Sutureless Appendectomy by Using Harmonic Scalpel: Is It Possible?

Introduction

Acute appendicitis is the most common surgical abdominal emergency. Its highest incidence is in second and third decades of life, with a lifetime risk of 6.7% in female and 8.65 in male population. ¹ Early diagnosis of appendicitis is important to prevent morbidity and mortality due to its complications such as abscess and perforation leading to peritonitis.

Worldwide, appendectomy is one of the most common emergency operations performed. With introduction of laparoscopy and the benefits reported, appendectomy also went the laparoscopic way. Various advantages such as early recovery, fewer wound complications, and cosmesis were claimed for laparoscopic appendectomy. ² In laparoscopic appendectomy, ligation of the appendicular base has been performed by certain techniques such as preformed suture loops (endoloops) and endoscopic linear cutting staplers (endo GIA). There have been some experimental reports of use of the energy-based devices for appendectomy. However, since pieces of evidence are limited for their use in appendectomy, surgeons have not widely accepted them. ³

The harmonic scalpel (HS) has been used successfully in a number of open and laparoscopic procedures. As compared with traditional electrosurgical instruments, HS has certain advantages such as limited thermal spread and lesser tissue charring, leading to minimal smoke formation. Besides, nonusage of electrical current within the patient helps in avoiding the risk of electrical injury. ⁴ It is also a versatile invention, which helps the surgeon to perform tasks of coagulation, dissection, and cutting by a single instrument.

This study was conducted to evaluate the role of HS in laparoscopic appendectomy to seal the base of appendicular stump without the need for any other suturing device.

Materials and Methods

This was a combined retrospective and prospective study conducted in the surgery department of a university hospital from January 2015 to June 2019. It was approved by the hospital ethical committee (19/UPUMS/Dean/2017-18/EC). Written informed consent was obtained from all patients participating in the study. All patients with uncomplicated appendicitis admitted for elective or emergency appendectomy were included. Patients with appendicular lump, appendicular abscess, or appendicular perforation were excluded from the study. All patients were operated by a single surgeon (V.G.) during the course of the study.

Based on the approach used for appendectomy, the patients were divided into two groups: the first group included patients who underwent a laparoscopic appendectomy by the classical method in which base was ligated by an endoloop (group 1), whereas the second group included patients who underwent laparoscopic appendectomy by HS (group 2). The time range for group 1 was January 2015 to May 2017, and that for group 2 was June 2017 to June 2019. During the specified time, all patients were operated upon by a single technique.

Procedure

The patient was placed in supine position, combined with the Trendelenburg position and left lateral position. A Veress needle was introduced through a 10-mm supraumbilical incision and carbon dioxide (CO₂) gas was insufflated at a pressure of 12–14 mm Hg depending on patients' age and bodyweight. After achieving pneumoperitoneum through the same incision, a camera was introduced. Laparoscopic appendectomy was performed using a three-trocar technique with a combination of 5- and 10-mm trocars. The mesoappendix was dissected and ligature was tied at the base of the appendix in group 1, and in group 2, HS was used to coagulate the mesoappendix. Thereafter, the base of the appendix was sealed by repeated application of HS in a stepwise manner at minimum settings so as to just obliterate the lumen (Gupta Technique). The procedure was deemed complete when a ring of constriction appeared at the site of HS application. The appendix was divided just distal to it with HS on maximum setting and retrieved through a 10 mm port (Fig. 1). The stump was checked after appendectomy for any evidence of incomplete sealing of the lumen (Supplementary Video S1).

OPEN IN VIEWER

FIG. 1.

Intraoperative pictures showing use of harmonic scalpel for appendectomy.

Postoperatively, all patients were given antibiotics according to the hospital protocol. Oral intake was restricted till return of bowel sounds. Thereafter, oral intake of fluids was allowed and patients were discharged after about 24 hours. We made a record of patients' age and gender, and operative time. Postoperative return of bowel movements and complications were also recorded. The patients were followed for a period of 3 months from the time of discharge. Thereafter, they were advised to attend the outpatient department or emergency in case of any urgent problem.

The data were entered into Microsoft Excel for Windows Version 11.0 (Microsoft Corporation) and results were analyzed using statistical package for social sciences (SPSS) version 19.0 (IBM Corp., Armonk, NY) software programs. The chi-square test was used for statistical analysis of the categorical data. All values of P < .05 were considered to indicate statistical significance.

Result

During the study period of 4.5 years, 210 patients fell in the inclusion criteria. Of these, 116 were male and 94 were female. One hundred two patients underwent laparoscopic appendectomy by ligature (group 1) and 108 by HS laparoscopic appendectomy (group 2). The mean age in group 1 was 29.26 ± 11.27 years (range 10 to 62 years) and that in group was 31.22 ± 13.35 years (12 to 65; P > .05).

Mean operating time for group 1 was 43.34 ± 6.7 minutes (range 29 to 58 minutes) and that for group 2 was 28.46 ± 7.19 minutes (range 17 to 48 minutes). The operating time was significantly shorter in group 2 than in group 1 (P < .0001). Return of bowel sounds was statistically insignificant in both groups. Complications included postoperative ileus (group 1 = 8, group 2 = 10) and surgical site infection (group 1 = 4, group 2 = 4). It was statistically insignificant in both groups.

No patient presented with any problem during the follow-up period or later on.

