Single-Port Hybrid Open and Laparoscopic Approach for Pediatric Appendectomy for Acute Appendicitis

CHAPTER 1

My name is Yuki Noguchi, and I serve as the Chief Surgeon of Pediatric Surgery at Osaka Women's and Children's Hospital in Osaka, Japan. Appendicitis is the most common indication for abdominal surgery in children. Several laparoscopic techniques have been reported including the conventional three-port method and the transumbilical single-site two- or three-port appendectomy. The three-port laparoscopic appendectomy allows easier manipulation of tissues around the appendix. However, it requires additional port site incisions, which inevitably result in visible postoperative scars. In contrast, transumbilical single-site laparoscopic appendectomy offers superior cosmetic outcomes, but the crowded instrumentations through the umbilicus often leads to significant interference between the laparoscope and the working instruments, thereby increasing procedural complexity. Before the laparoscopic era, open appendectomy was the sole operative option for acute appendicitis. Compared with pediatric laparoscopic surgery, which can be technically challenging in the confined intra-abdominal space of children and occasionally requires conversion to open surgery, open appendectomy provides a wider operative field and is generally more straightforward for tissue manipulation. However, this advantage comes at the cost of a larger incision, resulting in greater possibility of pain and poorer cosmetic outcomes. In pediatric patients, the intra-abdominal cavity is smaller than in adults, which makes laparoscopic manipulation more challenging. At the same time, however, the umbilicus is relatively close to the appendix, and the pediatric abdominal wall is typically soft and compliant. This allows the surgeon to physically shift the umbilical incision towards the target area, such as the inflamed appendix, and facilitates exteriorizing the appendix, because pediatric tissues are softer and are more easily mobilized. Taking these anatomical and technical considerations into account, we perform a hybrid laparoscopic open appendectomy for acute appendicitis. In this procedure, a small, longitudinal umbilical incision is made, typically extending from the cranial to the caudal edge of the umbilicus when it is fully retracted anteriorly. A wound protector is applied onto which a specialized lead containing two or three ports is mounted. The essential laparoscopic step is simply to grasp the base of the appendix, retract it towards the umbilical incision, and exteriorize the diseased appendix. The appendectomy itself is then performed extracorporeally under direct visualization. This hybrid approach eliminates the most technically demanding portions of laparoscopic appendectomy, such as dissecting the mesoappendix and ligating the appendiceal base entirely within the abdominal cavity. Admittedly, when severe inflammation or dense adhesions are present, it can sometimes be difficult to grasp and retract the appendix sufficiently toward the umbilicus. Even in such cases, however, blunt or sharp dissections through the two or three umbilical ports generally allows at least a portion of the appendix to be mobilized and exteriorized. Once the mesoappendix is gradually dissected externally towards the base and appendiceal base is adequately secured, extracorporeal resection of the appendix can be safely completed. This case involves a four-year-and-nine-month-old girl who presented with severe abdominal pain and vomiting that began the day before she visited the local medical center. Laboratory tests revealed mildly elevated inflammatory markers, including the white blood cell count, and the C-reactive protein. Ultrasonography demonstrated edema at the tip of the appendix, measuring more than six millimeters in diameter. Together with mild laboratory inflammation, the findings suggested early stage mild appendicitis. As suspected, a fecalith was also identified at the appendiceal tip, representing a potential risk for recurrence. Therefore, we elected to proceed with laparoscopic appendectomy.

CHAPTER 2

Can I have medium forceps? Medium forceps, please. And at first, we usually lift up the base of the umbilicus like this and make a full-thickness incision from the cranial to the caudal ends of the umbilical ring to open the abdomen. So can I get a muscle retractors? Thank you. Okay. So now, we're in the abdominal cavity. And next, rectus sheath and the peritoneum are farther opened, cranially and caudally to create enough space for inserting Lap Protector Mini-Mini. Okay. Okay. Okay. So, could you insert the lap protector? Okay, sorry. I cannot get it. Opening. And as a rule of thumb, if an index finger can be introduced easily like this, then, the subsequent procedures can usually be performed without difficulty. And then, the E-Z Access device with two primary middle ports is mounted onto the Lap Protector like this. And then, begin pneumoperitoneum at a pressure of eight millimeters of mercury. Okay, so let's inspect the abdominal cavity.

CHAPTER 3

Okay. And the first thing we need to do is to identify the appendix and its base. And this case, the appendicitis is mild, so there's no adhesion around there. If the appendix is adherent due to inflammation, then, we need to perform blunt dissection with forceps, and when necessary, carefully release the adhesions with electrocautery. At this time, we do not need to do this and identify the appendix. Okay. There. We can see the appendix. And let's check the base of it. If we identify an intact appendiceal base, then, gently grab it with forceps and confirm that it can be pulled out beneath the umbilicus. Yeah. Could you pull it? Yeah. Like this, so confirm it can be put pulled out beneath the umbilical incision.

