Journal of Minimal Access Surgery

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Year : 2012  |  Volume : 8  |  Issue : 4  |  Page : 140--144

Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery

Ashwin Rammohan, Paramaguru Jothishankar, AB Manimaran, RM Naidu 
 Department of General Surgery, Apollo Hospitals, Chennai, Tamil Nadu, India

Correspondence Address:
Ashwin Rammohan
Department of General Surgery, Apollo Hospitals, Chennai, Tamil Nadu


Introduction: The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA). Materials and Methods: All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot. Results: A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay. Conclusion: This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.

How to cite this article:
Rammohan A, Jothishankar P, Manimaran A B, Naidu R M. Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery.J Min Access Surg 2012;8:140-144

How to cite this URL:
Rammohan A, Jothishankar P, Manimaran A B, Naidu R M. Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery. J Min Access Surg [serial online] 2012 [cited 2019 Jun 24 ];8:140-144
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Over the past decade, the outcomes of laparoscopic appendectomies have compared favorably to those for open appendectomies because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better cosmesis. [1],[2],[3] However, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy. Recent research has led to the development of natural orifice transluminal endoscopic surgery (NOTES). However, there are numerous difficulties that need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation; and the necessity of reliable cost-benefit analyses. [4],[5] The technique we have described is virtually scarless as the intra-abdominal entry points are hidden within natural camouflages. This technique replicates the intraperitoneal view and operative technique of conventional laparoscopic appendicectomy and is hence associated with a very short learning curve as compared to the newer modalities with no extra need for expensive specialized equipment. Ours is an initial study to assess the practicality of two-port laparoscopic appendicectomy (TPA) and to compare the results with the conventional three-port laparoscopic appendicectomy (CLA).

 Materials and Methods

Following an approval from the ethics committee, patients were subjected to TPA over a 6-month period. All patients over the age of 16 with a diagnosis of acute appendicitis based on clinical findings, laboratory tests and imaging results were considered for the study. Patients with the ASA >2, shock on admission, peritonitis, suspected perforated appendicitis or peri-appendiceal abscess, cirrhosis, coagulation disorders and pregnancy were excluded from the study sample. Informed written consent was obtained from each of the patient. The data were collected prospectively from February 2009 to August 2009 for TPA and retrospectively for the CLA from August 2008 to February 2009. The clinical outcomes of the two procedures were then compared. Statistical analysis performed using Wilcoxon rank sum tests or Student's t-test for continuous or ordered discrete variables and Fisher's exact test for categorical variables. A P value < 0.05 was considered to represent a statistically significant difference between groups.

Operative technique

Laparoscopic access into the abdomen was obtained via Hasson's technique through the umbilicus, and the procedure was started by creating pneumoperitoneum through a 10-mm umbilical port with insufflation pressures being maintained between 10 and 12 mmHg. Under direct vision, a 5 mm trocar was inserted through a suprapubic incision made below the pubic hairline. The needle loop retractor (NLR) was prepared by using a simple hypodermic needle with a loop of 3-0 polypropelene through it [Figure 1]. The 5 mm camera was then shifted to the suprapubic port, and the umbilical port was used as a working and retrieval channel [Figure 2]. After a thorough exploration of the peritoneal cavity, the appendix was identified and held up by the NLR inserted through the right iliac fossa (RIF) into the peritoneal cavity [Figure 3], [Figure 4], [Figure 5] and [Figure 6]. Through the umbilical working trocar the appendicular artery was controlled and the mesoappendix transected with ultrasonic shears (Harmonic Scalpel, Ethicon Endosurgery, India). The base of the appendix was then ligated with a free tie knotted extra-corporeally [Figure 7] and [Figure 8]. The appendix was then resected and delivered via the umbilical port [Figure 9] and [Figure 10]. The CLA was performed in a similar fashion apart from the use of a 5 mm port in the RIF instead of the NLR.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}{Figure 10}


In our study, there were 146 patients. Sixty-two of them were in the TPA limb and 84 in the CLA limb. Out of the 62 patients, 11 had to be converted to the CLA (defined as the insertion of one or more 5 mm ports). The two groups were well matched with respect to demographic information (age, sex and weight) [Table 1]. The mean age of the OA group was higher than that of the mini-LA group, but this difference was not statistically significant.{Table 1}

There was no significant difference between the operative times, post-operative complications or return to work between of the two procedures, but the length of hospital stay was significantly shorter in the TPA group [Table 2]. The post-operative complications included urinary retention (two cases) and umbilical wound infection (four cases).{Table 2}


Our study was conducted safely and showed no differences in clinical outcomes between patients treated by the two techniques apart from a shorter hospital stay in the group which had TPA.

