La Pediatria Medica e Chirurgica 2016; volume 38:133

Intracorporeal hybrid single port vs conventional laparoscopic

appendectomy in children
Paul Anthony Karam,1 Amy Hiuser,2 David Magnuson,1 Federico Gian Filippo Seifarth3
1Department of Pediatric Surgery, Cleveland Clinic Foundation, Cleveland, OH; 2Department of
General Surgery, Sanford Aberdeen Clinic, Aberdeen, SD; 3Department of Pediatric Surgery,
Kalispell Regional Medical Center, Kalispell, MT, USA

Abstract Introduction
Transumbilical laparoscopic assisted appendectomy combines laparo- Appendectomy is one of the most common surgeries performed in
scopic single port dissection with open appendectomy after exterioriza- children. Innovations in laparoscopic surgery are continuously evolv-
tion of the appendix through the port site. Compared to the conventional ing in efforts to minimize scars, improve operative outcomes and

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three-port approach, this technique provides an alternative with excel- maintain cost effectiveness. In pediatric patients the transumbilical
lent cosmetic outcome. We developed a safe and effective technique to laparoscopic assisted appendectomy is widely conducted. This tech-

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perform an intracorporeal single port appendectomy, using the same nique combines the use of a straight telescope with inbuilt working
laparoscope employed in the extracorporeal procedure. Retrospective channel, with an open appendectomy after externalizing the appendix
review of 71 consecutively performed intracorporeal single port appen- through the umbilical port site.1-3 The natural umbilical scar provides

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dectomies and 30 conventional three-port appendectomies in children 6 an ideal location to gain access to the abdomen.4 In this transumbilical
to 17 years of age. A straight 10-mm Storz telescope with inbuilt 6 mm
working channel is used to dissect the appendix, combined with one
port-less 2.3 mm percutaneous grasper. Polymer WECK hem-o-lock
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laparoscopic assisted technique, blunt mobilization of the cecum to
provide leverage to extracorporealize the appendix is often neces-
sary.5,6 Cecal mobilization is not typically required during a standard
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clips are applied to seal the base of the appendix and the appendiceal single port appendectomy in an adult. The described technique allows
vessels. No intraoperative complications were reported with the hybrid for a completely intracorporeal appendectomy via one single 10 mm
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intracorporeal single port appendectomy or three-port appendectomy. umbilical port without the need for cecal mobilization or placement of
There were two post-operative complications in the group treated with a spacious multi-access system and it omits the need for exterioriza-
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the single port hybrid technique: one intra-abdominal abscess and one tion of the appendix through the umbilicus. Exteriorization can be
surgical site infection. Groups did not differ in age, weight, and types of challenging in overweight patients and potentially poses an increased
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appendicitis. Operative times were shorter for the hybrid technique (70 risk for surgical site infections.7
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vs 79 minutes) but did not differ significantly (P=0.19). This modified

technique to a previously described single port extracorporeal appendec-
tomy is easy to master and implement. It provides exposure similar to a
Materials and Methods
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three-port laparoscopic appendectomy, while maintaining virtually scar-

less results and potentially reduces the risk for surgical site infections
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compared to the extracorporeal technique. Patients

This is a retrospective study of patients who underwent the hybrid
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appendectomy technique by a single surgeon from October 2010 through