CHAPTER 4

Okay. Yeah. Okay. Could you wait?

CHAPTER 5

If appendiceal base is inflamed and fragile, making it difficult to grasp, then, we need to mobilize the cecum widely and try to exteriorize the entire cecum, or alternatively, exteriorize the tip of the appendix first, and then, proceed retrogradely towards the base of the appendix. But this time, we can easily exteriorize the base of the appendix. If the appendiceal base is exteriorized adequately like this, then we divide mesoappendix near the base to fully expose it. Okay. Okay. And then, the base is gently crushed with mosquito forceps. Here. Like this. And then ligated with 3-0 absorbable suture. And a second ligature is also placed a bit distally in the same fashion, creating a double ligation. Okay, good. Thank you. And the appendix is divided.

CHAPTER 6

Regarding the appendiceal stump, the stump may either be inverted or left as it is. This generally does not have significant impact on the possibility of cause. So this time, it's left as it is. Reinsert the laparoscope. And confirm that there is no bleeding, and also, damage or injury to surrounding tissue or organs. Okay. And if the cavity is contaminated with turbid ascites, then, we usually do thorough lavage with warm saline, continuing until the effluent is clear. Yeah, the cavity is clear, so we do not have to perform the lavage. And this time, it is very easy to grab the base of the umbilicus and exteriorize it. But if the appendix cannot be exteriorized adequately, then we start from the tip of the appendix first and divide the mesoappendix retrogradely toward the base of the appendix, progressively bringing the entire appendix out of the abdomen. Then, they divide the appendix in the same fashion. Okay. Okay. And finally, we usually perform entire inspection of the abdominal cavity for any anomaly. Hmm, okay. Yeah, especially in female case, we usually check the both ovaries. Okay, yeah, it looks good. Okay, so return the table to the neutral position.

CHAPTER 7

And stop the pneumoperitoneum, and close the wound. Can I get an Adson with teeth, please? And the closure of the peritoneum and rectus sheath is performed by first securing the caudal and cranial ends with sutures, and then, closing the interval at two to three millimeters spacing. Mosquito. Oh, I have... Scissors, please. Mosquito, please. And a closing total at two to three millimeters spacing. Mosquito. Scissors, please. Can I have a mosquito, please? And after all sutures are ligated, we usually check for gaps within the stitches with the forceps and adding stitches wherever the tip passes too easily. Okay, let's check the gap. Okay. We're now checking the gaps within the stitches. And if the tip passes too easily, we need to add stitches in between. And then, we close the dermis, making sure to shape the deepest part with the umbilical pit. So before doing that, we need to wash the wound. And for the subcutaneous irrigation and the pressure, we usually use 18-gauge needle with the tip gently bent with some mosquito forceps, which allows the saline to spray widely like a shower. And then, close the dermis, making sure to shape the deepest part with the umbilical pit so that the naval appears naturally depressed. Scissors, please. Can I get a mosquito? Mosquito. Is that the last one? One more? And then, apply a cotton ball with gentamicin ointment to the umbilicus. Okay, all done.

CHAPTER 8

Because inflammation was mild, the operation proceeded smoothly. Although the appendix appeared nearly normal on video, the combination of clinical symptoms and imaging findings supported the diagnosis of acute appendicitis. Whether visually normal appendix should be removed remains a matter of debate. However, our recent study supports appendectomy in pediatric patients and ongoing laparoscopy for suspected appendicitis when no alternative pathology is identified, even if the appendix appears normal, concluding that this approach is justified by low mobility and resolution of symptoms without recurrence. In this particular case, the pathological diagnosis actually confirmed acute appendicitis. A few technical points merit mention. First, the most important step in this procedure is securing a minimally invasive, yet sufficiently wide operative field at the umbilicus. As a rule of thumb described in the video, you should confirm that your index finger can be inserted adequately through the umbilical incision into the abdominal cavity. If this can be achieved, the subsequent maneuvers can usually be completed without difficulty. Second, inversion of the appendiceal stump remains controversial. We generally consider stump inversion unnecessary, and recent evidence supports this perspective, demonstrating that simple ligation does not compromise treatment efficacy or increase postoperative complications or lengths of hospital stay. Third, although there is admittedly risk of postoperative surgical site infection with this method, given that the inflamed appendix is primarily manipulated through a small umbilical incision, our experience suggests that such infections are uncommon, likely because the wound protector provides effective isolation of the incision site. We also believe that performing thorough, pressurized, wide flow irrigation of the wound itself at the end of the procedure further helps reduce the risk of infection. In conclusion, this hybrid laparoscopic-open appendectomy combines the advantages of both laparoscopic and open techniques, namely improved cosmetic outcomes and easier tissue manipulation. Because acute appendicitis is one of the most common surgical conditions encountered in pediatric practice, this hybrid method represents an essential procedure that pediatric surgeons should master.