From Laparoscopic-Assisted to Scarless Appendicectomy: Continuing Advances

Dear Sir,

I read with interest the article by Khan et al., describing a two-port technique for laparoscopic-assisted appendicectomy, in which the appendix, grasped under videoscopic guidance, is exteriorized through a 10 mm port near the McBurney point and after removal of the cannula, appendicectomy is completed in the conventional open manner [1]. The authors believe that leaving the mesoappendix intact until it can be more easily dealt with extracorporeally represents a novel contribution.

In fact, exactly the same “assisted” technique was publicized almost ten years ago - rather aptly then when laparoscopic surgery was still in its infancy [2] [3]. It was subsequently described in a text on laparoscopy [4]. Apparently, it has since fallen into disfavor because of well-rehearsed inherent drawbacks and limitations. Nonetheless, in all fairness, it must be mentioned that this technique may have a role in some children where the working space is small and the abdominal wall thin, even though a recent randomized study showed that, overall, it was inferior to the totally intracorporeal technique using EndoGIA [5].

Ten years down the road, very few surgeons would now echo the authors' sentiment that laparoscopic appendicectomy has a steeper learning curve and thus there is a need for conversion to a “half-hearted” approach. Quite the opposite: my trainees would seize every opportunity to do laparoscopic appendicectomy to hone their laparoscopic skills - and to try out novel techniques as well.

Realizing that a trocar scar in the right iliac fossa could be rather conspicuous (more so with the stretched 10-mm port wound made by the authors), they now routinely perform laparoscopic appendicectomy through portals on either side of the suprapubic area. In selected cases, only two ports are used: one in the umbilicus for the telescope and the other in the suprapubic midline for the instrument. In addition, a no. 1 catgut suture is introduced via a 20-G intravenous catheter which has punctured the abdominal wall directly over the appendix. Its intraperitoneal end is grabbed by an endograsper and pulled externally. A sliding knot is tied extracorporeally. The pre-knotted loop is then pushed down the same port to be used to ensnare, hold and retract, as well as to ligate the appendix [6]. The innovation can be carried a step further by performing the same intra-abdominal procedure via just one umbilical portal with the use of an operating telescope incorporated with a working channel. The port wound in the centre of the umbilicus is closed in an inverted fashion. The end result is a genuine “scarless” appendicectomy, the pinnacle of minimal-access endeavors (Figure [1]).

Figure 1 Young girl 2 weeks after “scarless” appendicectomy, showing the inconspicuous central umbilical port wound for the videoscope with working channel. The healed puncture hole (arrow) for the intravenous catheter for making endoloops is almost invisible

References

• 1 Khan Z, Mofidi R, Redmond H P. Laparoscopic-assisted appendicectomy (LAA): a novel advance on an established procedure.  Endoscopy. 2001;  33 554
• 2 Byrne D S, Bell G, Morrice J J, Orr G. Technique for laparoscopic appendicectomy.  Br J Surg. 1992;  79 574-575
• 3 Gajraj H, El-Din A, McGuiness C, Choy A. Technique for laparoscopic appendicetomy (letter; comment).  Br J Surg. 1992;  79 1246
• 4 Apelgren K N. Laparoscopic appendectomy. In: Brooks DC (ed) Current review of laparoscopy. Philadelphia; Current Medicine 1995: 121-124
• 5 Shalaby R, Arnos A, Desoky A, Samaha A. Laparoscopic appendectomy in children: evaluation of different techniques.  Surg Laparosc Endosc Percutaneous Tech. 2001;  11 (1) 22-27
• 6 Ng W T, Kong C K, Yeung H C. et al . The “lap-loop” as a substitute for the fourth trocar in laparoscopic cholecystectomy.  Surg Endosc. 2001;  15 426-427