Laparoscopic Appendectomy Using the LigaSure ® Vessel Sealing Device at the Time of Gynecologic Surgery

Introduction

Laparoscopy has been used for the performance of appendectomy for more than two decades. ¹ Despite outcomes, cosmesis, and convalescence being reported as superior,^2–8 laparoscopy has not gained widespread acceptance. This may be secondary to some disadvantages: Laparoscopic appendectomy can be technically challenging, and operative time may be longer, compared to the open technique.^2,3,6–8

Removal of the appendix in the course of gynecologic oncologic surgery is not uncommon.^9–13 Certain ovarian tumor histologies, specifically, mucinous neoplasms of the ovary, are associated with an increased incidence of either a metastatic deposit or synchronous or metachronous appendiceal neoplasms.^14,15 These justify the routine removal of the appendix for diagnostic and/or staging purposes. In other cases, an appendectomy may be performed to achieve optimal debulking because of the occurrence of an adnexal mass in close proximity to the appendix. Incidental appendectomy in the course of laparoscopic gynecologic surgery has been shown to be safe and does not increase complication rate or prolong operating time or hospital stay.^13,16

Techniques for performing a laparoscopic appendectomy vary, but all reports published to date include the ligation of the appendiceal base before it is separated. The LigaSure® vessel sealing system is a bipolar feedback-controlled sealing device designed for effective sealing of blood vessels. To date, its use in laparoscopic appendectomy has been described only with respect to use for dividing the mesoappendix.^17–19 The literature on bowel-wall division and sealing with the LigaSure is very limited. ²⁰ This report describes a series of consecutive appendectomies managed with the LigaSure to seal and separate the appendix from the cecum without the use of sutures or staples.

Materials and Methods

Since September 2004, all laparoscopic surgeries performed by 1 member of the Gynecologic Oncology service at the Sunnybrook Health Sciences Center for gynecologic malignancy were prospectively recorded. Appendectomies performed during the course of surgery were accomplished solely using the LigaSure device.

After obtaining informed consent, laparoscopy was performed through four ports: one 10-mm supraumbilical; one 10-mm suprapubic; and two lateral 5-mm ports. A 0° laparoscope was introduced through the supraumbilical port. In addition to the appendectomies, other procedures were performed—including hysterectomies, salpingo-oophorectomies, omentectomies, and lymphadenectomies—as indicated by individual clinical cases. The 5-mm LigaSure device was used to divide the mesoappendix sequentially. Once the mesoappendix was sealed and divided, the same device was used to move across the appendiceal base, sealing and separating it from the cecum.

Relevant patient data, including demographic and medical information, and details of the surgeries, were prospectively collected and recorded. Surgical information included duration of surgery, estimated blood loss, and intraoperative and postoperative complications, including conversion to a laparotomy. At the time of this data analysis, the electronic patient records and the patient charts were reviewed retrospectively to reensure accuracy of medical and demographic information.

Results

Between September 2004 and May 2009, 14 patients had laparoscopic surgery that included appendectomy for a gynecologic malignancy by 1 member of the division of gynecologic oncology at the Sunnybrook Health Sciences Center. This series included patients undergoing primary or secondary surgery. Twelve of 14 cases in this series had adnexal tumors of mucinous histology. The diagnosis was made by frozen section in 10 cases; the remaining 4 patients underwent a laparoscopic staging procedure after previous removal of the adnexae at another institution. The mucinous tumors were invasive in 5 cases and borderline in 7.

The patients' median age was 34 years (range, 22–76 years) and their median body mass index was 25 (range, 19–37).

The median total operative time was 1.5 hours (range 0.8–3 hours). Surgery included an adnexectomy in 10 patients; hysterectomy in 5 patients; and a full staging procedure, including pelvic and para-aortic lymph-node dissection in 2 patients. There are no data on the isolated duration of the appendectomy, but it was estimated to be approximately 5 minutes. There were no conversions to laparotomy and no major intraoperative or postoperative complications, with a median follow-up of 2 years. The median blood loss was 50 mL (range, 0–400 mL).

Discussion

Laparoscopy has been used for the performance of appendectomy since Semm's first description of the procedure in 1983. ¹ It is reported to have several advantages over the open procedure, including shorter hospital stay,^2,4 lower rates of wound infection,^4,6,8 better pain control and lower use of analgesia,^2,6,7 a more rapid return to activity and work,^2,5–8 and, consequently, a higher cost–benefit ratio. ² Despite its merits, laparoscopic appendectomy has not gained widespread acceptance and, unlike laparoscopic cholecystectomy, ²¹ has certainly not become the standard of care. Some studies comparing laparoscopic appendectomy to the open procedure have not shown an advantage^22–25 ; and, in fact, the excellent results of open appendectomy combined with the heterogeneity of variables and other methodological flaws in published studies comparing the two techniques have excluded a definitive conclusion on the topic.^26,27 There may be several reasons for this, not the least of which is the speed and simplicity of the open procedure and its low morbidity. Laparoscopic appendectomy is more technically challenging, dependent on technology, and associated with longer operative times in comparison to the open procedure.^2,3,5–8 Any technical improvements allowing simplification of the procedure and leading to shorter operative time would make laparoscopic appendectomy a more feasible surgical option.

