Journal of Pediatric Surgery 51 (2016) 341–343

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Appendix extraction after laparoscopic appendectomy in children: An

easy, safe, and inexpensive technique☆
Mario Mendoza-Sagaon, Flurim Hamitaga, Yannick Hurni ⁎,1, Natalia Voumard
Department of Pediatric Surgery, Ospedale Regionale Bellinzona e Valli, 6500 Bellinzona, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Background: Laparoscopic appendectomy is becoming an increasingly common operation among children. It is
Received 14 September 2015 well known that the abdominal wall should not be exposed to the appendix’s inflamed tissue during its removal.
Received in revised form 29 October 2015 Several ways to protect the retrieval site have been described, with controversial results. Elevated costs, large sur-
Accepted 19 November 2015 gical wounds and high contamination risks are typical reported issues.
Objective: We describe a safe, cheap and easy technique to remove the appendix after a laparoscopic appendec-
Key words:
tomy in pediatric patients.
Appendix retrieval
Appendix extraction
Methods: We retrospectively collected and analyzed the files of all children operated on at our institution for lap-
Laparoscopic appendectomy in children aroscopic appendectomy between September 2004 and April 2015. To remove the appendix, we used the cut end
of a glove’s finger.
Results: We performed 291 laparoscopic appendectomies using this technique during an 11-year period. Patients’
ages ranged from 2 to 16 years old. The appendix could be extracted using this technique in all the cases. No in-
traoperative complications related to the technique were observed. Overall, only one patient (0.34%) presented
wound complications.
Conclusions: Avoiding wide surgical incisions and abdominal wall contaminations is essential during laparoscopic
appendectomies in children. Our easy, safe and cheap technique allows these important goals to be achieved.
© 2016 Elsevier Inc. All rights reserved.

Acute appendicitis is the most common emergency surgical condi-
tion in children. For a long time, open appendectomy (OA) was the con-
ventional procedure for appendicitis in this population. Laparoscopic
appendectomy (LA) was introduced in 1983 [1] and gained popularity
among pediatric surgeons during the late 1990s and early 2000s [2,3].
LA is more and more often being adopted for both complicated and
uncomplicated appendicitis in children [4]. Compared to OA, better pain
management, shorter hospital stays, and lower overall complication
rates are typical reported advantages [4–7]. LA allows reduced abdom-
inal wall exposure to contaminated tissues and fluids, ensuring fewer
surgical site infections [4,7,8]. This is remarkably important in pediatric
patients, in which a high rate of perforated appendicitis is typically ob-
served [9,10]. This elevated frequency is essentially because of recurrent
delayed diagnosis in young children because of their inability to com-
municate and the high rate of benign pediatric digestive disorders [4].
☆ Funds and Conflict of Interest: No funding has been allocated for this project. Dr. Men-
doza Sagaon, Mr. Hurni, Dr. Voumard and Dr. Hamitaga declare that they have no conflict
of interest.
⁎ Corresponding author at: Department of Pediatric Surgery, Ospedale Regionale Bellin-
zona e Valli — Bellinzona, 6500 Bellinzona, Switzerland. Tel.: +41 91 811 87 87; fax: +41
91 811 91 65.
E-mail address: yhurni@gmail.com (Y. Hurni).
1
Permanent and personal address: Mr Yannick Hurni, Via Fabrizia 34a, 6512 Giubiasco,
Switzerland.
In LA, the highest risk of abdominal wall contamination occurs dur-
ing appendix extraction. It is therefore of extreme importance to protect
the retrieval site, avoiding abdominal exposure to this inflamed and po-
tentially contaminated tissue. Several ways to protect the extraction site
have been described [11]. Typical appendix removal procedures use re-
trieval bags [5,8,12] or extraction through the umbilical trocar [8,12].
Each method presents its own benefits and drawbacks. Elevated costs,
large surgical wounds, and high contamination risks are potentially re-
lated issues [11].
We describe a safe, cheap and easy technique to remove the appen-
dix after an LA in pediatric patients.
1. Materials and methods
We retrospectively collected and analyzed the files of all children
who had received an LA at our institution between September 2004
and April 2015. The surgical technique described below was performed
in all cases.
1.1. Surgical technique
General anesthesia and supine patient positioning were used in all
cases. A 5 mm primary trocar was inserted at the umbilicus with the
Hasson technique. A 10 mmHg CO2 pneumoperitoneum was