Discussion

Serious postoperative complications such as appendicular stump leak may happen if the appendicular base is not secured properly. Hence, proper closure of its base during laparoscopic appendectomy is of utmost importance. In laparoscopic appendectomy, ligation of the appendicular base has been performed by various techniques such as staplers, endo-loop, titanium clips, nonabsorbable polymer clips (Hem-o-lock clips), hand-made loops, extracorporeal sliding knot, intracorporeal ligation, LigaSure use, or division with bipolar cautery.^5,6

There are numerous studies, which have compared various stump closure techniques. A very recent Cochrane review comparing conventional appendix base ligation and various mechanical devices in uncomplicated appendicitis did not find convincing evidence to abandon conventional appendix base ligation for any of the mechanical devices. ⁷ However, we feel that tying a ligature, or even a mechanical device, is going to increase the duration of time.

Apart from ligatures and mechanical devices, there are some reports of use of energy-based devices for managing the stump in laparoscopic appendectomy. ³ These have been presented as a sutureless appendectomy. In a study of 47 patients, Khanna et al. utilized bipolar cautery for obliterating the appendix lumen with good results. ⁸ In an experimental study on rats, authors found that bipolar cautery usage for appendectomy was effective. ⁹ However, this technique, for unknown reasons, has not achieved high popularity.

LigaSure (Valleylab, Boulder, CO) is a bipolar vessel sealing system. It works by sealing of tissues containing collagen. The effect is brought about by protein denaturation and fusing the opposing layers. These can be easily transected. This can also seal blood vessels up to diameter of 7 mm effectively. Also, tissue bundles and lymphatic vessels up to the size of jaws of the instrument can be sealed effectively. ¹⁰ There have been some experimental studies, which have evaluated LigaSure in laparoscopic appendectomy. Elemen et al. evaluated LigaSure in 48 rats and found better healing, less inflammation, shorter operation time, and equal strength as compared with sutures. ¹¹ In another experimental study on rabbits, Souza et al. also observed that LigaSure was able to achieve coagulation and division with LigaSure alone, resulting in 100% fibrosis of the appendix stump. ¹² However, the concern for lateral thermal damage of the mesoappendix and appendiceal base has been raised in one study. ¹⁰

The HS (Ethicon, Somerville, NJ) is an instrument that uses ultrasonic vibrations for cutting and coagulation of tissue. ¹³ It has been in use since early 1990s. There are sporadic reports of HS use in experimental models. Yavuz et al. evaluated 24 specimens of right hemicolectomy or subtotal colectomy and used HS, LigaSure, and conventional technique for luminal obliteration. They found all three to be equally safe. ³ However, Gozeneli et al., in an ex vivo study of 20 patients, observed that using ultrasonic instruments alone to close the appendiceal stump caused an incomplete closure. ¹⁴

It may be queried as to the need of adopting a new procedure when safer options in the form of suture ligation are available for appendectomy. As there was evidence for safe luminal division in a “sutureless” manner by cautery ⁸ as well as experimental confirmation, ³ after ethical approval, we proceeded for discarding the use of any foreign material at the appendicular stump. During the early part of group 2 evaluation, we were extra vigilant to look for any possible complication. Fortunately, none resulted. Since we were performing appendectomy by suture usage, we decided to take this as group 1 and further patients were recruited into group 2. This gave us the advantage of more patients for better statistical analysis. As mentioned in the results, both groups were age and gender matched, hence, both were comparable. Disease severity was similar in both groups and all operations were performed by the same surgeon, thereby eliminating any possibility of bias. To the best of our knowledge, there was no other factor that may have affected the duration. Our results have proved that sutureless appendectomy is feasible without any specific complications.

We also like to mention possible benefits of sutureless appendectomy. These include (1) this technique may avoid the cumbersome procedure for making Roeder's knot and applying it at the appendicular stump, (2) avoidance of any foreign body at the appendicular stump such as endoclip, staples, and suture and may prevent foreign body reaction and adhesions, (3) no requirement of clip applicator, needle holder, or knot pushers, etc., (4) staples or clip require 10 or 12 mm port, which can be avoided with harmonic appendectomy, (5) no need to change the instrument from coagulating to cutting and sealing the appendix that may cause spillage of content, and finally (6) the technique requires less time that was proved statistically. Although not a part of this study, we feel that this procedure may also be applied to single-incision laparoscopic surgery.

To the best of our knowledge, this study is the largest series that has evaluated HS for laparoscopic appendectomy. Important benefits of HS are nonusage of any suture or stapling device, ease of performing, and less time to perform appendectomy. The apprehension of Gozeneli et al. of incomplete closure was not found in a single patient during the study period. The other benefit of HS is minimal lateral thermal spread as compared with LigaSure as observed by Pogorelic et al. ¹⁰ Complication rates and postoperative recovery were comparable with conventional knotting as observed during this study. Since there was no problem during follow-ups, we may assume that there was no delayed complication after using HS. Although HS has been used in laparoscopic appendectomy, its use has been limited to dissection of the mesoappendix and not the appendix stump. We were able to find one pediatric study of 3 patients wherein HS was used for managing the appendiceal base. ¹⁵

To conclude, it appears that use of HS for laparoscopic appendectomy is feasible and safe. Its results appear to be comparable with other methods of laparoscopic appendectomy. Complications are minimal. Further studies at other centers may substantiate our efforts.