Needlescopic Appendectomy in Children and Adolescents Using 14-Gauge Needles: A New Era

Abstract

Purpose:

We are presenting a very minimally invasive technique for laparoscopic appendectomy (needlescopic appendectomy [NAP]) in children and adolescents using suture grasper device, epidural needle, and homemade isolated long diathermy probe without any conventional laparoscopic instruments.

Patients and Methods:

NAP was attempted in 48 patients with uncomplicated acute appendicitis at Al-Azhar, Tanta University Hospitals and other allied hospitals during the period from May 2017 to November 2018. The study included patients with acute appendicitis and patients scheduled for interval appendectomy. Exclusion criteria were patients with concealed appendix, patients with appendicular abscess or appendicular mass, patients with acute appendicitis complicated with generalized peritonitis, and patients unfit for laparoscopy. The appendix was brought outside through the umbilical port and the operation was completed extracorporeally. In cases of appendicitis with tethered cecum, the whole procedure was completed intracorporeally.

Results:

Forty-eight patients with acute uncomplicated appendicitis were treated by NAP. They were 36 males and 12 females with a mean age of 9 ± 3.7 years (range = 4–15 years). Two cases with concealed appendix and one case with appendicular mass were diagnosed during initial laparoscopy and excluded from the study. Thirty-two cases (71.11%) were completed intracorporeally and 13 cases (28.89%) were completed by extracorporeal NAP. The mean operative time was 33.29 ± 3.95 minutes (range = 27–40 minutes) for intracorporeal NAP and 20.9 ± 7.01 minutes (range = 14–40 minutes) for extracorporeal NAP. Degrees of cosmetic satisfaction of the patients and parents were excellent in 93.33% (N = 42/45 patients), and very good in 6.67% (N = 3/45 patients) of patients.

Conclusion:

NAP using needles only is a new technique that is very minimally invasive, very cheap, safe, reproducible, and easy to be done with outstanding cosmetic results.

Introduction

Open appendectomy is still the gold standard treatment for acute appendicitis. Recently, laparoscopic surgery gained popularity in developing countries because it offers early hospital discharge, less pain, improved cosmoses, and earlier return to daily activities. Worth mentioning is that the routine use of laparoscopy is slowly growing because of the cost, learning curve, and visible scars in comparison with open procedures, especially in the pediatric age group; hence, the introduction of single-incision laparoscopic appendectomy (SILAP). However, SILAP is facing several challenges due to the cost of the port, improper instrument ergonomics, and a relatively big umbilical wound, and so, it is not popular and far from being the gold standard.^1,2

Nowadays, appendicitis in children and adolescents can be successfully treated laparoscopically through multiport techniques.^3,4 Several recent trials have been performed to use smaller instruments (2 mm), decrease number of ports, reposition port sites to hide the scars, and improve cosmetic results of laparoscopic appendectomy (LAP). However, these 2-mm instruments are fragile, flexible, not durable, and expensive. Moreover, it needs more skills for dissecting in-flamed tissues.

Needlescopic appendectomy (NAP) is an acceptable and safe technique and has many advantages such as better cosmoses, less postoperative pain, and less hospital stay. However, the published trials in adults reported that multiport LAP is superior to NAP as the latter is more time consuming, with high conversion rate to open appendectomy.⁵ Ismail et al. are the first innovator of NAP by Mediflex needle. They used Mediflex needles for removal of a non-complicated appendicitis (CAP) in children and adolescents.⁶ In this study, we present our experience of NAP for non-CAP using only needles with 14-Gauge in children and adolescents.

Patients and Methods

Forty-eight children presented to the Pediatric Surgery Departments, at Al-Azhar, Tanta University Hospitals and other allied hospitals, during the period from May 2017 to November 2018, with a diagnosis of acute appendicitis or for scheduled interval appendectomy. Exclusion criteria were patients with concealed appendix, patients with appendicular abscess or mass, patients with acute appendicitis complicated with generalized peritonitis, and patients unfit for laparoscopy. All patients were subjected to full history taking, stressing on the following: onset, course and duration of abdominal pain, fever, and associated vomiting or diarrhea, full clinical examination, and laboratory workup (complete blood count, prothrombin time, international normalize ratio, activated partial thromboplastin time, C-reactive protein, and urine analysis). All children had pelvic/abdominal ultrasound, and radiological investigations in the form of plain X-ray of the abdomen, pelvis, and chest, or computed tomography if indicated.