Correspondence: Federico Gian Filippo Seifarth, Department of Pediatric November 2015. After institutional review board approval, 101 charts of
Surgery, Kalispell Regional Medical Center, 1333 Surgical Services Drive, patients with appendicitis as the exclusive diagnosis were included in
59901 Kalispell, MT, USA. the study. 30 of 101 patients underwent conventional three port laparo-
Tel: +1.4064071345 Fax: +1.4067528220. scopic appendectomy and 71 underwent the single port hybrid tech-
E-mail: [email protected] nique. All surgeries were performed at a single pediatric quaternary care
center. Procedures were performed by the same surgeon. Data were
Key words: Single port; Appendectomy; Laparoscopy; Polymer clips;
Pediatrics.
extracted from operative reports, surgical progress notes, and 6 week
follow up clinic visits with pediatric surgery, nutrition, and pediatric gas-
Received for publication: 1 March 2016. troenterology. Our summary includes operative time and any postopera-
Revision received: 2 August 2016. tive complications through a 6-week follow up period.
Accepted for publication: 30 November 2016.
Technique
This work is licensed under a Creative Commons Attribution
NonCommercial 4.0 License (CC BY-NC 4.0). Hybrid single port appendectomy
A weight-appropriate dose of Ampicillin/Sulbactam (50 mg/kg) or
Copyright F.G.F. Seifarth et al., 2016 Piperacillin/Tazobactam (100 mg/12.5 mg/kg) is given intravenously
Licensee PAGEPress, Italy
within the hour prior to incision. The patient is placed in supine posi-
La Pediatria Medica e Chirurgica 2016; 38:133
doi:10.4081/pmc.2016.133 tion on the operative table and undergoes standard general anesthe-
sia. Bladder and stomach are both decompressed. A longitudinal 11mm

[La Pediatria Medica e Chirurgica - Medical and Surgical Pediatrics 2016; 38:133] [page 89]
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incision is made directly through the umbilicus and entrance into the Instruments
abdominal cavity is obtained under direct visualization through the Instruments used were as follows. A straight 10 mm 0 degree Storz tel-
central umbilical defect. An 11 mm Step bladeless trocar (Covidien, escope with inbuilt 6 mm working channel (Figure 2); an 11mm Step
Mansfield, MA, USA) is inserted and the abdomen is insufflated with bladeless trocar (Covidien); medium sized Polymer WECK Hem-o-Lock
CO2 to 12 mmHg. The 10 mm Storz Hopkins telescope with a 6mm Clip (Teleflex, Research Triangle Park, NC, USA) (Figure 3); 2.3 mm
working channel is used to identify the inflamed appendix. All instru-
Clutch Grasper (Stryker) (Figure 4).
ments used through working channel are a minimum of 43 cm long.
Through a suprapubic stab incision, a 2.3 mm Clutch Grasper (Stryker,
Conventional three port laparoscopic appendectomy
MiniLap, Kalamazoo, MI, USA) is introduced under direct visualization
(Figure 1). The appendix is bluntly released from its peritoneal attach- An infraumbilical incision is made and a Verress needle is used to
ments. With the appendix retracted using the clutch grasper, dissection create a capnoperitoneum. A 12-mm umbilical trocar is introduced into
of the appendiceal base and vasculature is further carried out with a the peritoneal cavity followed by a 5-mm trocar in the suprapubic posi-
blunt grasper, introduced through the working channel of the tele- tion and a 5-mm trocar in the left lower quadrant. The appendix and the
scope. A polymer WECK hem-o-lock clip is placed around the mesoappendix are divided with a 10mm EndoGIATM stapler (Covidien).
mesoappendix, 2 clips proximally and 1 clip distally. The mesoappendix The appendix is extracted from the umbilical trocar in an EndocatchTM
is then sharply transected between clips. A laparoscopic bowel clamp is pouch (Covidien). Trocars are removed under direct vision. The umbil-
used to compress the base of the appendix in similar fashion to an open ical fascial defect is closed with a figure-of-eight polyglactin suture.
appendectomy. Two laparoscopic-polymer WECK hem-o-lock clips The 5mm port sites are closed with polyglactin and poliglecaprone in
are then applied proximally and one distally to the appendiceal base. two layers. A vacuum dressing with dry gauze and Tegaderm is
The appendix is sharply divided between the clips. The appendix is applied on the umbilicus.8
released by the clutch grasper and handed to the blunt telescope instru-
ment. The mini grasper is extracted and under direct vision, the appen-