http://dx.doi.org/10.1016/j.jpedsurg.2015.11.013
0022-3468/© 2016 Elsevier Inc. All rights reserved.
342 M. Mendoza-Sagaon et al. / Journal of Pediatric Surgery 51 (2016) 341–343

established and a 30-degree laparoscope was introduced. Two addition-
al 5 mm trocars were inserted under vision in the suprapubic region and
in the right iliac fossa, respectively. The appendix dissection was per-
formed with monopolar electrocauterization. The base of the appendix
was ligated with 3 absorbable endo-loops® of 1/0 PDS and subsequent-
ly divided between the central and distal ligatures. The stump was sub-
sequently cauterized.
To remove the appendix from the abdominal cavity we used the
cut end of a glove’s finger (Fig. 1). The glove was cut at the base of the
middle finger of a latex-free glove number 7, 7.5 or 8. A partial trans-
verse section was then performed at the finger’s distal quarter. A
5 mm Johann grasper was placed into the glove’s finger, seizing its
distal part, and both were inserted into the abdominal cavity through
the right iliac fossa port. Particular attention was paid so that the
proximal end of the glove’s finger remained in the abdominal wall.
Two Kelly clamps were fixed to the outer part of the glove’s finger,
preventing its intraabdominal displacement. Using the Johann grasper,
the appendix was grabbed at its base and removed in an axial way
through the glove’s finger, avoiding any contact with the abdominal
wall and thus reducing the risk of contamination. During the removal
procedure, the intraabdominal part of the glove’s finger was stabilized
with another grasper. In rare cases of significant swollen appendix the
enlargement of the wound was necessary. Once the appendix was
removed, the glove’s finger was retrieved from the abdominal wall,
verifying its integrity.
2. Results
We performed 291 laparoscopic appendectomies using this tech-
nique during an 11-year period. Patients’ ages ranged from 2 to
16 years old. A total of 55 (18.9%) patients presented with complicated
appendicitis with perforation, generalized peritonitis or abscess. Each
operation was performed by either a fully trained pediatric surgeon or
by a senior resident. The appendix was extracted using the described
technique in all patients. The procedure typically took 2 to 4 minutes.
No intraoperative problems related to the technique were observed.
Overall, only one (0.34%) patient presented wound complications. In
this particular case, an immunosuppressed child developed wound in-
fections at the three trocars’ incision sites. No direct correlation with
the appendix extraction technique was detected.
3. Discussion
LA is becoming an increasingly common operation in pediatric sur-
gery. Typically described advantages over the laparotomic approach in-
clude less postoperative pain, reduced hospitalization time, fewer
wound infections, less antibiotic use, and better cosmetic appearance
[4–8]. The low abdominal wall infection rate is one of the main benefits
of the laparoscopic approach. This is likely to be even truer for the fre-
quently encountered cases of complicated appendicitis in children,
where a high contamination risk is present [7]. The low infection rate
is probably because of reduced abdominal wall exposure to contaminat-
ed tissues and fluids, which is very difficult to prevent in OA [5].
In LA, proper protection of the incision site during appendix retrieval
is extremely important. Although this is a universally accepted princi-
ple, standardized recommendations for how to accomplish this task
are still lacking. An international clinical practice guideline for LA
was published in 2009 [13], but limited attention has been given to ap-
pendix extraction procedures, their technical aspects, or their particular
indications. Several ways to protect the extraction site exist. The two
most-used techniques are based on the use of a retrieval bag [14] or di-
rect extraction of the appendix through the umbilical trocar [15,16].
These procedures were initially described in adults and rapidly imple-
mented in pediatric surgery [5,8,12]. Each method presents its own

