Surg Endosc DOI 10.1007/s00464-014-3436-7

and Other Interventional Techniques

Minilaparoscopic appendectomy using a new spiral needle Ahmed E. Lasheen • Reda Ezz • Khaled Safwat Ayman Salem • Wesam Amr



Received: 30 September 2013 / Accepted: 9 January 2014 Ó Springer Science+Business Media New York 2014

Abstract Background Acute appendicitis is the most frequent abdominal disease and requires urgent surgery. At the present time, laparoscopic appendectomy is a well-accepted emergency procedure at most centers. In this study, we used a new spiral needle to facilitate the procedure, making it easy, minimally invasive, and cost effective. Methods The study included 70 patients of both sexes with acute appendicitis that was treated by laparoscopic appendectomy using a new spiral needle. These cases were treated at the General Surgery Department, Zagazig University, Egypt, from May 2012 to August 2013. In the procedure we used only two ports (a 10-mm port directly below the umbilicus for the camera and a 5-mm port at the left iliac fossa at the midclavicular line). The new spiral needle was used to hold the appendix during the procedure and was inserted into the right iliac fossa depending on the site of the appendix. Results The mean age of the patients was 27.3 years, mean operative time was 40 min, and mean hospital stay was 1.3 days. Ten patients (14 %) had minimal bleeding at the site of needle passage into the mesoappendix. Wound infection at the site of umbilical port occurred in four patients (5.7 %) postoperatively. Conclusion Laparoscopic appendectomy using our new spiral needle is easy, minimally invasive, and cost effective. Keywords Laparoscopic appendectomy  Spiral needle  Mini-invasive A. E. Lasheen (&)  R. Ezz  K. Safwat  A. Salem  W. Amr General Surgery Department, Faculty of Medicine, Zagazig University, Zagazig 44519, Egypt e-mail: [email protected]

Although laparoscopic appendectomy was performed several years before laparoscopic cholecystectomy, only recently has it become a common laparoscopic procedure [1, 2]. One of the reasons is that classic appendectomy through McBurney’s incision is a simple, quick, and efficient procedure that can be performed by most surgeons. Laparoscopic appendectomy requires particular experience in laparoscopic surgery and needs a special expensive setup. The potential advantages of laparoscopic appendectomy, such as fewer wound infections, shorter hospital stay, faster recovery, and faster return to every day activities, were accompanied by a relatively longer operative time, higher cost, and more postoperative complications at the time when the method was accepted [3–5]. In the last decades many published papers showed that it is a safe and feasible procedure in the treatment of acute appendicitis [6]. Our study presents a new instrument, the spiral needle, that makes laparoscopic appendectomy an easy, minimally invasive, and cost-effective procedure.

Materials and methods This research was approved by the ethics committee of Zagazig University. The study was conducted on 70 patients (37 females and 33 males) diagnosed with acute appendicitis. These patients underwent laparoscopic appendectomy in the General Surgery Department, Zagazig University Hospital, Egypt, from May 2012 to August 2013. The age of the patients ranged from 18 to 47 years (mean = 27.3 years). The procedure included the use of the new spiral needle, which was explained to all patients, and all patients gave written consent for inclusion of their data in this study. The spiral needle was prepared from Key wire No. 2. It consists of two parts. The proximal part is the

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coil, which is about 5 cm long. Its pointed tip is used to pierce the abdominal wall by pushing while turning it clockwise to reach the abdominal cavity. The distal part is the straight part, which is about 20 cm long and has small handle at the end to manipulate the needle. For this study the needle’s entire length was 25 cm and was 2 mm thick (Fig. 1A, B). The needle can be sterilized as other metal surgical instruments in an autoclave and reused. We used two ports (one 10-mm port directly below the umbilicus for the camera and one 5-mm port at left iliac fossa at the midclavicular line). Technique The urinary bladder is decompressed by asking the patient to void before the operation. With the patient under general anesthesia, the pneumoperitoneum is established and then the laparoscope is introduced into the peritoneal cavity. Under direct vision, the 5-mm trocar is inserted at left iliac fossa at the midclavicular line. Also, under direct vision, by

turning clockwise and slightly pushing, the spiral needle is inserted in the right iliac fossa to about 5 cm from the appendix. The appendix is grasped by the grasper and the spiral needle is rotated around the appendix from the tip to the base, flush with appendix. A small opening is made in the mesoappendix at an avascular area near the base. Three extracorporeally pretied ligatures using Vicryl No 1 or 0 are made: one at the base of the appendix, one at the mesoappendix, and one on the appendix 10 mm above the first ligature. While the extracorporeally pretied ligatures are made, the spiral needle can be moved backward and forward by turning it counterclockwise or clockwise, respectively, as needed. We cut the appendix in between the two ligatures on the base of the appendix. The ligature on the excised appendix is used to extract it through the camera port (Fig. 2A–G). After peritoneal lavage, the two port sites are closed. Any postoperative complications were recorded. The follow-up period ranged from 2 to 15 months (mean = 10 months).

Results The mean age of the study group was 27.3 years (range 18–47 years)and the mean hospital stay was 1.3 days (range 1–2 days). The operative time ranged from 30 to 60 min (mean = 40 min). The only intraoperative complication was minimal bleeding at the site of passage of needle through the mesoappendix in 10 patients (14 %), which stopped spontaneously or was controlled by diathermy. Four patients (5.7 %) developed wound infection at the site of umbilical port.

