Study on single incision laparoscopic appendectomy with a focus on the frontal view of the “inverted check mark and flap”

Hideaki Tsutsumida, PhD, Mitsunobu Uto, MD, Mari Kamimura, MD, Toshiro Kamimura, MD. Keiaikai Kamimura Hospital.

At our hospital, we began performing laparoscopic appendectomy in September 2009, and single incision laparoscopic appendectomy in February 2011. To date, treatments have been provided to 40 patients, with average operation times of 41.8 minutes, with no cases requiring additional laparotomy. We focused on promoting abrasion with the aim of obtaining images to show the frontal view of the “inverted check mark” of the appendix and the ”flap” of the mesoappendix on the dorsal side in the field viewed from the side of the umbilicus. When the frontal view of the “inverted check mark and flap” can be obtained, subsequent procedures, i.e., subserous incision of the mesoappendix, identification and incision of the arteries, and root procedures, can be performed with no problems. Among the 29 subjects of our study, 8 subjects exhibited “craniad inverted check mark and flap,” in which the top of the appendix faced the head side, and 21 subjects exhibited the “foot-side inverted check mark and flap,” in which the top of the appendix faced the foot side. The operation times for the subjects with the craniad type and those with the foot-side type were 28.9 and 48.1 minutes, respectively, showing a high level of difficulty in the subjects with the foot-side type. To obtain the frontal view of the “inverted check mark and flap,” ingenuity is required for patients with severe adhesion. In particular, for patients with severe adhesion to the retroperitoneum on the dorsal side of the cecum, sufficient abrasion is required, not only for the cecum but also for the external and dorsal side of the ascending colon. In addition, for patients with difficulty in securing the view to the appendix due to expansion/adhesion of inflammation to the terminal part of the ileum, for appropriate operation, it is important to compress the small intestine and elevate the surrounding tissues of the cecum and appendix by providing supplemental thin forceps or a 5-mm port.

It is important to perform single incision laparoscopic appendectomy by obtaining the frontal view of the “inverted check mark and flap” from the education perspective, and this operation method will provide a leading mark in the process of abrasion in severe cases. Herein, we report the key points of this surgical method, as well as a comparison with the conventional method, based upon 54 patients.

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