Technique of ‘suture less’ appendicectomy by laparoscopy in children: Preliminary communication

Abstract

Objective:

Objective of this study is to present our experience by harmonic scalpel enabled, single external port appendicectomy using extracorporeally inserted ‘pick and fix’ stitch in three cases.

Materials and Methods:

Of the eighteen appendicectomies performed with only the use of harmonic scalpel in the last 11 months, the last three were performed using a single external port with the second port accessed under the subcutaneous tissues. The procedure consists of anchoring the mesoappendix to anterior abdominal wall by an extracorporeally inserted ‘pick and fix’ stitch followed by dissection and division of mesoappendix and appendix only with harmonic scalpel.

Results:

There were three patients, one female and two males aged 5, 7, and 11 years, respectively. Two were elective and one was emergency appendicectomy. Mean operating time was 30 min without any surgical complications. All patients are in follow-up with no complications.

Conclusion:

This study demonstrates the combined virtue of single external port, use of harmonic scalpel, and ‘pick and fix’ suture in laparoscopic appendicectomy in children. This approach avoids the use of an additional port as well as endosuture; and is safe, efficient, cost-effective, and is associated with reduced surgical time.

INTRODUCTION

Laparoscopic appendicectomy is now the standard approach for appendicectomy. Gradually, the number of ports is being reduced and the feasibility of single-incision laparoscopic surgery (SILS)[1] is now being explored. However, in children, the size of the SILS port is still large in the context of most children. We describe a novel technique of harmonic scalpel enabled and extracorporeally taken stitch-fixed appendicectomy using a single external port in three cases.

MATERIALS AND METHODS

We have been routinely performing laparoscopic appendicectomy since the last 1 year. Those with appendicular lump, abscess, and perforation are being excluded at present. Diagnostic investigations include routine blood and urine tests, X-ray of the abdomen, and ultrasonography. Symptomatic cases of less than 48 h of duration are subjected to this procedure. In others, after initial conservative management an interval appendicectomy is performed after 6-8 weeks.

Surgical technique

Child is placed in supine position with the right side and foot end of the table elevated by 30°. An intraumbilical incision is made. The skin at the inferior margin of this incision is held in Alice forceps, subcutaneous dissection is done for 5 cm where a point in the midline is selected on the linea alba and a 5 mm accessory port [Figure 1a] is inserted and fixed. Another 10 mm or 5 mm laparoscope is inserted through the umbilical port. An intestinal holding grasper is passed through the accessory port and appendix is identified. The tip of the appendix is grasped and pulled towards the overlying peritoneum in the right iliac fossa. Once this is achieved a 1-0 Ethibond stitch on a 45 mm needle is used to pierce the anterior abdominal wall in right iliac fossa (at a point closely corresponding to position of the appendix), entering the abdominal cavity, picking up the mesoappendix, and coming out of the skin all in a single rotation of the needle holder. The two ends of this ‘pick and fix’ stitch [Figure 1b] are held in artery forceps and used as the conventional stay suture.

Figure 1.

(a) Position of umbilical and accessory ports. m = muscles. (b) Pick and fix stitch

The intestinal grasper in the accessory port is replaced by the harmonic scalpel. The mesoappendix is approached, which is kept taut and held steadily grasped by the ‘pick and fix’ stitch. By the serial use of harmonic scalpel the mesoappendix is coagulated and divided [Figure 2] exposing the base of the appendix at its attachment with the cecum. While the appendix is still being kept taut, the base of appendix is held in the jaws of the harmonic scalpel and using slow current, coagulated and divided, at least 1 cm away from the cecal wall [Figure 3a]. After detaching the appendiceal stump [Figure 3b], free end of the omentum is placed around the appendiceal stump. After removal of specimen, cut end of appendix was examined for adequacy of sealing of the lumen. Operating table is restored to flat position, ports are removed, and closed.

Figure 2.

Operative: Pick and fix suture and harmonic scalpel

Figure 3.

(a) Operative: Appendix coagulated and divided. (b) Diagrammatic: Pick and fix suture; mesoappendix and appendix, coagulated and divided

All cases were given third generation cephalosporin, aminoglycoside, and metronidazole just before the start of the procedure. Patients were kept nil per orally for 6 h and discharged after full feeds within 24 h.

RESULTS

There were three patients, one female and two males aged 5, 7, and 11 years, respectively. Mean operating time was 30 min without any surgical complications. All patients are in follow up with no complications.

DISCUSSION

Clinical presentation of appendicitis may vary from inflamed and edematous appendix to gangrene and perforation. In this report we describe two interval appendicectomies and one performed during the acute stage when the appendix had already become edematous and turgid.

There is an increasing trend to reduce the number of ports in laparoscopic procedures. Currently, SILS is being explored as a new technique for laparoscopic procedures without leaving a scar. However, its place is still to be established; while, its use in children is certainly limited by the current size of the SILS port.[2,3,4,5]

Fixing and stabilizing the mesoappendix is an essential step in appendicectomy. Stabilization of appendix is conventionally done by a grasper passed through a separate port. In the present report we used the pick and fix stitch [Figure 1b] which helped in avoiding an additional port. In our cases we have used an intraumbilical port for the laparoscope and a concealed port passed subcutaneously through the linea alba. Therefore, externally there is only one port. The second infraumbilical port should be placed about 2 cm from the umbilical laparoscopic port and both should be, preferably, 5 mm size each to avoid collision of instruments.

Currently two techniques are used for laparoscopic appendicectomy: Division of the mesoappendix with the harmonic scalpel and ligation of the appendix with an endoloop, or division of the mesoappendix and appendix with an endostapler.[6]

The commonly used methods to ligate the appendix are a loop (using thread), absorbable clip, and an endoscopic stapler. While endoscopic stapler is considered to lower the risk of intra-abdominal surgical-site infection by some,[7] there are contrary views, too.[8]

Using the harmonic scalpel, both, for division of mesoappendix and removal of appendix is a cost-effective technique that provides an outcome benefit in children who require appendicectomy.

The results of this preliminary communication demonstrate, that, stabilization of the appendix by applying ‘pick and fix’ suture is technically feasible just prior to application of harmonic scalpel for removing the appendix. All patients in the present report could be successfully operated using the combined virtues of the ‘pick and fix’ stitch, harmonic scalpel, and the single external port (SEP) approach without needing conversion.

The mean operating time of less than 30 min in our cases is an improvement over SILS procedure in other series as well as Cochrane review.[1,9]

The present report addresses the extended use and efficacy of the increasingly popular, percutaneously placed stay suture during laparoscopy. It adds to the enhanced convenience of appendicectomy performed by harmonic scalpel without the use of endosuture which is conventionally used during laparoscopy for appendicectomy.

CONCLUSION

This study demonstrates the combined virtue of single external port, use of harmonic scalpel, and ‘pick and fix’ suture in laparoscopic appendicectomy in children. This approach avoids the use of an additional port as well as endosuture, is safe, efficient, cost-effective, and is associated with reduced surgical time.