Sergey V. Kantsevoy, MD, PhD; Mercy Medical Center, Baltimore, MD
Introduction: Appendectomy traditionally performed through open or laparoscopic surgery and requires incisions (or punctures) of anterior abdominal wall causing post-surgical pain, risk of postoperative incisional hernias, restricting physical activity and delaying return to work post appendectomy. Previously reported Natural Orifice Translumenal Endoscopic Surgery (NOTES) appendectomy required incision of gastric or vaginal wall for advancement of the endoscope into peritoneal cavity with subsequent risk of intraperitoneal infection, adhesions and dyspareunia. A new double balloon endolumenal interventional platform (DBEIP) consists of a flexible overtube with 2 manually inflatable balloons, one behind the endoscope tip, the other with the ability to be advanced beyond the scope tip. Aim of the presentation: To describe purely endoscopic appendectomy using DBEIP.
Methods: The patient is a 51-year old women referred for endoscopic removal of cecal submucosal lesion. Colonoscope preloaded with DBEIP was advanced into the cecum. Submucosal mass was visualized in the cecum. Endoscopic ultrasound demonstrated hyperechoic lesion originating from submucosal layer. Circumferential incision around the lesion was performed. The lesion was attached with 2 endoscopic clips to a suture-loop mounted on fore- balloon of the DBEIP and pulled into colonic lumen. The lesion was carefully dissected from surrounding tissues. At this point it became evident that lesion originated inside the appendix. Using multidirectional dynamic retraction the appendix was pulled into cecum and removed en bloc. DBEIP served as a conduit to remove colonoscope and then to deliver endoscopic suturing device into the cecum. Full-thickness defect post appendectomy was completely closed with 2 continuous sutures. The patient had no pain post procedure and was discharged home from endoscopy unit on oral antibiotics. She restarted her regular physical activity and returned to work the morning after appendectomy. Discussion: Purely endoscopic appendectomy using DBEIP is technically feasible, does not require advancement of the endoscope into the peritoneal cavity and abolishes incisions/punctures of the abdominal wall, eradicating the risk of post-surgical incisional hernias and intraperitoneal adhesions. Endoscopic appendectomy eliminates pain post appendectomy and need for hospital admission, enables early return to work and regular physical activity and can become a valuable alternative to surgical/laparoscopic/NOTES appendectomy.