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Two port laparoscopic appendicectomy--an alternative to SILS and notes.

INTRODUCTION: Acute Appendicitis (AA) is one of the most common surgical emergencies encountered, for which there is an increasing trend towards Laparoscopic Appendicectomy (LA). The advantages of LA compared to open method are decreased pain, fewer post-operative complications, shorter hospitalization, earlier return to work and better cosmesis. (1, 2, 3) requiring three ports. No doubt single incision laparoscopic Surgery (SILS) can be done with special multiport umbilical trocar and specialized instruments but has a steep learning curve due to loss of triangulation, clashing of instruments, lack of maneuverability, decreased technical expertise among the surgeons and an added financial burden to the patients, thus limiting its widespread use especially in rural/peripheral centers with limited resource. (4, 5) Recent development is natural orifice trans-luminal endoscopic surgery (NOTES). But, there are numerous difficulties including, complications of opening hollow viscera, failed sutures, lack of fully developed instrumentation and necessity of reliable cost-benefit analyses. (6, 7) In conventional three-port LA (CLA) from a cosmetic viewpoint, the umbilical and suprapubic port sites are hidden by natural camouflages, but scar of the third port in the iliac fossa is the only visible external sign of surgery. The two port LA (TLA) technique avoids even this marker of abdominal invasion. The technique, we are describing is virtually scar-less as the intra-abdominal entry points are hidden within the natural camouflages. This technique replicates the intra peritoneal view and operative technique of CLA, hence has a very short learning curve. Compared to SILS and NOTES, there is no need for expensive specialized equipment. TLA can be considered as the best procedure for selective cases of AA. (8)

MATERIALS AND METHODS: All patients presenting to surgical OPD at SSMCH, Tumkur with clinical features of AA were confirmed by ultrasonography were included. Patients who are unfit for General anesthesia, perforation with peritonitis, appendicular abscess and pregnancy were excluded.

Informed consent from all the patients and ethical clearance from the committee were obtained. A detailed proforma was recorded, confirmed by ultrasound and laboratory blood investigations were done All operations were done under General anesthesia.

PROCEDURE: In TLA, after creating pneumoperitoneum, one 10mm camera port and another 5mm supra-pubic working port just below the hair line are introduced. A hypodermic needle with polypropelene loop (fig. 1) is introduced in the right iliac fossa to retract the appendix (fig. 2, 3). With bipolar diathermy, mesoappendix is cauterized and the cut (fig. 4). Roeder knot with vicryl 1-0 is made, introduced into the abdomen with Maryland forceps. Appendix released from the prolene loop, introduced into the vicryl loop and again held taught by the prolene loop. Appendicular base ligated with vicryl using a knot pusher (fig. 5). Similarly one more vicryl knot is applied to the appendix just distal to it. Appendix is cut in between the knots and delivered out through umbilical port. TLA was done (fig. 6). Those cases which were difficult for TLA were converted to CLA by introducing the third 5mm port in right iliac fossa. Total duration of the procedure was calculated from the time of incision upto the completion of skin closure. Pain in the post-operative period was rated using a Visual Analogue Scale (from 0 to 1). Procedure related complications during and after operations, viz. wound infection, adhesions, hernia, reasons for extended hospitalization were recorded. Patients will be discharged from the hospital once they are fully mobilized and able to tolerate a normal diet.

RESULTS: Of the total 30 cases, 5 required conversion to CLA (2 peri-appenidicular adhesions, 3 retrocolic appendix). Among 25 included, we had 12 men, 8 women, and 5 children aged <8 years who underwent TLA. In all these 25cases there was no difference compared to CLA. The two scars were invisible after 3 months as they were hidden by the natural camouflage and hence patients had better cosmetic satisfaction. For the surgeons there was no difference in technique except to get oriented for traction of appendix using needle with prolene loop retractor which can be accustomed in the initial 3 cases of TLA. There were extensive adhesions in 2cases, which posed difficulty in releasing and visualization of appendix with one working port. 3cases were retrocolic appendices with a narrow mesoappendix which we could not release. Hence in these 5cases we had to convert TLA to CLA.

DISCUSSION: Appendicitis is one of the most common surgical emergencies encountered, for which there is an increasing trend towards Laparoscopy as a treatment modality. Surgical advancement in the management of AA has evolved dramatically in the last 120 years, from McBurney's simple large incision, to minimally invasive LA, to barely noticeable incisions after Single Incision Laparoscopic Surgery (SILS). (9) LA significantly decreases the requirement of post-operative analgesia. (10) Two-port Laparoscopic Appendectomy (TLA) has all the advantages of Conventional Laparoscopic Appendectomy (CLA) with significantly reduced operative time and cost. Ours is modified technique of Ashwin Rammohan et al. (11) The needle with loop retractor has an added merit of holding the appendix even with extensive inflammation, enables the surgeon for stable manipulation and gives better counter-traction than conventional forceps (11). Also with the intraoperative view the surgeon can decide the best site for placement of the needle-loop which is ergonomically and cosmetically suitable (11). The only drawback is that it is difficult if there are dense adhesions or long retrocolic appendix. In such cases it can easily converted to CLA by placing an additional trocar in the right iliac fossa--"port rescue" (4). TLA can be considered as best procedure for selective cases of AA. (8) TLA is a better procedure over CLA and Open technique with significantly shorter operative time, lesser incidence of surgical sites infection, lesser post-operative pain and significantly lesser hospital stay. (2) TLA has an advantage over SILS and NOTES in being safe, easy, feasible, not requiring specialized instruments and also economical. (11) TLA is a safe and feasible in children with the operative time and post-operative complications being the same to that of CLA. (12)