Our primary outcome was to evaluate feasibility, and safety of NAP. Patients were followed for 6 months to assess postoperative cosmetic results and track delayed complications such as postoperative pelvic collection and umbilical hernia.

Preoperative preparations

The patient kept nothing by mouth (NPO) 6 hours before surgery with fluids and electrolyte homeostasis, and broad-spectrum antibiotics were intravenously administered (third-generation cephalosporins 100 mg/kg/day and metronidazole 7.5 mg/kg/dose).

Ethical consideration

The study was approved by the Institutional Review Board of Al-Azhar, Tanta, Mansoura, and Alexandria Universities. The procedure was clearly explained to the parents/guardian, and a written informed consent signed before enrollment in the study.

Instruments

Ten-millimeter trocar and a 10-mm 30° telescope, two 14-G suture grasper devices (SGDs; Mediflex Company, Islandia, NY) (Fig. 1A), 18-G epidural needle (EN) (Fig. 1B), and a thin homemade insulated long diathermy probe (LDP) (Fig. 1C) were used. The LDP is a tapered out 15-cm-long Kirschner wire of 1.5-mm thickness and insulated by a thin autoclavable sheath. It fits directly in the regular diathermy handle (Fig. 1D).

FIG. 1.

Showing the instruments used for needlescopic appendectomy. (A) Suture grasper device. (B) ENs. (C) Long diathermy probe. (D) Handle of diathermy. ENs, epidural needles. Color images are available online.

Incisions

(1)

Vertical transumbilical incision is made for insertion of 10-mm port for a 30° telescope.

(2)

A 1.5-mm 11-blade scalpel puncture is done at point A (2 cm above the McBurney's point).

(3)

A 1.5-mm 11-blade scalpel puncture is done at point B (midway between the umbilicus and pubic bone or slightly lower and to the left in younger patients) (Fig. 2).

FIG. 2.

Showing the umbilical port and skin puncture points (A, B). Color images are available online.

Operative details

Patient was placed in a supine position with little tilting to the left side, and the table to 30° Trendelenburg. Betadine solution was applied from nipple to midthigh. NAP was started by transumbilical vertical skin incision, and 10-mm trocar was introduced by open method for a 30° telescope. Pneumoperitoneum was established with CO₂ flow of 2–5 L/minute keeping the intra-abdominal pressure between 8 and 12 mmHg according to the age. The abdomen is explored to confirm the diagnosis. In the presence of concealed appendix, appendicular mass, or generalized peritonitis, the procedure was converted to conventional laparoscopy and the cases were excluded from the study.

One SGD was introduced through point A (SGD-A) and another one through point B (SGD-B). Both SGDs were used to explore, manipulate, and assess the mobility of the cecum and appendix (Fig. 3); if they were freely mobile, the tip of the appendix was grasped by SGD-A and exteriorized through the umbilical port and appendectomy was completed extracorporeally. Then, the ligated appendicular stump was repositioned into the abdominal cavity and the abdomen was re-insufflated to check for any bleeding points and for suction/irrigation if needed using a Veress needle, which was inserted through point B.

FIG. 3.

Showing steps of manipulation of the appendix, division of adhesions, and intracorporeal ligation of the base of the appendix. (A) Identification of the appendix. (B) Grasping of the mesoappendix with SGD. (C, D) Passing a Vicryl^® suture around appendix using EN. (E, F) Ligation near the base of the appendix using extracorporeal French sliding knot. SGD, suture grasper device. Color images are available online.

If the appendix is inflamed, thick, and cannot be grasped by SGD, we introduced EN G-18 (its tip was intentionally bent into a gentle curve for easy handling and tissue manipulations) through point A and advanced to pierce the mesoappendix in the avascular area. We then passed a 2/0 Vicryl^® (Ethicon, Inc., Somerville, NJ) suture through it around the appendix near its base and EN was removed. Both ends of the thread were extracted by SGD-B outside the abdomen (note that both ends of the suture line leave the abdomen through one skin puncture, but different peritoneal punctures, and so, they have tissues in-between and cannot slide freely to form a sliding knot).