According to the Cochrane review and the EAES guidelines, there is a small but certain advantage of laparoscopic appendectomy over open appendectomy. [6],[7] Routinely, laparoscopic appendectomy is performed using three-ports. In our study, we have used two-port techniques as mentioned above. The mean operative time was 55.7 min, which is a little longer than that reported in other studies, but after our learning curve plateaus the operative time should shorten. [8],[9],[10] The average length of hospital stay was 2.3 days in our study which compared favorably with other studies. [8],[9],[10] Early discharge in our study was probably because patients had lesser pain but it was also likely due to a selection bias leading to a more favorable patient cohort in the TPA as compared to the CLA, but this also shows that the new technique is in no way inferior to the conventional method especially regarding the length of hospital stay.

In CLA, the use of 5-10 mm ports in the umbilical and RIF, right hypochondrial or left iliac fossa regions often leave clearly visible scars. We have demonstrated that TPA using a loop retractor to replace the RIF trocar and the suprapubic trocar strategically placed below the hairline to be a safe and feasible procedure. It also has other advantages, even when inflammation is extensive, the ability to hold both the appendix and the mesoappendix at the same time with a loop retractor enables more stable manipulation and countertraction than the use of conventional forceps and this procedure is also associated with less risk of causing an uncontrolled tear in the mesoappendix or an iatrogenic perforation of the appendix. Even though we have described the site of NLR as RIF, flexibility in its placement is vital and best decided following an intraoperative view of the pathology. The NLR can easily be sited elsewhere in the abdomen so as to ergonomically and cosmetically suit the pathology and the surgeon. If necessary, a surgeon can easily convert a two-port procedure to a conventional three-port procedure by adding another trocar. This allows the safety of the patient to be preserved. Our technique also eliminates one site of peritoneal invasion thereby reducing the chances of adhesions.

Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendicectomy by using fewer and smaller ports. [8],[9],[10],[11],[12],[13] Kollmar et al. described moving laparoscopic incisions to hide them in the natural camoflauges like the suprapubic hairline and improve cosmesis. [14] Additionally, reports in the literature indicate that mini-laparoscopic appendectomies using 2-3 mm or even smaller instruments along with one 12-mm port minimizes pain and improve cosmesis. [11],[15],[16] More recently, studies by Ates et al. and Roberts et al. have described variants of an intracorporeal sling based single-port laparoscopic appendicectomy with good clinical results. [17],[18]

There is also an increasing trend towards single incision laparoscopic surgery (SILS) with use of a special multiport umbilical trocar. With SILS, there is a more conventional view of the field of surgery as compared NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars, this conversion to conventional laparoscopy being called 'port rescue'. [19] It has also been shown to be feasible, reasonably safe and cosmetically advantageous to standard laparoscopy. [19],[20] However, this newer technique involves specialized instruments and has a steep learning curve due to a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability. [19],[20] There is also the additional problem of decreased exposure and an added financial burden of procuring special articulating or curved coaxial instruments. [20] SILS is still evolving, being used successfully in many a centre, but with a significant way to go before it becomes mainstream. [19],[20] Thus limiting its wide spread use especially in rural/peripheral centres with limited resources. Our technique mimics the conventional laparoscopic appendicectomy technique and uses a hypodermic needle with a suture loop to complete the procedure with the appendicular base being ligated extracorporeally with a free tie. This reduces operative costs of an extra trocar and an endoscopic stapler or an endoloop.

We believe that this is a safe and feasible procedure, which while being cosmetically acceptable has an economic advantage and acts as an ideal bridge before SILS appendicectomy or even NOTES appendicectomy become standardized, affordable and widely accepted. However, it is difficult to draw definitive conclusions about the procedure based on a study comprising a limited number of cases but it definitely deserves further evaluation in studies with larger sample sizes.


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