In The Name of GOD

Laparoscopic appendectomy: Selection the method of stump closure Mohammad Kermansaravi MD.Fellowship of Advanced Minimally Invasive and Bariatric Surgery, Minimally Invasive Research Center, Iran University of Medical Science, Tehran, Iran MISTIC 2016: 9 November 2016

The most common acute abdominal pathology requiring emergency surgery is acute appendicitis. Laparoscopic appendectomy for acute appendicitis is one of the most common emergency laporoscopic procedures in general surgery performed in the US. Laparoscopic appendectomy is currently a well-established and widely accepted method. Semm first defined laparoscopic appendectomy (LA) in 1983 as an alternative approach to open surgery.

Indications: 1)Clinically suspected or confirmed acute appendicitis 2)Morbidly obese patients 3)Women of child-bearing age in whom the diagnosis is uncertain 4)Pediatric population 5)Interval appendectomy

Contraindications: 1)Lack of surgeon experience 2)Inability to tolerate general anesthesia 3)Refractory coagulopathy 4)Diffuse peritonitis with hemodynamic compromise 5)Extensive previous surgery(Relative) 6)Portal hypertension(Relative) 7)Severe cardiopulmonary disease(Relative) 8)Advanced pregnancy(Relative)

Surgical Anatomy:

Patient Position and Room Setup:

Trocar Position and Choice of Laparoscope:

Procedure: 1)Identify and mobilize the appendix 2)Mobilize The cecum if needed 3)Retract the cecum medially 4)Grasp the appendix with an atraumatic grasper 5)Transect The appendix at its base(How?) 6)Divide the mesoappendix

The ideal method : Methods for closure of appendix stump: 1)safety 2)Accessiblilty 3)Technically simple to use 4) Cost effectiveness

1. Polymeric Clips(Hem-o-Lock) Capable of securing tissue bundles up to 16mm in thickness Safe to use electrocautery near the clip (Nonconductive and inert) Contraindications: 1) Severe inflammation with associated poor tissue quality 2)Tissue diameter > 16mm

Absorbable polymeric surgical clips(Lapro-clips) The clip can close tissue with a diameter ≤ 12 mm witout residual FB Adverse risk factors associated with the use of absorbable clips in LA : 1)BMI ≥ 27.5 kg/m2 2)Diabetes 3)ASA degree ≥ III 4)Gangrenous appendicitis 5)Severe inflammation of the appendix base 6)Appendix perforation 7)Absence of peritoneal drainage

Titanium endoclip Closure of appendices with a diameter of 20 mm Contraindications: Necrosis or very large thickening of the inflamed appendicular base

Endoloop Made of silk or polyglactin.

Hand made endoloop Analogous to Endoloop Advantage: Cheap

Suture Knot Intracorporeal tie knot requires more experience than other methods. Advantage: Cheap Disadvantage : Prolonging the operation time

Extra-corporeal Ligation Extracorporeal tie knot: Simple and Cheap

Laparoscopic Linear-stapler Staplers allow simultaneous sealing and division of both the mesoappendix and the appendix base. Safe even when the appendix base is inflamed and its diameter is too large.

Vessle sealing devices In Experimental Studies: 1)Bipolar coagulation:for approximately 90 sec 2)Ligasure 3)Harmonic Scalpel

Cost Endostapler 200-300 $ Vessle Sealing Handle 250-500 $ Endoloop 20-40 $ Hem-o-lock 15-30 $ Titanium clip 5-10 $

Conclusion: The selection of stump closure’s techniqe, must be modified based on: Safety of technique Condition of appendix base Diameter of appendix base Surgeon experience Applicablity of technique Cost of technique

Thanks for Attention