Then, another SGD-A and both ends of the suture were grasped together to exit the abdomen at the same time through point A to ensure smooth sliding of the knot through the abdominal wall. Base ligation is then completed by French sliding knot (Fig. 3). The suture was then grasped and passed through the umbilical port as a guide to exteriorize the appendix and complete the procedure extracorporeally as mentioned previously.

In cases with fixed cecum, the whole procedure was completed intracorporeally, after assessment and manipulation of cecum and appendix, as explained previously (Fig. 4). Then, SGD-A was removed and EN G-18 inserted through point A and advanced to pierce the mesoappendix through the avascular point near the base of the appendix, while SGD-B was holding the appendix. A 2/0 Vicryl suture was then threaded through the EN to appear on the other side of the mesoappendix. SGD-B dropped the appendix and pulled the short end of the thread out of the EN, which was then withdrawn outside the abdomen leaving short end of the thread intra-abdominally and long end outside the abdomen through point A. The short end of the thread was retrieved outside the abdomen by SGD-B through point B. Then, the long end was also brought out through point B using SGD-B passing around the mesoappendix, and then, both ends were brought out from point A using SGD-A to ensure exit of both ends of the thread through the same skin and peritoneal point to allow free sliding of the knot as described before. Now the suture line encircled the mesoappendix and both ends are outside the abdomen through point A. The suture was knotted around the mesoappendix using one of the following techniques: (1) extracorporeal French sliding knot as described by Shalaby et al.⁷ (Fig. 4C, D) and (2) using SGD-A as a Maryland to apply Shalaby-Ismail intracorporeal single instrument tie for ligation of the mesoappendix.⁸

FIG. 4.

(A, B) Showing exposure of the appendix and mesoappendix. (C, D) Photos showing French sliding knot. Color images are available online.

After secure ligation of the mesoappendix, LDP was directly introduced through point A to separate the mesoappendix from the appendix. Then pulling both ends of the thread where they were cut outside flush with the abdominal wall using surgical scissors. Appendicular base was then doubly ligated by the same technique and the appendix was transected between two ligatures using LDP through point A. The base of the appendix or the suture ends around the base were grasped by SGD-A and pushed within the umbilical trocar where the appendix was completely delivered inside the port (Fig. 5). Procedure was then completed as previously mentioned. Deflation of the abdomen was done, and the umbilical fascial incision was closed using 2/0 or 3/0 Vicryl, and the umbilical skin layers were closed using 4/0 Vicryl.

FIG. 5.

Showing extraction of the appendix through umbilical port. Color images are available online.

Postoperative management

Patients received intravenous fluids, antibiotics, and analgesics according to hospital protocols. Patients started oral fluids 6 hours postoperatively and the diet was advanced gradually as tolerated. Patients were discharged the second postoperative day. Measurements: All patients' data were collected in a data sheet, including mean skin to skin operative time in minutes, intraoperative complications, hospital stay in hours, and postoperative complications (Table 1). Patients'/parents' satisfaction was evaluated using a subjective 0–4 score, where 0 = no satisfaction, 1 = fair, 2 = good, 3 = very good, and 4 = excellent. Follow-up: after discharge, all children were followed 1 week, 2 weeks, 1 month, and 6 months for assessment of the cosmetic outcome, presence of pelvic collection, and port-site hernia.

Table 1.

Showing the Data of Our Patients

Procedure	NAP using only needles
Number of patients	48
Sex
Male	36
Female	12
Mean age in years	9 ± 3.7 SD
Range in years	4–15
Excluded cases
Concealed appendix	2
Appendicular mass	1
Indication of appendectomy
Acute appendicitis	37
Chronic appendicitis	9
Interval appendectomy	2
Mean operative time of extracorporeal NAP (minutes)	20.9 ± 7.01 SD
Range	14–40
Mean operative time for intracorporeal NAP (minutes)	33.29 ± 3.95 SD
Range	27–40 minutes
Postoperative complications	0
Mean hospital stay in hours	18.45 ± 1.6 SD
Range in hours	24–48
Patients'/parents' satisfaction
Excellent 93.33% (N = 42/45)	93.33% (N = 42/45)
Very good 6.67% (N = 3/45)	6.67% (N = 3/45)

NAP, needlescopic appendectomy; SD, standard deviation.

Statistical analysis

Data were analyzed using the Statistical Package for Social Sciences^®, version 24.0 (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.). Quantitative data were expressed as mean—standard deviation. Qualitative data were expressed as frequency and percentage. Independent-samples t-test of significance was used to compare between two means.

