True Single-Port Laparoscopic Appendectomy: First Experience with the “Puppeteer Technique”

Introduction: Our novel “puppeteer technique” using an intraabdominal pulley system enabled us to perform the first true single-port appendectomy. In this report, we describe our first experience with this innovative technique which allows us to remove the appendix safely and successfully through one single incision.
Methods: Five consecutive patients were assigned prospectively to undergo a true single-port laparoscopic appendectomy at our institution from July through September of 2007. An 11-mm infraumbilical port for a 10-mm rigid endoscope with a 5-mm working channel was used. Retraction of the appendix was achieved in the following way.
First, a “pulley” was created by mounting a loop tied as an air knot to the anterior abdominal wall, just cephalad and lateral to the base of the appendix. The loop was subsequently used as an axle.
Next, a string (SurgitieTM) was placed around the appendix. The string was then thread through the previously created loop and pulled through the 11-mm port to rest outside the abdominal cavity. This enabled the surgeon to pull on the string extracorporeally like a “puppeteer,” which resulted in a lateral and anterior movement of the appendix to the abdominal wall exposing the base of the appendix.
In a final step, the appendix and mesoappendix were dissected and the base ligated with a SurgitieTM. The appendix was then divided and removed from the abdomen in an EndoCatchTM bag.
Results: All five true single-port appendectomies were completed without difficulty. The mean operative time was 87 minutes. All patients were discharged on postoperative day 1. No immediate or late postoperative complications were encountered.
Conclusion: Our “puppeteer technique” is a safe, novel and innovative technique which allowed us to perform the first true single-port laparoscopic appendectomy. It advances minimally invasive surgery to a new level with decreased invasiveness and better cosmesis.

Session: Podium Presentation

Program Number: S077

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