Discussion

Fig. 1 A Lasheen’s spiral needle: A proximal (coiled) part of needle about 5 cm in length. B Distal (straight) part of needle about 20 cm in length. C Small handle on distal part of needle to direct the tip B. D Window was made in mesoappendix after putting the spiral needle in right position. E The appendix inside the coiled part of the spiral needle. F Forward movement of spiral needle only by clockwise rotation. G Backward movement of spiral needle only by counterclockwise rotation. H The anterior abdominal wall. The appendix can be moved in any direction by using the needle handle without rotation

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McBurney [7] described open appendectomy in 1894. In 1983, Semm [1] introduced laparoscopic appendectomy. Compared to the open technique, laparoscopic appendectomy has less postoperative pain, less consumption of analgesics, early ambulation, and a short hospital stay with early return to normal life. Besides its association with less tissue injury, laparoscopic appendectomy causes less irritation of the intestine with reduced adhesion after surgery. For these reasons, laparoscopic surgery is now widely performed [8, 9]. During the past 10 years, laparoscopic surgery advanced to less invasive methods such as singleincision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES), and saw new advances in operative technology and instruments [10]. Although these techniques have many advantages such as less scarring and less postoperative pain, laparoscopic appendectomy still has several disadvantages. First, the

Surg Endosc Fig. 2 A The appendix is grasped near its tip. The spiral needle is inserted into the abdominal cavity at an avascular point of the anterior abdominal wall and pierces by clockwise rotation the mesoappendix at an avascular point under direct vision. B The spiral needle is rotated around the appendix from the tip to the base flush with mesoappendix. C The appendix hangs allowing a small window to be made in the mesoappendix near its base. D Extracorporeally pretied ligature is placed around the base of the appendix by using Vicryl No. 1. E An extracorporeally pretied ligature is placed around the mesoappendix. F The last extracorporeally pretied ligature is placed around the base 10 mm above the first ligature. G The appendix is cut between the two ligatures, leaving the thread of the ligature on the appendix long enough for traction during its removal through camera port

movement of the equipment is limited due to the number of ports and use of the most favorable instruments for the complexity and technical challenges of the procedure is limited [11]. In conventional three-port laparoscopic appendectomy and other less invasive methods, the handling of the appendix is done by using a grasper, which may lead to squeezing and rupture of the appendix, causing more peritoneal soiling or bleeding from mesoappendix [12]. There has been some research to make laparoscopic appendectomy minimally invasive with the use of two ports, where the appendix is suspended by using a stainless-steel wire or suture percutaneously from the right

lower quadrant of the abdomen and pulling it toward the anterior abdominal wall [13–16]. However, the problems with this technique is that the appendix hangs from one fixed site only and the movement of the appendix is only up and down during procedure. In our technique we use only two ports, one port (10 mm) for the camera and one port (5 mm) for the working instrument in addition to the spiral needle which is used for handling of the appendix. The appendix hangs by the spiral needle along its entire length without squeezing or rupturing. This facilitates exposure of the mesoappendix and its ligation. Also, the spiral needle allows movement of the appendix in all directions during

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procedure. Laparoscopic appendectomy using this spiral needle is easy, safe, minimally invasive, and cost effective.

Disclosures A. E. Lasheen, R. Ezz, K. Safwat, A. Salem, and W. Amr have no conflicts of interest or financial ties to disclose.

References 1. Semm K (1983) Endoscopic appendectomy. Endoscopy 15:59–64 2. Schreber JH (1987) Early experience with laparoscopic appendectomy in women. Surg Endosc 1:211–216 3. Delibegovic S, Matovic E (2009) Hem-o-lok plastic clips in securing of the base of the appendix during laparoscopic appendectomy. Surg Endosc 23:2851–2854 4. Baik SM, Hong KS, Kim YI (2013) A comparison of transumbilical single port laparoscopic appendectomy and conventional three-port laparoscopic appendectomy from diagnosis to the hospital cost. J Korean Surg Soc 85:68–74 5. Gundavda MK, Bhandarwar AH (2012) Comparative study of laparoscopic versus open appendectomy. Indian J Med Sci 66:99–115 6. Koluh A, Delibegovic S, Hasakic S et al (2010) Laparoscopic appendectomy in the treatment of acute appendicitis. Med Arch 64:78–83 7. McBurney C IV (1894) The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg 20:38–43

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8. Khan MN, Fayyad T, Cecil TD et al (2007) Laparoscopic versus open appendectomy: the risk of postoperative infectious complications. JSLS 11:363–367 9. Towfigh S, Chen F, Mason R et al (2006) Laparoscopic appendectomy significantly reduces length of stay of perforated appendicitis. Surg Endosc 20:495–499 10. Kalloo AN, Singh VK, Jagannth SB et al (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60:114–117 11. Mintz Y, Horgan S, Cullen J et al (2008) NOTES :a review of the technical problems encountered and their solutions. J Laparoendosc Adv Surg Tech A 18:583–587 12. Liang M, Helen GL, Marks JL (2006) Stump appendicitis: a comprehensive review of literature. Am Surg 72:162–166 13. Sato N, Kojika M, Yaegashi Y et al (2004) Mini-laparoscopic appendectomy using a needle loop retractor offers optimal cosmetic results. Surg Endosc 11:1578–1581 14. Konstadoulakis MM, Gomatos IP, Antonakis PT et al (2006) Two-trocar laparoscopic-assisted appendectomy in patients with acute appendicitis. J Laparoscopic Adv Surg Tech A 1:27–32 15. Ates O, Hakguder G, Olguner M, Akgur FM (2007) Single-port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture. J Pediatr Surg 6:1071–1074 16. Panait L, Bell RL, Duffy AJ, Robort KE (2009) Two-port laparoscopic appendectomy: minimizing the minimally invasive approach. J Surg Res 1:167–171

Minilaparoscopic appendectomy using a new spiral needle.

Acute appendicitis is the most frequent abdominal disease and requires urgent surgery. At the present time, laparoscopic appendectomy is a well-accept...
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