Page 3 - WJOLS - Laparoscopic Journal

WJOLS

10.5005/jp-journals-10007-1106
ORIGINAL ARTICLE Technical Modifications in Laparoscopic Appendectomy
Technical Modifications in Laparoscopic

Appendectomy

Ali Aminian, Faramarz Karimian, Karamollah Toolabi, Rasoul Mirsharifi
Department of General Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran

ABSTRACT

The technique of laparoscopic appendectomy has been modified several times in the past 20 years. In this report, we have described
our modifications regarding the position of ports placement and closure of the base of appendix. Three surgeons successfully
performed laparoscopic appendectomy in 108 cases with these modifications during the 3-year period. The first 10 mm port is placed
in the periumbilical region. The second 10 mm and third 5 mm ports are inserted in the left and right side of abdomen below the pubic
hairline respectively. Then the telescope is transferred from the periumbilical to the left suprapubic port. This mode of access leads to
optimal ergonomics and cosmesis. For securing the base of appendix, only one Hem-o-lok clip (nonabsorbable polymer clip) is applied
on each side. The use of Hem-o-lok clip is simple, safe and decreases the time and cost of laparoscopic appendectomy.
Keywords: Appendicitis, Laparoscopic appendectomy, Hem-o-lok clip, Polymer clip.

INTRODUCTION The first 10 mm port is placed in periumbilical region.

Since the first introduction of laparoscopic appendectomy Introducing telescope and careful transillumination of skin
by Semm in 1987, this procedure has been modified several enables to find a suitable position of two other ports. The
1,2
times. Two important issues in this procedure are mode second 10 mm and third 5 mm ports are inserted in the left
of port placement and control of appendiceal stump. and right side of abdomen below the pubic hairline
Laparoscopic appendectomy is usually done through respectively (Fig. 1). Then we transfer the telescope from
three ports. In some circumstances, one or two puncture the periumbilical to the left suprapubic port. Ergonomically,
techniques have been performed, and occasionally the fourth this technique with the optical axis lying between the two
port became necessary. In standard technique, the telescope working axes with wide manipulation angle is optimal for
is inserted through periumbilical port. Then a 10 mm port is laparoscopic surgery (Fig. 2). Additionally, the elevation
placed in left lower quadrant and a 5 mm port is placed in angle of the working instrument traversing the umbilical
right lower quadrant. This configuration of port insertion region (which is at a higher level than the suprapubic region
has two drawbacks with respect to cosmesis and in an inflated abdomen) is suitable (see Fig. 1). 4
ergonomics. First, the cosmetic result is not ideal. The other For securing the base of appendix and ligation of
disadvantage is that it requires the operating surgeon to stand mesoappendix, Hem-o-lok clip (Weck Closure Systems,
in an ergonomically unfavorable position with one arm Research Triangle Park, NC, USA) is applied (Figs 3A to E).
crossed over the patient’s body. 3,4
The standard technique for securing the base of the
appendix is by double endoloop ligatures. However,
application of endoloop requires dexterity and training.
Another technique is application of endoscopic staplers. But
this is a more expensive method for closure of the stump of
the appendix, which is particularly important in developing
countries. 5,6
In this report, we described our technique regarding
configuration of ports and control of base of appendix during
laparoscopic appendectomy.

OPERATIVE TECHNIQUE
We have modified the position of ports placement and
closure of base of appendix. Three surgeons performed
laparoscopic appendectomy in 108 cases with these Fig. 1: Ports position for laparoscopic appendectomy: Two ports in
suprapubic region and reinsertion of laparoscope through left
modifications during the past 3 years. suprapubic port

World Journal of Laparoscopic Surgery, January-April 2011;4(1):1-4 1