CONCLUSION: Two port Laparoscopic appendicectomy is safe, cost-effective, cosmetically effective, easy to learn and perform. Its aesthetic benefits are comparable to SILS and NOTES without requiring any special instruments. If intra-operatively found to be difficult, it can be converted into conventional laparoscopy by introducing a third port.

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DOI: 10.14260/jemds/2014/2799

REFERENCES:

(1.) Eypasch E, Sauerland S, Lefering R, Neugenbauer EM. Laparoscopic versus open appendectomy: Between evidence and common sense. Dig Surg 2002; 19: 518-22.

(2.) Yagnik VD, Rathod JB, Phatak AG. A retrospective study of two-port appendectomy and its comparison with open appendectomy and three-port appendectomy. Saudi J Gastroenterol 2010; 16: 268-71.

(3.) Garbutt JM, Soper NJ, Shannon WD, Botero A, Littenberg B. Meta-analysis of randomized controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc 1999; 9: 17-26

(4.) Udwadia TE. Single-incision laparoscopic surgery: An overview. J Minim Access Surg 2011; 7:1 2.

(5.) Rao PP, Rao PP, Bhagwat S. Single-incision laparoscopic surgery - current status and controversies. J Minim Access Surg 2011; 7: 6-16.

(6.) Chamberlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) technique for cholecystectomy J Gastrointest Surg 2009; 13: 1733-40.

(7.) Romanelli JR, Earle DB. Single-port laparoscopic surgery: An overview. Surg Endosc 2009; 23: 1419-27.

(8.) M Husain, S Sahu, P Sachan. Two-Port Laparoscopic Appendectomy.The Internet Journal of Surgery. 2010; Volume 27, Number 2.

(9.) Noah J. Switzer, Richdeep S. Gill, and Shahzeer Karmali, "The Evolution of the Appendectomy: From Open to Laparoscopic to Single Incision," Scientifica, vol. 2012, Article ID 895469, 5 pages, 2012. doi:10.6064/2012/895469.

(10.) Rajab Ali, Muhammad R. Khan, Turab Pishori, and Mohammad Tay, Saudi J Gastroenterol. 2010; Jan-Mar; 16(1): 25-2 doi: 10.4103/1319-3767.58764.

(11.) Rammohan A, Jothishankar P, Manimaran A B, Naidu R M. Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery. J Min Access Surg 2012; 8: 140-144.

(12.) Ahmed Khairia, d, MagdiLolah b, Ahmed A. Khalafc, d, MostafaTolba, Pediatric Surgery Units, Departments of Surgery, a: Alexandria Faculty of Medicine, Alexandria and b: Monofya. Faculty of Medicine, Monofya, c: Department of Surgery, Ein-Shams Faculty of Medicine, Cairo, Egypt, d: Department of Surgery, Dallah hospital, Riyadh KSA. Annals of Pediatric Surgery. Vol. 6, No. 3, 4 July, October 2010, PP 140-143.

AUTHORS:

[1.] Kiran Kumar K. M.

[2.] Naveen Kumar M.

[3.] Srinivas Arava

[4.] Kishore Krishna

[5.] Pratheek K. C.

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of General Surgery, Sri Siddartha Medical College, Tumkur.

[2.] Assistant Professor, Department of General Surgery, Sri Siddartha Medical College, Tumkur.

[3.] Professor, Department of General Surgery, Sri Siddartha Medical College, Tumkur.

[4.] Junior Resident, Department of General Surgery, Sri Siddartha Medical College, Tumkur.

[5.] Junior Resident, Department of General Surgery, Sri Siddartha Medical College, Tumkur.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Kiran Kumar K. M, 109, 6th Main Road, Ashoka Nagara, Tumkur--572102.

E-mail: kirankumarkmgpls@gmail.com

Date of Submission: 22/05/2014.

Date of Peer Review: 23/05/2014.

Date of Acceptance: 03/06/2014.

Date of Publishing: 12/06/2014.
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Title Annotation:ORIGINAL ARTICLE
Author:Kiran, Kumar K.M.; Naveen, Kumar M.; Arava, Srinivas; Krishna, Kishore; Pratheek, K.C.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jun 16, 2014
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