Laparoscopic Appendectomy via Single Port
In a single-port appendectomy, the retraction required to permit dissection of the base of the appendix is achieved not with a grasping instrument, as in two- and three-port techniques, but with a surgically created "pulley." [15] This pulley is used as an axle over which the appendix is pulled laterally, anteriorly, and cephalad (see the video below).
The steps of the procedure are as follows.
Placement of trocar
A single 11-mm trocar is placed transumbilically; alternatively, the trocar may be placed in a suprapubic position. [23, 24] A 10-mm rigid endoscope with a 5-mm working channel is usually employed. If necessary, a 5-mm 30º angled laparoscope may be used for better visualization.
Creation of "pulley"
To achieve a fulcrum effect, a pulley of sorts is created from synthetic suture material (eg, 0 glycolide-lactide) by mounting a loop tied as an air knot to the anterior abdominal wall within the abdominal cavity, just cephalad and lateral to the base of the appendix.
Next, a string (eg, Surgitie; Covidien, North Haven, CT) is placed around the appendix (see the first image below). This string is threaded through the previously created loop (see the second image below) and pulled through the 11-mm port so that it rests extracorporeally (see the third image below).
After string attached to appendix is threaded through loop, it is brought out through port for extracorporeal manipulation by surgeon.
Mobilization of appendix
Once the string around the appendix has been brought out extracorporeally, the surgeon pulls on it in much the same way as a puppeteer would, thereby drawing the appendix laterally and anteriorly to the abdominal wall. The change in the position of the appendix yields the intended exposure of the appendiceal base (see the image below).
The mesoappendix is then dissected from the base of the appendix (see the image below). Either a tie (eg, 0 glycolide-lactide) or a tissue fusion device (eg, LigaSure; Covidien, North Haven, CT) may be used for ligation of the mesoappendix. A tie is placed at the base of the appendix.
Excision and retrieval of appendix
Just 1 cm from the tie at the appendiceal base, another tie is placed around the appendix. The appendix is then divided between the two ties. The surgical specimen is placed in an endoscopic retrieval bag (eg, Endo Catch; Covidien, North Haven, CT) and retrieved from the patient's abdomen (see the image below).
Completion and closure
The loop (pulley) is cut and removed. The 11-mm fascial defect is closed with a figure-eight stitch (eg, 0 glycolide-lactide). The skin is approximated with 4-0 polyglytone, and tissue adhesive (eg, Indermil; Covidien, North Haven, CT) is applied.
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Single-port appendectomy: retraction of appendix.
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After string attached to appendix is threaded through loop, it is brought out through port for extracorporeal manipulation by surgeon.
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String is placed around appendix.
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Placement of surgical tie around appendix.
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String attached to appendix is threaded through loop.
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Exposure of appendiceal base.
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View of appendiceal base after placement of surgical tie.
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Dissection of mesoappendix.
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Placement of appendix in endoscopic specimen retrieval bag.
