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Two-port laparoscopic appendectomy assisted

with needle grasper comparison with
conventional...

Article in Annals of Surgical Treatment and Research · August 2016

DOI: 10.4174/astr.2016.91.2.59

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Original paper Videosurgery

Two-port laparoscopic appendectomy with the help of a needle

grasper: better cosmetic results and fewer trocars than
conventional laparoscopic appendectomy

Turgut Donmez1, Oguzhan Sunamak2, Sina Ferahman3, Server Sezgin Uludag3, Dogan Yildirim4, Adnan Hut4
1
Department of General Surgery, Lutfiye Nuri Burat State Hospital, Istanbul, Turkey
2
Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
3
Department of General Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
4
Department of General Surgery, Haseki Training and Research Hospital, Istanbul, Turkey

Videosurgery Miniinv 2016; 11 (2):

DOI: 10.5114/wiitm.2016.60504

Abstract
Introduction: The two-port laparoscopic appendectomy technique (TPLA) lays between the conventional three-port
trocar procedure and single-port laparoscopic appendectomy surgery. During TPLA, the appendix is suspended with
stitches, resulting in perforation risk and difficulty in exploration.
Aim: We used a needle grasper in TPLA to hang and manipulate the appendix.
Material and methods: Thirty-four patients (10 female, 24 male) who underwent TPLA between February 2015
and November 2015 were analyzed retrospectively for patient demographics, duration of operation, laparotomy
or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. The needle grasper was
inserted at the right under the abdominal quadrant (McBurney point) without an incision to hang and manipulate
the appendix.
Results: The mean age was 25.19 ±8.464 years; the mean body mass index (BMI) was 23.50 ±3.246 kg/m2. ASA
scores were 1 and 2. The operations were completed without any additional trocar in 34 patients. The mean opera-
tion time was 57.03 ±3.814 min. There were no intraoperative complications in any patients. Three patients required
a drain; all were discharged after drain removal. Thirty-one patients were discharged on the 1st postoperative day;
three patients with drains were discharged on the 2nd day. The mean hospital stay period was 1.18 ±0.535 days.
Conclusions: Using the needle grasper, the appendix was held and suspended and the mesoappendix was cauterized
and skeletonized successfully in TPLA. Inserting a needle grasper into the abdominal cavity at the McBurney point to
manipulate the appendix helps and does not leave a visible scar.

Key words: laparoscopic appendectomy, minimally invasive surgery, needle grasper.

Introduction talization, and early recovery are the advantages of

Laparoscopic appendectomy (LA) was recently LA [2, 3]. The recently developed single-port tech-
accepted as the gold standard procedure for com- nique advanced the level of minimally invasive sur-
plicated or uncomplicated acute appendicitis [1]. gery. Most of the single-port appendectomy studies
Better cosmetic results, less postoperative pain, less have not revealed any advantages other than tech-
postoperative infection, decreased length of hospi- nical feasibility and cosmetic results. In spite of the

Address for correspondence

Turgut Donmez MD, Department of General Surgery, Lutfiye Nuri Burat State Hospital, 50. yıl Mh. A blok 2106 sok., 34300 Istanbul,
Turkey, phone: +90 5347400967, e-mail: surgeont73@[Link]

Videosurgery and Other Miniinvasive Techniques 1

Turgut Donmez, Oguzhan Sunamak, Sina Ferahman, Server Sezgin Uludag, Dogan Yildirim, Adnan Hut

advantages of the reduced port number, increased nosed with acute appendicitis by abdominal ultra-
incision diameter, and wider fascia defect, more sonography (25 patients) or computed tomography
postoperative pain and longer operation times are (9 patients). The chosen LA techniques were the sur-
among the disadvantages of the single-port tech- geon’s own choice. Thirty-two patients who under-
nique. Another disadvantage of the single-port tech- went TPLA were included. Cases of complicated ap-
nique is higher operation costs [3–6]. Two-port LA pendicitis, such as generalized peritonitis or plastron
(TPLA) is a minimally invasive surgical procedure and formation, were excluded. Informed consent forms
results in shorter incisions, less postoperative pain, were obtained from all patients before the surgery.
and a good cosmetic result. There are many studies Age, sex, height, weight, body mass index (BMI),
related to this technique [7, 8]. and co-morbid diseases of the patients were re-
We performed TPLA with the help of an addition- corded. Duration of operation, complications, hospi-
al needle grasper (percutaneous organ holder de- tal stay period, and enteral feeding initiation time
vice). This method, due to having fewer ports than were recorded. Postoperative complications, such
the three-port LA and less surgical trauma, resulted as wound infections, stump leakage, ileus, and in-
in better cosmetic results. tra-abdominal abscess, were recorded. The needle
grasper scar was checked at the 20th and 30th post-
Aim operative days and recorded.
This study was approved by the Ethics Commit-
This study presents our experience with the nee-
tee of Haseki Research and Training Hospital on
dle grasper in two-port laparoscopic appendectomy.
11.11.2015 with approval number 274.