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dix is subsequently pulled into the trocar. Trocar and telescope are

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removed from the abdominal cavity, avoiding direct contact of the pro- Results
tected appendix to the tissues of the abdominal wall at the umbilicus.
The umbilical ring and skin are closed with absorbable sutures and The results for all appendectomies were stratified by operative pro-

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dressed with a Tegaderm vacuum dressing.8 The suprapubic stab inci- cedure: 71 patients underwent the hybrid technique while 30 were
sion is closed with Dermabond skin glue.
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operated by conventional laparoscopic three-port appendectomy.
The median age in the hybrid technique is 12.3, and 13.1 in the triple
port (P=0.59).
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The hybrid technique was used to treat 63% male patients and 37%
female patients whereas the three-port procedure was used on 93%
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male and 7% female (P=0.002).

Median weight in the hybrid technique was 45.2 and 51.4 kg in the
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three-port technique (P=0.16).

In the hybrid technique, 63% of patients were categorized as under-
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weight/normal weight, 12% were overweight and 28% were obese. In

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the group treated with the three-port technique, 53% were under-
weight/normal weight, 10% were overweight, and 37% were obese
(P=0.26).
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The median operative time was 70 minutes in the hybrid group and
79 minutes in the group treated with conventional laparoscopy
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(P=0.19). The relatively high operating time is reflective of involve-

ment of surgical trainees who were often first-time laparoscopic users.
Based on histo-pathology, in patients treated with the hybrid technique
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82% had acute appendicitis, 6% had gangrenous appendicitis and 13%

had perforated appendicitis, against 80% acute, 3% gangrenous and
17% perforated in the three port technique (P=0.91).
One patient in the hybrid technique group had a surgical site infec-
tion (1.4%), which was treated with oral antibiotics. Another patient
(1.4%) developed a peritoneal abscess associated with perforated
appendicitis, necessitating drainage by interventional radiology and a
course of intravenous antibiotics. No patient in the three-port group
had any postoperative complication. There were no intraoperative com-
plications in the conventional or hybrid technique.

Discussion
Figure 1. Introducing a 2.3 mm Clutch Grasper through a supra- In recent years the laparoscopic appendectomy has evolved modify-
pubic stab incision. Reproduced with permission, Cleveland ing the number of ports and location of port sites. Furthermore, several
Clinic Center for Medical Art & Photography 2015. All Rights single access techniques have been described to perform laparoscopic
Reserved.
surgeries. These involve transumbilical incisions to accommodate a

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multi- instrument port or enough space to position multiple ports Ates et al.11,12 This method involves insertion of a polypropylene suture
through one skin incision simultaneously. Compared to the infraumbil- through an angiocath to sling the appendix into the suture for traction.
ical access, the transumbilical incisions provide excellent cosmetic This method provides a similar approach to our proposed single port
outcome and omit the use of a Verress needle. Therefore, the transum- technique with regards to the use of traction on the appendix.
bilical access was applied in the more recent patients undergoing the Compared to the angiocath, the clutch grasper is stiffer and longer
hybrid technique in this single surgeon series. The need for a relatively which allows higher range of motion and changes of retraction.11
large umbilical incision makes many single access techniques less One potential benefit to conducting a completely intracorporeal
attractive for its use in the pediatric population. To obviate dispropor- appendectomy is the presumed decreased risk of surgical site infec-
tionate incisions, several surgical alternatives have been described. A tions. The all in one appendectomy, which requires extracorporealiza-
widely used technique is the extracorporeal transumbilical laparoscop- tion of an infected appendix that inevitably comes into contact with the
ic assisted appendectomy, which requires mobilization of the cecum in skin, does pose concerns for surgical site infections. The rate of surgi-
order to gain enough mobility to exteriorize the appendix through the cal site infections of the transumbilical laparoscopic assisted appen-
umbilicus. This technique has been shown to be cost efficient, safe, dectomy with extracorporeal amputation of the appendix ranges from
quick and with excellent cosmetic outcome.2,6 The latter can be very 7.4% to 11.1%.2,6,13 Wound infections after conventional three port
challenging in obese patients. As described by Knott et al. the single laparoscopic appendectomies are less frequent ranging from 0.09 to
site approach is not recommended in obese patients due to a longer 3.1%.14,15 In our study only 1 patient operated by the hybrid technique
operative time, longer length of stay, more doses of postop analgesics developed a wound infection (1.4%). Of the 30 patients treated with
and greater costs.9 We propose a hybrid technique - combining a single conventional three-port laparoscopy, no surgical site infection was
port laparoscopic instrument with a port-less grasper to provide trac- recorded. We speculate that the low wound infection rate of patients
tion and exposure of the appendix. A similar approach has been operated with the hybrid technique compared to the extracorporeal
described by Schier in 1998 without the use of a disposable port-less transumbilical technique is influenced by the lack of contact of the
grasper and non-absorbable polymer locking clips.10 We did not study appendix with the tissues of the abdominal wall. Further investigation