Results

Our study included 48 patients (36 males and 12 females) with acute non-CAP treated by NAP from May 2017 to November 2018. The mean age was 9 ± 3.7 years (range = 4–15 years). Patients' demographic data are shown in Table 1. Two cases with concealed appendix and one case with appendicular mass were diagnosed during initial exploratory laparoscopy and were converted to conventional LAP and excluded from the study.

Thirty-two cases (71.11%) with fixed cecum were completed by intracorporeal NAP and the remaining 13 cases (28.89%) with mobile cecum were completed extracorporeally. No single case was converted either to conventional laparoscopy or open appendectomy. Mean operative time was 33.29 ± 3.95 minutes (ranged from 27 to 40 minutes) for intracorporeal NAP and 20.9 ± 7.01 minutes (ranged from 14 to 40 minutes) for extracorporeal NAP. No pelvic collection or port-site hernia complicated NAP was detected, and the scars were almost invisible (Fig. 6). The degrees of cosmetic satisfaction of the patients and parents were excellent in 93.33% (N = 42/45) of patients and very good in 6.67% (N = 3/45) of patients.

FIG. 6.

Showing early and late postoperative cosmetic results. (A) Immediate postoperative. (B) Three-months postoperative. Color images are available online.

Discussion

The first open appendectomy was performed in an 11-year-old boy complaining of inguinal hernia with inflamed appendix as a content by Amyand in 1735. Then, McBurney in 1894 described the classical open appendectomy incision.⁹ The first LAP was described by Semm in 1983,¹⁰ whereas the first LAP in children was performed by Ure et al. in 1992.³ Since that time, many trials reported good outcomes of LAP for non-CAP and it became an alternative way of management.^10,11 A recent meta-analysis studied >6000 patients and showed that LAP had fewer postoperative complications compared with open appendectomy. Meanwhile, the importance of laparoscopy in CAP is still showing controversy.^12,13 In 1996, Frazee and Bohannon were the first to conclude the benefits and safety of LAP in CAP.¹⁴

Nowadays, LAP has been widely applied for the treatment of complicated and non-CAP.^13,14 LAP has many advantages over open appendectomy, including better visualization of the entire abdomen, reduced postoperative adhesions, decreasing rate of surgical-site infection, shortened hospital stay, reduced postoperative pain, and significant improvement of cosmetic outcome.^15–17 However, the scars of conventional laparoscopic surgery are still visible, especially in comparison with open procedures in the pediatric age group.

Hence the introduction of single-incision laparoscopic surgery, including cholecystectomy, splenectomy, and SILAP. Homemade glove single-port has been described recently by several authors to decrease the cost of SILAP with excellent cosmetic results..^18–20 However, SILAP is facing several challenges due to the cost of the port, improper instrument ergonomics, and a relatively big umbilical wound, and so, it is not popular and far from being the gold standard.^1,2,19,20

We tried to reduce costs and make invisible scars by using only needles that are cheap, thin (1.6 mm), durable, strong, and readily available. They are easy to handle with outstanding cosmetic results in the form of tiny skin punctures, which are almost invisible with no port-site infection. We think NAP is not suitable for CAP because we believe that a perforated appendix tends to be more demanding and challenging, frequently requires the retrieval of fecolith, peritoneal toilet, and adhesiolysis of fibrinous bands, all of which cannot be perfectly achieved using SGD.

In this study, we attempted NAP in 48 patients with non-CAP. Of these 48 patients, 2 cases with concealed appendix and 1 case with appendicular mass were diagnosed during initial laparoscopic exploration and converted to conventional LAP and excluded from the study. Thirty-two cases (71.11%) with fixed cecum were completed by intracorporeal NAP, and the remaining 13 cases (28.89%) with mobile cecum were completed extracorporeally. No single case was converted to either laparoscopic or open appendectomy. Perea et al. concluded that transumbilical extracorporeal LAP for nonperforated appendicitis is safe, effective, and feasible in >60% of cases and it can be easily converted to conventional LAP.²¹

Boo et al.²² mentioned that exteriorization of the appendix through the umbilicus is simple in children than adults due to shorter distance. So, transumbilical extracorporeal LAP was possible in most pediatric cases. Whereas in few instances they had to do some lateral cecal mobilization and even ligation division of the mesoappendix for easy and safe exteriorization of the appendix.²³

