Laparoscopic Traction Device for Assistance of 2-Port Laparoscopic Appendectomy

Laparoscopic appendectomy (LA) traditionally uses 3 ports: 2 for the videoscope and 3 for the procedure. ¹ More recently a large single port technique groups the 3 ports in a single site that uses a larger incision. ² As an alternative to the 3-port and single-port methods, we developed a laparoscopic traction device to pull the appendix to facilitate its removal.

Our experience indicates that it improves cosmetics by using a traction device designed by us to manipulate the appendix and placing ports for the scope and surgical instruments on the upper and lower margin of the umbilicus, respectively. The device can be placed with a 2 mm incision near McBurney’s point (Figure 1). It has an outer and inner cylinder that incorporates the principle of a Veress needle to allow penetration into the abdominal cavity with less risk of visceral injury. The inner cylinder is removed to allow the passage of a wire snare used to pull and control the appendix. The appendix can then undergo dissection and removal by any method (the use of clips is shown in Figure 1). Removal is by an endoscopic bag retrieval device through one of the umbilical ports.

OPEN IN VIEWER

Figure 1

The photos of operation procedure and the postoperative recovery. (A) Preparation of the laparoscopic traction device with a tip structure as well as the wire loop. (B) The incision appearance 1 week after operation. (C) The appendix pulled by the laparoscopic traction device after removal operation. (D) The appendix in the suspension of the laparoscopic traction device and the treatment of the mesentery.

After approval of a study protocol by our hospital ethics committee, we randomly assigned 74 patients to the 2-port technique plus the traction device and 75 patients to the standard 3-port procedure. The groups were equivalent to age (from 15 to 7, 45.07 ± 16.84 years for the entire study group), and the distribution among simple appendicitis (17 for the whole group), suppurative appendicitis (38), and gangrenous appendicitis (19). None required conversion to an open procedure.

The average operation time (excluding the anesthesia time and instrument preparation) was less in the 2-port group (13.14 min), compared with the 3-port group (15.81 min; t = 3.924, P < .001). No postoperative analgesia was used.

Analysis of the postoperative pain score revealed that the 2-port LA significantly reduced pain level compared with the 3-port LA (mean score 1.33 vs 3.27), and more than 98% of the individuals in the 2-port group had a score between 0 and 2 and about 93% in the 3-port group had a score between 3 and 5 (Mann-Whitney U = 199.5, P < .0001). Using a patient satisfaction score, the 2-port protocol scored better than the 3-port technique (U = 2108, P < .0001).

In properly selected patients, the 2-port LA assisted by laparoscopic traction device is a safe procedure for all degrees of appendicitis. From our experience, it decreases operative time, relieves the postoperative pain, and enhances patient satisfaction.