Surgeon at Work

Laparoscopic Finger-Assisted Technique (Fingeroscopy)for Treatment of Complicated Appendicitis

Namir Katkhouda, MD, FACS, Rodney J Mason, MD, Eli Mavor, MD, Guilherme MR Campos,Raymond T Rivera, MD, Michael B Hurwitz, MD, Donald Waldrep, MD

Laparoscopic appendectomy for acute appendicitis,first described by Semm in 1982,1 is still a procedureunder evaluation:2,3 The small incision used in theopen technique approximates the one required forthe insertion of a laparoscopic port. Furthermore,published data have demonstrated conflicting resultsor have failed to establish laparoscopy as the techniqueof choice for the management of acute appendicitis.2,4-10

The laparoscopic management of perforated ap-pendicitis is even more questionable.11 The tech-nique is challenging because of the loss of tactile feel-ing and the difficulties in distinguishing healthybowel from necrotic tissue. Conversion rates for at-tempted laparoscopic appendectomy in perforatedappendicitis range from 6.5% to 17.6%, mainly be-cause of excessive inflammation, presence of adhe-sions, or retrocecal position of the appendix.2,3-10 Infact, a preoperative diagnosis of perforated appendi-citis is a contraindication to laparoscopy in most cen-ters. Adequate exposure frequently requires a largeopen incision.

We describe a finger-assisted technique, or “fin-geroscopy,” as a simple add-on procedure that can beused during laparoscopic treatment of complicatedappendicitis. This technique restores the surgeon’stactile ability and allows gentle and safe blunt dissec-

tion of appendiceal masses under laparoscopic guid-ance. The technique is applied without enlarging theport incision and reduces the conversion rate to anopen procedure.

METHODS

Study populationRecords were analyzed for 158 consecutive patientswith complicated appendicitis who underwent alaparoscopic appendectomy at the Los AngelesCounty1University of Southern California MedicalCenter between 1994 and 1997. This included allpatients who were either diagnosed preoperativelywith complicated appendicitis (history of more than2 days, WBC count greater than 15,000 cells/mm3,mass on physical examination) or who had the diag-nosis of complicated appendicitis confirmed intraop-eratively. Patients with acute appendicitis withoutperforation were excluded from this series.

The finger-assisted laparoscopic appendectomytechnique was developed in January 1996. We di-vided the 158 patients into two groups based on theintraoperative technique used. The first group con-sisted of 121 patients (87 male, 34 female) operatedon before January 1996 without the finger-assistedtechnique, and the second group consisted of 37 pa-tients (25 male, 12 female) operated on subsequentlywith the finger-assisted technique.

All patients were treated with IV antibiotics and,according to the protocol, were discharged to homeonly after they were afebrile and had a normal WBCcount for 48 hours.

Received October 22, 1998; Revised February 3, 1999; Accepted March 10,1999.From the Division of Emergency Non-Trauma and Minimally Invasive Surgery,Department of Surgery, University of Southern California, Los Angeles, CA.Correspondence address: Namir Katkhouda, MD, FACS, Division of Emer-gency Non-Trauma and Minimally Invasive Surgery, Department of Surgery,University of Southern California, 1510 San Pablo St, Ste 514, Los Angeles, CA90033-4612.

131© 1999 by the American College of Surgeons ISSN 1072-7515/99/$19.00Published by Elsevier Science Inc. PII S1072-7515(99)00054-X

Surgical techniqueAfter pneumoperitoneum is initiated using a Veressneedle, the patient is placed in a slight right lateraldecubitus and Trendelenburg position, which allowsthe small bowel to roll naturally to the left side of theabdomen. A 30° laparoscope attached to a high-definition camera (Karl Storz, Tuttlingen, Germany)is inserted in the umbilicus to allow a thorough ex-ploration of the abdominal cavity. Another 10- to12-mm trocar (Ethicon Endosurgery Inc, Cincin-nati, OH) is inserted in the left lower quadrant, anda 10-mm Babcock grasper is passed through the port.This allows gentle manipulation of the ileocecaljunction and retraction of the terminal ileum. Aphlegmon appears as an indistinguishable mass in-cluding the greater omentum, the appendix, and thececum.The third and last trocar is then introduced inthe right lower quadrant. Placement of the trocar hasto be selected precisely to minimize the distance be-tween the skin incision and the ileocecal junction.The trocar is then removed and replaced with theindex finger of the surgeon’s double-gloved left hand.The insufflation pressure is reduced to 9mmHg, fur-ther reducing the distance between the skin incisionand the appendix. Insertion of the double-gloved fin-ger can be done without loss of the pneumoperito-neum (Fig. 1).