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the cost of this hybrid technique but hypothesize that the charges are is required to substantiate this reduced risk for surgical site infection

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comparable or less costly than for conventional laparoscopic appendec- with a completely intracorporeal appendectomy compared to transum-
tomy, considering the addition of one inexpensive port-less grasper and bilical laparoscopic assisted appendectomy in a prospective random-
6 polymer clips and the lack of endoscopic staplers. ized study.

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An alternative method to the single port appendectomy with extra- The use of polymer clips in appendectomies has been reported in the
corporealization, is the SWING suture technique described by Akgur,
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literature. Akkoyun et al. demonstrated the use of polymer clip in a tra-
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Figure 2. A straight 10 mm 0 degree Storz telescope with inbuilt

6 mm working channel. Figure 3. Medium sized Polymer WECK Hem-o-Lock Clip.

[La Pediatria Medica e Chirurgica - Medical and Surgical Pediatrics 2016; 38:133] [page 91]
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ditional 3 port laparoscopic appendectomy was feasible and safe in clos-

ing the appendiceal stump.16 The polymer clips are non-absorbable and Conclusions
range in size between 7 and 13 mm. The clips have small serrated teeth
which allow it to firmly attach to tissue and limit shifting or migra- The hybrid single port laparoscopic appendectomy using the 10 mm
tion.16 We apply the clips to the base of the appendix to seal the Storz telescope with inbuilt working channel, Polymer WECK Hem-o-
mesoappendix. Alternatively, the mesoappendix can be divided by the Lock Clip and 2.3 mm Clutch Grasper has been shown to be safe, effec-
use of electrocautery. Polymer clips are reported to induce minimal soft tive, replicable, with a virtually scar-less results and was successfully
tissue inflammation.17 In our cohort we did not encounter any sympto- applied in normal weight and overweight pediatric patients. We have
matic foreign body reaction. found that the surgical site infection rate is similar to the conventional
The polymer clips are applied with long appliers through the 6mm three-port laparoscopic appendectomy with a lower incidence compared to
working channel of the straight 10 mm 0 degree Storz telescope. the transumbilical laparoscopic assisted extracorporeal appendectomy. We
Conventional staplers do not fit the channel and commercially available speculate that wider application of the hybrid technique results in reduced
Endoloop ligatures (Ethicon part of the Johnson & Johnson family of cost compared to the conventional three-port technique but a prospective
companies; Johnson & Johnson, New Brunswick, NJ, USA) are too randomized study is necessary to enforce this suggested benefit.
short. A potentially limiting step in our proposed method is the size of
the clips. Only the medium sized clips fit the instrument channel,
which allow ligation of up to 10 mm thick tissue. Larger appendices are
not amenable to this technique. This method of single port appendec- References
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