during hernia repair. This method does not require a 10-mm telescope to be changed to a 5-mm one (as not all hospitals have one) or the need to extend a 5-mm port incision.4
References
- 1.Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg. 2004;139:1248–56. doi: 10.1001/archsurg.139.11.1248. [DOI] [PubMed] [Google Scholar]
- 2.Nezhat C, Nezhat F, Seidman DS, Nezhat C. Incisional hernias after operative laparoscopy. J Laparoendosc Adv Surg Tech A. 1997;7:111–5. doi: 10.1089/lap.1997.7.111. [DOI] [PubMed] [Google Scholar]
- 3.El-Dhuwaib Y, Hamade AM, Issa ME, Balbisi BM, Abid G, Ammori BJ. An ‘all 5-mm ports’ selective approach to laparoscopic cholecystectomy, appendectomy, and anti-reflux surgery. Surg Laparosc Endosc Percutan Tech. 2004;14:141–4. doi: 10.1097/01.sle.0000129399.95866.5b. [DOI] [PubMed] [Google Scholar]
- 4.Jain PK, Sedman P. Appendix retrieval after laparoscopic appendectomy: a safe and inexpensive technique. Surg Laparosc Endosc Percutan Tech. 2003;13:322–4. doi: 10.1097/00129689-200310000-00007. [DOI] [PubMed] [Google Scholar]