The operation is then performed under laparo-scopic guidance, with the surgeon’s right hand hold-ing a suction irrigation device and the left index fin-ger gently dissecting the mass. It is possible to feel thetissues, break inflammatory adhesions under directvision, and identify the appendiceal base. Thismethod can also help determine the need topromptly terminate the procedure and place a drainto treat an eventual abscess if the ruptured appendixcannot be clearly identified. In the event of a retro-cecal appendix, the finger can help expose the appen-dix by a “hooking” maneuver. The right lower-quadrant trocar is then reinserted, and the appendixis transected using an endolinear stapler (EthiconEndosurgery Inc). The appendix is extracted in a bag.The pelvis is thoroughly irrigated while retracting thesigmoid colon and exposing the cul-de-sac to preventaccumulation of purulent material and the occur-rence of a pelvic abscess.The operative site is irrigatedmeticulously with a diluted antiseptic solution, andclosure of the fascia and all other skin incisions com-pletes the procedure.

Statistical methodsAll data are expressed as median and range. Thegroups were compared using the nonparametricMann-Whitney U test. For the comparison of con-

Figure 1. Finger-assisted laparoscopic technique (“fingeroscopy”): The surgeon’s left index finger is in the right lower-quadrant port site and the right hand is dissecting using a suction irrigation device under laparoscopic guidance.

132 Katkhouda et al Fingeroscopy for Appendicitis J Am Coll Surg

version rates, a chi-square test was used. A differenceat the 5% level was considered statistically significant(p,0.05).

RESULTSIt was possible to successfully dissect the appendix,place an endolinear stapling device, and transect theappendix safely in 92 of 121 patients in the groupwithout the finger-assisted procedure and in 31 ofthe 37 patients in the finger-assisted group. Threepatients in the finger-assisted group were drainedonly because no clear anatomy was identifiable, andthree patients were converted to an open procedure(8.1%). This conversion rate was significantly lower(p,0.05) than the 24% rate found in the 121 pa-tients who underwent laparoscopic appendectomyfor complicated appendicitis before implementationof the technique.

The median operating time for the group under-going fingeroscopy was 58 minutes (range 37 to 76minutes), which was significantly less than the me-dian time of 72 minutes (range 41 to 88 minutes)in the group that did not undergo fingeroscopy(p,0.01). There were no deaths in either group.Morbidity was similar between the groups and oc-curred in 2 patients (5.4%) in the finger-assistedgroup and in 13 patients (10.7%) in the group nothaving the finger-assisted method (p50.333). In thefingeroscopy group, intraabdominal abscess devel-oped in one patient and was drained under CT guid-ance, and another patient presented with an ileusthat resolved spontaneously. There were no woundabscesses in this group. In the group not undergoingfingeroscopy, one patient had an intraabdominal ab-scess, six had a wound seroma, and six had an ileus.The median length of stay in the group undergoingfingeroscopy was 5 days (range 4 to 6 days), whichwas significantly different (p,0.05) from the me-dian of 6 days (range 4 to 8 days) in the group thatdid not undergo fingeroscopy.

DISCUSSIONThe finger-assisted laparoscopic appendectomy is asimple technique that restores tactile feeling and al-lows blunt and atraumatic dissection of an appen-diceal phlegmon. The technique restores the sur-geon’s ability to distinguish between necrotic andhealthy tissues and intuitively mimics the maneuversused in the open technique. This is not possible witheven the best atraumatic laparoscopic instruments.There is no learning curve, and the technique speeds

the procedure. Conceptually, it is not different fromother assisted techniques, such as laparoscopic as-sisted colectomy,12 in which the sigmoid colon is ex-teriorized and manipulated outside the abdomen.The only potential risk inherent in the technique ispostoperative wound infection at the trocar site, butthis is minimized by careful irrigation of the righttrocar site at the end of the procedure with a dilutedantiseptic solution. We did not encounter any trocarport abscess or seroma in this series.

The technique does have limitations and is diffi-cult to perform on obese patients with a thick ab-dominal wall.

In summary, the finger-assisted technique de-scribed here has allowed a reduction of the conver-sion rate for complicated laparoscopic appendec-tomy in our series. It has the potential to improveoutcomes, as demonstrated by a shorter hospital stayin this study. These results, however, are based onretrospective data, and the limitations of these stud-ies are well known. These preliminary results haveencouraged us to proceed with a prospective ran-domized study that will allow us to establish whetherthe laparoscopic finger-assisted technique is as effec-tive or better than the open procedure for the treat-ment of perforated appendicitis.

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133Vol. 189, No. 1, July 1999 Katkhouda et al Fingeroscopy for Appendicitis