Material and methods Surgical method

This retrospective study was performed at a state Operations were performed by a left-positioned
hospital with 100 beds in Istanbul, between Febru- surgeon and an assistant (scopist). All patients were
ary 2015 and November 2015, with two surgeons given general anesthesia. In the TPLA, a  1-cm skin
who are experienced in laparoscopic surgery. We incision under the umbilicus was performed and the
retrospectively analyzed the 34 patients with acute intra-abdominal cavity was accessed with a Veress
appendicitis who underwent LA. Patients were diag- needle. For pneumoperitoneum, 14-mm Hg of CO2
pressure was generated and a  10-mm trocar was
A inserted into the intraperitoneal cavity. A 0°, 5 mm
optical camera was inserted through the umbilical
trocar and the 5  mm trocar entered through the
suprapubic area. Patients were positioned in the
Trendelenburg position with a  15-degree angle to
the left. Diagnostic exploration was performed and
acute appendicitis was verified. A  needle grasper
(Percutaneous Organ Holder Device, Suture Grasper
B Closure Device, Mediflex Surgical Products, Islandia,
NY, USA) was entered through the McBurney point
(Photos 1 A, B). The appendix was held with the nee-
dle grasper. Similarly to an endograsper, the appen-
dix was manipulated easily and successfully (Pho-
to 2 A). The mesoappendix was cauterized and cut
with a LigaSure instrument (Covidien, Boulder, CO).
An endoloop was inserted through the 5-mm trocar
and passed around the tip of the appendix to the
radix and tightened (Figure 2 B). Appendectomy was
Photo 1. A – Needle grasper (percutaneous or- performed. The optical camera was inserted through
gan holder device), B – abdominal entry point of the 5-mm suprapubic trocar and the endobag was
the needle grasper inserted through the 10-mm umbilical trocar; the

2 Videosurgery and Other Miniinvasive Techniques

Two-port laparoscopic appendectomy with the help of a needle grasper: better cosmetic results and fewer trocars than conventional laparoscopic
appendectomy

A B
a a

C D

Photo 2. A – Holding of appendix by needle grasper, B – a: Needle grasper device, b: Endoloop, C – immedi-
ate image of the abdomen, D – image of the abdomen, 20 days after the operation

surgical specimen was put into the endobag and were ASA 1 and 2 patients were ASA 2. Two patients
taken out of the abdomen. The fascia was closed had a perforated plastron appendicitis upon laparo-
with 2/0 vicryl and the skin was closed with 4/0 in- scopic exploration and were excluded.
tracutaneous vicryl sutures. The operations were completed without any
additional trocar or complications in the remaining
Results 34 patients. The mean operation time was 57.03
±3.814 min (minimum: 48 min, maximum: 68 min).
Thirty-four (10 female, 24 male) patients were in- One patient who underwent TPLA had a postop-
cluded. The mean age was 25.19 ±8.464 years (min: erative infection. We observed the infection at the
16; max: 48), and the mean BMI was 22.49 ±2.951 periumbilical incision region. The patient recovered
kg/m2 (min: 19.6; max: 43.25). Thirty-two patients with medical treatment.

Videosurgery and Other Miniinvasive Techniques 3

Turgut Donmez, Oguzhan Sunamak, Sina Ferahman, Server Sezgin Uludag, Dogan Yildirim, Adnan Hut

