Re: “In Pursuit of the Most Cost-Effective Pediatric Laparoscopic Appendectomy: The Effect of Disposable Instrument Choice on Operative Time and Surgeon-Controllable Cost” ( J Laparoendosc Adv Surg Tech A 2017;27:1309–1313)

Dear Editor:

I have read the article by Abbott et al. ¹ regarding the most cost-effective approach for pediatric laparoscopic appendectomy with great interest. The authors tested the scenario that surgeons can mainly influence the following two cost variables during surgery: the use of disposable instruments and the time required for surgery. As the most important result, Abbott et al. ¹ found that transumbilical laparoscopic-assisted appendectomy was most quickly performed and was associated with the lowest costs. In addition, the analyses supported the use of a standard three-port laparoscopic appendectomy performed with disposable trocars and an endostapler. Surprisingly, appendectomy with endoloops was not associated with cost savings. However, surgery performed by residents increased the time for surgery but not did not increase the costs for disposable surgical instruments.

I would like to contribute two further aspects to the ongoing discussion. I am convinced that there may be other benefits of the use of loops in addition to the economic aspects.

First, I feel that the laparoscopic use of endoloops may improve the surgical skills of trainees or residents. Their application seems somewhat difficult but can be achieved quickly by a skilled surgeon.

Second, I would like to contribute a short case report regarding an uncommon complication after the application of an endostapler. A 15-year-old boy was admitted to our department with abdominal crescendo pain, and colic and bile-stained vomiting with increasing frequency for 5 days. He had undergone standard laparoscopic appendectomy for appendicitis 10 weeks prior elsewhere. The boy had a normal body mass index of 20 kg/m², but his general condition was poor. Bowel sounds and abdominal X-ray results indicated the presence of a small bowel obstruction. Treatment for dehydration was initiated with an intravenous infusion of isotonic fluid. Metamizole and piritramide were administered to provide analgesia. Laparoscopy was performed immediately. Inspection of the right lower quadrant revealed two dilated and bluish-colored bowel loops within the right small pelvis. Since it was not possible to obtain a sufficient overview, we converted to an open infraumbilical minilaparotomy. After eventration of the affected bowel, we were able to identify the underlying cause of the obstruction. A lost 2.5-mm staple had lodged in both the greater omentum and the small bowel mesentery, and external strangulation and partial volvulation of the bowel had occurred (Fig. 1). The hemorrhagic infarcted segment of the ileum was resected, and an anastomosis was established. Early initiation of enteral nutrition led to the patient's rapid recovery, and he was discharged 5 days after surgery with full enteral feeding by mouth.

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FIG. 1.

The staple (arrow head) served as an unintended connection between the greater omentum and the mesentery. Entrapment, partial volvulation, and hemorrhagic infarction occurred.

Our case is not an argument against the use of endostaplers. However, this case shows that even very small staples lost during an appendectomy should be removed. Since I did not find any comparable cases in the literature, this type of complication might be underreported. As a result, more “intelligent” stapling devices are needed to prevent the loss of staples during surgery.