Laparoscopic appendectomy using only two 5 mm trocars

Laparoscopic appendectomy is now the standard and most surgeons use two 5 mm and one 10–12 mm port; the latter placed into the umbilicus. Various attempts have been made to reduce the number and sizes of ports for this procedure.

A 22-year-old male with acute right lower quadrant pain came to our emergency room. His white blood count (WBC) was 15000 l/ml and on CT scan signs of acute appendicitis were found. He was taken to the operating room. His abdomen was accessed with a Verres in the left upper quadrant (LUQ) and once pneumoperitoneum was established a 5 mm trocar was placed under visual control into the left lower quadrant (LLQ). A phlegmonous appendix was found attached to the right abdominal wall. The Verres needle was exchanged for another 5 mm trocar. A Maryland grasper was used to bluntly create a window between appendix base and mesoappendix. The appendiceal artery was dissected out and secured with a 5 mm clip and the mesoappendix was cut off the appendix. Two endoloops were lassoed around the appendix and tied at the appendix base and the specimen was amputated between the ties. The appendix was pulled with the distal tie towards the LUQ port, which was removed. The appendix base was grabbed with a Kelly clamp and the specimen was pulled through the port site. Pneumoperitoneum was released and the LLQ port removed and the skin closed. The patient was discharged after 2 h and had a completely uneventful recovery.

In selected cases with favorable anatomy, laparoscopic appendectomy with two 5 mm ports may be possible. Miniaturizing this procedure while carefully weighing patient safety and costs should be a goal for laparoscopic appendectomy.