Three patients required Hemovac drain place- nique,” a  suture outgoing from the right iliac fos-
ment into the cul-de-sac or Douglas cavity due to sa and suspended by the left hand of the surgeon
minor blood leakage from the mesoappendix. All [16]. The procedures were performed successfully in
the patients were discharged after removal of the 13 of 14 cases in this puppeteer technique report,
drain. Thirty-one patients were discharged on the and they reported less postoperative pain and better
1st postoperative day. Three patients with drains cosmetic results.
were discharged on the 2nd postoperative day. The Yeung used a  string loop, which was passed
mean hospitalization period was 1.18 ±0.535 days through an intravenous catheter at McBurney’s
(min: 1 day, max: 2 days). The cosmetic results of the point, to hang the appendix. In this technique, they
needle grasper entry port were very impressive, both used an intravenous catheter and inserted the
during the early postoperative period and during the needle into the abdomen, suspended the appen-
20-day follow-up. dix against the abdominal wall, and performed the
appendectomy in 14 cases without complications.
Discussion They stated that it was especially useful in cases
with inflamed appendixes, and the McBurney point
Technological progressed has opened a new era is ideal for decreasing infections and complications;
in medicine. As a  result of laparoscopic improve- there was no scarring at the catheter port [17].
ments, operations have quickly progressed to SILS Ate et al. fixed the mesoappendix to the right ili-
ports and robotic surgery. Many researchers have ac fossa with a transabdominal suture in single-port
developed different techniques for natural orifice LAs [18]. They reported better cosmetic results with
transluminal endoscopic surgery, and there are re- this technique and had fewer tools in the abdomen.
ported LAs via a vaginal approach [9, 10]. However, In another study of TPLA, the appendix was fixed
there are many risks to these procedures. Umbilical to the abdominal wall via a suture loop on the an-
access laparoscopic procedures are a  standardized terior abdominal wall in the right lower quadrant,
methodology for laparoscopic intra-abdominal sur- which was used as an axle [19]. A suture from the
gery. LAs are usually performed via umbilical access. appendix to the outside of the abdomen through the
There are many techniques for LAs: standard mul- port was used to handle the appendix.
tiport LA, single-port LA, and TPLA are some such In our study, inserting the needle grasper (a per-
transumbilical methods. Standard LA is a  surgical cutaneous organ holder device) at the McBurney
procedure using 3 ports. SILS port LA is a  surgical point, which has been proven to be a safe point by
procedure using a single port that has 3 or 4 internal many studies, provided a means of holding and sus-
lumens. In the SILS port procedure, a 2-cm incision is pending the appendix. The surgeon could adjust the
necessary, and this may result in more postoperative position of the appendix by the needle grasper in his
pain and infection. Many studies have reported post- left hand. The mesoappendix was cauterized by the
operative pain occurring more often after the SILS LigaSure instrument through the suprapubic trocar
port technique [11–13]. In one study, Mayer et al. re- and the appendix was skeletonized. The appendix
ported less postoperative pain in the SILS group [14]. was sutured at the radix with an endoloop through
In TPLA, better angulation, compared to the SILS the suprapubic trocar and appendectomy was per-
port and conventional LA operation, can be easily formed. We did not encounter complications, such
achieved. In this technique, the percutaneous organ as appendix perforation or organ perforation, due to
holder device may function like a grasper [15]. With the use of the needle grasper. We did not observe
the help of this device, postoperative pain and scar- postoperative pain or infection at the entrance point
ring may be minimized. of the needle grasper. The diameter of the device
The most important point for SILS port appen- was 2.1 mm, and there was no need for an extra
dectomy and TPLA is the proper position for me- incision for the needle’s insertion. The reason for us-
soappendix dissection. During the dissection of the ing the McBurney point was its safety and because
mesoappendix, in order to cauterize and cut the ap- that point is an ideal region for infection sparing
pendicular artery, the appendix should be tracked. [16–19]. With the help of camera light transillumina-
There are many defined techniques to achieve tion, insertion into the abdomen was easier and saf-
this position. Roberts defined the “puppeteer tech- er. Using the needle grasper, the appendix was held

4 Videosurgery and Other Miniinvasive Techniques

Two-port laparoscopic appendectomy with the help of a needle grasper: better cosmetic results and fewer trocars than conventional laparoscopic
appendectomy

and suspended and the mesoappendix was cauter- The benefits of these new techniques need to be
ized with the LigaSure instrument and skeletonized assessed in randomized clinical trials.
successfully. Decreased postoperative pain and easy
suspension of the appendix were the advantages of Conflict of interest
this technique. We think that this technique can be
The authors declare no conflict of interest.
used in single-port LAs.
The immediate postoperative view of the en-
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Videosurgery and Other Miniinvasive Techniques 5

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Received: 19.04.2016, accepted: 30.05.2016.

6 Videosurgery and Other Miniinvasive Techniques

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