Page 26 - World Journal of Laparoscopic Surgery

Mini Two-port Laparoscopic Appendicectomy with Novel Knotting Technique
ports in suprapubic region and left iliac fossa. Laparoscopy gives required, which may result increased infection risk, port-site hernia,
great advantage to both patient and surgeon and also the efforts postoperative pain, and subsequently a large visible scar which is
to reduce the resultant trauma and to increase better cosmetic avoided in 2-port technique. SILS also demands requirements of
results by decreasing the size and number of cuts created for the specialized instruments leading higher operation cost. 24–27
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ports. Mini-laparoscopy poses as an option to achieve this by using The only limitation of TPA with as described by Kiran et al. is
portals located as usual but with using instruments of smaller the presence of dense adhesions and long appendix, but here a
diameter. 15,16 Our technique of mini two-port appendicectomy double retraction technique described in our study can overcome
gives the advantages of the both decreased number and size of this shortcoming. Our study also describes the technique pragmatic
the scar as compared to the CLA (Fig. 4). in cases of edematous cecum and grossly inflamed appendix,
The TPA technique with loop polypropylene retraction provides which further circumvents the likelihoods of conversion to CLA or
a good result even with extensive inflammation, enables stable open appendicectomy. The suture used polyglactin 2-0 in ligating
manipulation, and gives better counter traction than conventional the base of the appendix in our technique is easily available and
forceps used in three-port technique. The site for placement of the cost-effective in contrast to the endoloop or Endo GI stapler. The
needle loop is decided on the basis of the position of the appendix two-port technique further reducing the financial burden and can
on laparoscopic visualization of the appendix, also considering be used in rural and peripheral areas with limited resources. 29,30
ergonomic viewpoint. The umbilical and suprapubic port sites are This novel suturing technique is easy to learn (reproducible) and
hidden by natural camouflages, and the left Iliac fossa (LIF) port is apply (replicable), with short learning cure. The overall procedure
the only visible external sign of surgery in the CLA. The two-port can be performed by trained laparoscopic surgeon, whereas SILS
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technique avoids even this marker of abdominal invasion, and and NOTES demand expertise and also have a steep learning curve. 5
5-mm umbilical port further reduces the scar size. In pursuit of minimizing surgical trauma and achieving better
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As per Khan and Al-Bassam, studies suggest that the two-port esthetics by reducing the size and number of ports, this mini two-
appendicectomy compared to three port was quicker to perform port technique is devised to offer an easier and safe alternative in
with less postoperative analgesia requirement with an added comparison to conventional three-port technique. This led to the
advantage of smaller incision and a better cosmetic result. There invention of laparoscopic surgical knot which can be tied with a
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are many studies that have used this surgical technique but with single instrument through a single port and single hand which can
use of commercially endoloop, knot pusher. also be used to ligate cystic duct, renal vessels, splenic vessels, or
Our intracorporeal two-port laparoscopic appendicectomy any other tubular structure without need for additional port.
with indigenously completely intracorporeal novel knotting
technique is an appealing alternative for the treatment of acute conclusIon
appendicitis because of its decreased invasiveness and improved This mini two-port technique with novel knotting technique is easy
cosmesis. The use of an intra-abdominal sling technique by using to learn and helps to overcome the challenges and limitations faced
needle retraction suture counterpoises for the lack of the retraction during two laparoscopic appendicectomies; however, conversion
port in the left iliac fossa and eliminates any skin scarring at that to conventional approach in complicated cases is still advisable. It
site. The use of novel knotting technique helps reduce the size of is safe and effective intermediate option from conventional three
the working port as 12-mm ports are used in case of stapler-assisted port to SILS/NOTES/Endo GIA staplers.
ligation of base of appendix.
In epochs where surgeons are focusing on transluminal stAteMent of AuthorshIp And conflIct of
approaches to access the abdominal cavity, laparoscopy is favored Interest
for its extended advantages of enhanced exposure, ergonomics,
instrument diversity, economically sound, and overall patient All authors listed below have participated sufficiently in the work to
7
safety. TPA is a hybrid technique combines the advantages of take public responsibility for appropriate portions of the content.
laparoscopy, which consists of aspects like improved visualization
and better abdominal exploration, and traditional techniques of references
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fundamental stage of investigation. List of disadvantages include controlled trial of ultrasonography in diagnosis of acute appendicitis,
lack of triangulation and ease of maneuverability due to clashing incorporating the Alvarado score. Br Med J 2000;321(7266):919. DOI:
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24 World Journal of Laparoscopic Surgery, Volume 13 Issue 1 (January–April 2020)