The LigaSure vessel sealing system is a feedback-controlled bipolar vessel sealer. It is designed to reform collagen and elastin in the vessel wall, creating a permanent seal, and has been shown to be effective for vessels up to 7 mm in diameter with a burst strength comparable to that of ligatures or clips. ²⁸

The use of the LigaSure sealing device has been described in many articles with respect to use for various endoscopic and open procedures. A meta-analysis of prospective randomized trials ²⁹ concluded that across disciplines—including otolaryngology, gynecology, colorectal, and hepatobiliary surgery—the LigaSure device for hemostasis shortens operative time, minimizes blood loss, and reduces the rate of complications.

There are, however, limited descriptions of the use of LigaSure for laparoscopic appendectomy in the English literature.^17–19 Groups from Taiwan and Turkey described the division of the mesoappendix using the LigaSure; in all these reports, transection of the appendix itself was accomplished after applying a silk ligature or endoloop to the base of the appendix. A report from Taiwan ¹⁸ described excellent outcomes and listed potential advantages of this technique, including obviating the need to change instruments from coagulating to cutting, and sealing the appendix before dividing it, preventing any spillage of contents. This was a descriptive rather than a comparative report, and, thus, no conclusions can be drawn regarding operating time reduction or complication rates. Articles from Turkey reported a retrospective comparison ¹⁷ and a prospective randomization, ¹⁹ comparing division of the mesoappendix with the LigaSure to its division with the Endoclip. They both produced similar outcomes, with a shorter operative time using the LigaSure.

The composition of the bowel wall is similar to that of blood vessels and may, theoretically, be amenable to this technique. The literature on use of sealing devices, such as the LigaSure, for sealing and division of bowel and hollow organs is limited. There are a few reports on animal models. Reports on a porcine model for cystic-duct sealing and ligation^30,31 did not show promise because of a high rate of necrosis. A report on a porcine model for small-bowel sealing and division ³² showed the LigaSure to be unsafe in this context because of low burst pressures. Different LigaSure techniques were associated with burst pressures of 11–27 mm Hg, compared to 131 mm Hg with a stapling device. The intraluminal pressure in the normal appendix has been shown to be close to 0, as opposed to inflamed or phlegmonous appendices, where pressure is much higher at 15–93 mmHg.^33,34

Another report on a porcine model investigated the utility of a prototypical anastomotic device based on LigaSure technology, and capable of transecting and fusing bowel wall to create anastomoses ³⁵ ; this application showed promise but is not yet clinically available. Finally, an Italian study ³⁶ evaluated the use of LigaSure for resection of the cecum and small bowel in rabbits and found this device to be effective for small-bowel sealing but not for the cecum. The only report on this application in humans is another Italian study ²⁰ describing the use of LigaSure for sealing and division of the terminal ileum during a right hemicolectomy. However, this was only done as a temporary measure and the seal was then reversed for the creation of the anastomosis.

Conclusions

Based on the literature discussed above, the low intraluminal pressure in normal appendices, and previous anecdotal experience of inadvertent appendectomies using bipolar cautery alone, it seemed reasonable to expect that using the LigaSure device for laparoscopic appendectomy would be safe and effective, allowing simplification of the procedure and shortening of operating room (OR) time.

This article's current data suggest the feasibility of using the LigaSure sealing device for laparoscopic appendectomy, both to divide the mesoappendix and to seal and transect the appendix itself without use of a ligature. This is a descriptive report that does not allow us to draw comparative conclusions regarding operative time, complication rates or other important clinical parameters. The data are, however, promising; there was no intraoperative spillage of appendiceal contents and no postoperative leaks.

Whether the current results can be extrapolated to situations in which appendectomy is performed for acute appendicitis remains to be established. An acute inflammatory process involving the appendix would add complexity to the procedure, increasing the volume and thickness of the mesentery to be divided as well as the diameter of the appendix itself and the thickness of its wall. Furthermore, intraluminal pressures have been shown to be higher.^{33, 34} These changes may make the appendix less amenable to sealing with the LigaSure device. Notwithstanding, several groups already shown that this tool may be used safely for the division of the mesoappendix in patients with acute appendicitis.^17–19

The authors propose that this technique may make laparoscopic appendectomy a more widely applicable alternative by simplifying the procedure and shortening OR time. Further investigation of the use of the LigaSure device for the performance of laparoscopic appendectomy in various surgical settings should be undertaken.