The continuous search for refinement and perfection of minimally invasive surgery led to the appearance of needlescopic surgery using 2- or 3-mm instruments. This approach was reported to be successful in cholecystectomy, fundoplication, sympathectomy, appendectomy (NAP), and many other procedures.^22,24 NAP is a relatively new technique that offers the benefits of intracorporeal and extracorporeal appendectomy with the use of 2- or 3-mm instruments, and further decreases recovery time and postoperative pain. Recently, many trials of NAP using 2-mm instruments were conducted to gain better cosmetic results and early recovery.^25,26 However, these 2-mm instruments are weak, not durable, expensive, hard to handle, and need experience, which limited the usage on a wide scale.²⁴ Ismail et al. used Mediflex needle for the first time to remove non-complicated acute appendicitis in 117 children with encouraging results.⁶

In our study, we used needles rather than 2-mm instruments, which are cheap, durable, and easily available. Besides the 10-mm umbilical port for the telescope, we used EN, SGD, and homemade LDP. SGD was used as a Maryland manipulating the appendix, holding the mesoappendix, and handling sutures. Both SGDs and EN were used for passing, ligation, and tightening of the suture around the mesoappendix and appendicular base, as shown (Fig. 2). Pulling and cutting of the threads with scissors outside the abdomen saved operative time. Our new technique enabled us to perform totally intracorporeal NAP in an efficient, safe, and easily reproducible way in a limited working space. Compared with 2-mm NAP and SILAP, our NAP using smaller size and rigid needles is less invasive, lower cost, and with better cosmetic results.

We managed to successfully treat all cases with our new technique using only needles with almost invisible scars (Fig. 6). As expected, the mean operative time of extracorporeal NAP (20.9 ± 7.01 minutes) was significantly shorter than that of intracorporeal one (33.29 ± 3.95 minutes). Oral feeding started 6 hours postoperatively, and early mobilization was stressed on; this allowed all cases to be discharged on the second postoperative day. Wound infection after LAP is common due to soiling from appendix and can be avoided by extracting the appendix in a sterile glove or passing it through the trocar.^17,21

In our study, we only had one umbilical wound with no postoperative infection, port-site hernia, or intra-abdominal collection, mostly because we eliminated extra wounds and had only needle punctures not liable to infection or herniation, limited NAP to noncomplicated cases, and extracted the appendix through the port avoiding wound soiling as much as possible.

We looked through the literature trying to find an objective tool for scar evaluation. Unfortunately, we did not find such a tool. Several scales, including the Patient and Observer Scar Assessment Scale (POSAS), modified POSAS, Matching Assessment of Scars and Photographs, and modified Vancouver Scar Scale, have attempted to incorporate subjective data (pain and pruritus) into scar assessment, but this was not applicable in our study.

Nguyen et al.²⁷ concluded that multiple scar assessment scales have been developed to help assist in the consistent evaluation of scar severity, progression, and response to treatment. However, no gold standard scar scale exists to date. Looking at our scars, they are nearly invisible as there are two tiny skin punctures <1.5 mm (needle punctures), and the 10-mm scar of the telescope is already hidden in the umbilical cicatrix. Eventually, the procedure almost ended with a scarless abdomen after a 3-month follow-up.

Because of the aforementioned issues, we elected to use a subjective 0–4 score for patients'/parents' satisfaction evaluation, where 0 = no satisfaction, 1 = fair, 2 = good, 3 = very good, and 4 = excellent, directly reflecting the satisfaction of the patients and their families with the cosmetic results of our new procedure. Patients'/parents' satisfaction was excellent in almost all cases.

Conclusion

The present technique for NAP optimizes the minimal invasiveness of LAP. NAP uses only needles in children and adolescents, is safe, cheap, reproducible, and with scarless abdomen.

Informed Consent

Written informed consent was obtained from all participants included in the study.

Footnotes

Authors' Contributions

Study conception and design by R.S. and M.M.; acquisition, analysis, and interpretation of data by S.M.; drafting of the article by M.M.; and critical revision of the article by M.I.E. and A.H.

Disclosure Statement

All authors declare that they have no conflict of interest and nothing to disclose.

Funding Information

No funding was received for this article.

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