Using the endoscopic snare to facilitate two-port laparoscopic appendectomy

We retrospectively investigated the hospital records of a total of 85 (48 female and 37 male) patients at two research centers in Zagazig city; 53 patients at the emergency Surgery Unit in Zagazig University Hospitals and 32 patients at the emergency Surgery Unit at Al-Ahrar teaching hospital from July 2022 till July 2023 that underwent two-port laparoscopic appendectomy using the endoscopic snare. Patients with acute perforated appendicitis or with appendicular mass, phlegmon, or with appendicular abscess are excluded. The specimens’ histopathological reports showed the diagnosis of acute catarrhal appendicitis (n = 71) and acute suppurative appendicitis (n = 14).

Patients’ demographic characteristics are collected and analyzed (Table 1). The mean age was 27.12 ± 9.24 years (minimum age = 17 and maximum age = 56), and the mean BMI was 28.37 ± 6.51 kg/m2 (minimum BMI = 18.25 and maximum BMI = 45.35).

Most of our patients underwent successful surgery and for only 4 patients (4.44%), the two-port technique was failed and required conversion either to open surgery nor the traditional three-port technique were required. Those 4 patients had relative difficulties with two-port technique and either were necessitated further dissection of the meso-appendix or anatomically deep seated adherent retro-cecal appendicitis. The mean operative time was 43.78 ± 8.46 min (minimum: 34 min, maximum: 57 min). It was interestedly noticed that the mean operative time in patients operated with the standard 3-port technique was 41.56 ± 7.38 min (minimum: 32 min, maximum: 54 min), which was nonstatistically significant lower than the two-port laparoscopic appendectomy. This relatively nonstatistically significant longer operative time while using the endoscopic snare is related to the fact that the snare lakes rigidity and its manipulation takes a very few minutes early intraoperatively till ligating and suspending the appendix, then no surgical ergonomic issues to be faced. The 5-mm port instrument facilitated this process of snare appendicular suspension by guiding and encircling the appendix (Fig. 5a and b). It was noticed also that by elapsing time, the learning curve of operating surgeon was increasing, and this longer time was improving. Only 3 patients who had a postoperative infection at the periumbilical port site region are recovered with medical treatment and dressing and all are related to cutting the appendicular stump without overlying staple. The mean hospitalization period was 1.12 ± 0.74 days (min: 1 day, max: 2 days).

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The wound satisfaction score Mean ± SD was 4.73 ± 0.32, which was confirmed by patients after three weeks and was 4.86 ± 0.28 after 3-month postoperatively to measure the cosmetic results for our port site wounds (Table 2).

For the traditional three-port laparoscopic appendectomy, there are a number of literatures that outline how to minimize this minimally invasive surgical technique as reducing the quantity of ports, reducing the sizes of the ports, or describing a modified approach to suspended the appendix [5].

There are numerous established methods for doing this two-port laparoscopy appendectomy. Roberts described the "puppeteer technique," which involves the surgeon's left hand suspending a suture that emerges from the right iliac fossa. Thirteen out of fourteen instances in this puppeteer technique study had effective surgeries, with patients reporting improved cosmetic outcomes and less postoperative pain [6].

Another method was employed for a 36 patients (with failure in 5 cases) by Yeung et al., who inserted an intravenous cannula through the abdominal wall, leaving the plastic cannula in place as the future knot pusher, after the needle was removed. Using a catheter, one end of a ligature is inserted into the peritoneum. Through one of the ports, the intraperitoneal end is gripped and extracted. A suture loop is created by creating a sliding knot extra-corporeally. To bring the loop back into the peritoneum, gently tug on the opposite end. There was no scarring at the catheter site, they said the McBurney point is perfect for reducing infections and problems, and it was particularly helpful in instances with inflamed appendices [7].

In a different modification by Ateş et al., for the trans-abdominal sling suture technique for 38 patients (with failure in 3 cases), where he used a single port but contained a two channels (one for the laparoscope), the appendix is lifted after being gripped and separated from the surrounding tissues using a single grasper or dissector. The appendix was dragged against the abdominal wall after a suture was percutaneously (with a needle) inserted from the right lower quadrant into the peritoneal cavity and then passed through the mesoappendix [8].

Donmez et al. employed a needle grasper as a percutaneous organ holding device at the McBurney point for a total of 32 patients, allowing him to manipulate the appendix's position with his left hand. The appendix was skeletonized when the LigaSure device cauterized the mesoappendix through the suprapubic trocar. An endoloop was used to suture the appendix at the radix through the suprapubic trocar and an appendectomy was carried out [9].

Bonatti utilized two 5-mm ports and a needle grasper for a total of 39 patients, in an attempt to avoid inserting the classic 10/12-mm trocar. A 5-mm port should be used to begin this approach. After exploring the abdominal cavity, the surgeon can determine the following steps, such as additional port placements, based on anatomical findings and the appendix's appearance. He frequently fully skeletonizes the appendix so that it can be removed via a smaller incision [1].

The mean operative time in our study was 43.78 ± 8.46 min (minimum: 34 min, maximum: 57 min) and in patients operated with the standard 3-port technique was 41.56 ± 7.38 min (minimum: 32 min, maximum: 54 min), which was nonstatistically significant shorter than the two-port laparoscopic appendectomy. This was relatively near results from Augustin G and Morshed G, where the operative time ranged from 37 to 54 min (mean = 50 min) and from 45 to 60 min, respectively [5, 10].

Meanwhile, results from Olijnyk et al. and Donmez et al. showed relatively longer operative time where the mean operation time was 64.5 min and 57.03 ± 3.814 min (minimum: 48 min, maximum: 68 min), respectively [2, 9].

The failure and conversion rate in our study was only 4 patients (4.44%), which is less than results from Yeung et al. with failure in 5 cases of their total 36 patients (13.88%) and from Ateş et al. with failure in 3 cases of their total 38 patients (7.89%) [7, 8].

In our study, only 3 patients (3.52%) who had a postoperative infection at the port site region, and this was similar to results from Donmez et al. where they reported postoperative infection at the port site region in only one patient (2.94%) from a total of 34 patients in their study, and less than results from Panait et al. where they mentioned a postoperative infection and periumbilical cellulitis in only one patient (12.25%) from a total of 8 patients in their study [9, 11].

To the best of our knowledge, we present in our study the first literature to utilize the endoscopic snare as an organ holding device for the appendix to facilitate the two-port laparoscopic appendectomy. Also, because our study was performed in two research centers simultaneously, we have the highest number of operated patients (n = 85) using the two-port laparoscopic appendectomy approach in comparison to other mentioned before published literatures.

We believe that the patient will find this modified intracorporeal two-port approach to be a highly satisfactory cosmetic operation that is both safe and feasible. Although this is not a state-of-the-art surgery, some patients with physically "easier" forms of appendicitis and/or earlier presentations may benefit from it in facilities equipped with traditional laparoscopic equipment.

Laparoscopic appendectomy, using only two ports and endoscopic snare, is feasible and has been linked to high patient satisfaction and excellent cosmetic outcomes. We think that using fewer and smaller incisions in an effort to minimize surgical trauma is beneficial to patients as evidenced by the wound satisfaction score, which was confirmed by patients after three weeks and after 3 months postoperatively to measure the cosmetic results for our port site wounds. The results of this study from two research institutions should encourage other surgeons to attempt this approach, especially for a common and reasonably easy operation like laparoscopic appendectomy. In our research, we found that the endoscopic snare can be useful for many minimally invasive laparoscopic procedures in addition to appendectomy.