Fig. 1. (A) The glove is cut at the base of the middle finger and (B) a partial transverse section is then realized at the finger’s distal quarter. (C) A 5-mm Johann grasper is placed in the glove’s
finger, seizing its distal part and both are inserted in the abdominal cavity through the right iliac fossa port. (D) Using the Johann grasper, the appendix is grabbed at its base. (E) While the
intraabdominal part of the glove’s finger is stabilized with another grasper, (F) the appendix is extracted in an axial way.
 M. Mendoza-Sagaon et al. / Journal of Pediatric Surgery 51 (2016) 341–343
advantages and disadvantages, but no defined superiorities have been
proven. To our knowledge, no studies comparing the feasibility, inci-
dence of wound infection, and cost effectiveness of each technique
have been reported.
Elevated costs and often-required wide incisions are the two most
commonly reported disadvantages associated with retrieval bag use
[11]. Many commercial bags have been developed and their cost varies
between 30 and 150 US dollars [17]. The cost of a pair of sterile gloves
required for our technique is much cheaper, being approximately 0.50
US dollars. Extraction through a trocar is a suitable alternative, but its
use is limited only to thin, nonfragile appendices [15]. In addition, peri-
toneal and abdominal wall contamination is a potential risk associated
with this technique [11,14].
Thanks to the use of a simple surgical glove’s finger, we introduced a
secure and inexpensive technique that avoids the aforementioned prob-
lems. Since 2004, we have used this approach for all the laparoscopic ap-
pendectomies at our facility, with excellent results. To the best of our
knowledge, this is the first time that a similar procedure has been de-
scribed. Some authors have previously reported the use of a glove’s fin-
ger for appendix extraction, but their techniques include the complete
introduction of this tool into the abdominal cavity, using it as a retrieval
bag [18–20].
The main advantages of our method are the easy availability of the
required tools, the extremely reduced costs, and the ease of execution.
This technique takes advantage of the positive features of both
abovementioned methods. The arrangement of a tubular conduit
through the abdominal port leads to the essential ease of handling dur-
ing the procedure, while the elasticity of the surgical glove’s material al-
lows for complete duct adaptability to the shape of the appendix,
avoiding the risk of tissue damage and consequent abdominal contam-
ination. In addition, contrary to most retrieval bag systems, in which the
appendix rolls and twists increasing considerably its extraction diame-
ter, our axial way of removing the specimen generally prevents any un-
wanted exit hole enlargement. Thanks to these features, our technique
appears to be a valid choice for safe appendix retrieval in both compli-
cated and uncomplicated appendicitis.
4. Conclusions
The appendix extraction during LA should always respect the princi-
ple of abdominal wall protection. Until the advent of valid comparative
studies, the method of extraction should be at the discretion of the sur-
geon. The choice should be based upon the appendix’s size, its grade of
inflammation, surgical costs, and the operator’s familiarity with the
343
procedure. Our easy, feasible, safe and inexpensive technique repre-
sents a valuable option for appendix removal during a laparoscopic ap-
pendectomy in pediatric patients.
References
[1] Semm K. Endoscopic appendectomy. Endoscopy 1983;15:59–64.
[2] Jen HC, Shew SB. Laparoscopic versus open appendectomy in children: outcomes
comparison based on a statewide analysis. J Surg Res 2010;161:13–7.
[3] Lee SL, Yaghoubian A, Kaji A. Laparoscopic vs open appendectomy in children: out-
comes comparison based on age, sex, and perforation status. Arch Surg 2011;146:
1118–21.
[4] Masoomi H, Mills S, Dolich MO, et al. Comparison of outcomes of laparoscopic versus
open appendectomy in children: data from the Nationwide Inpatient Sample (NIS),
2006–2008. World J Surg 2012;36:573–8.
[5] Wang X, Zhang W, Yang X, et al. Complicated appendicitis in children: is laparoscop-
ic appendectomy appropriate? A comparative study with the open appendectomy —
our experience. J Pediatr Surg 2009;44:1924–7.
[6] Esposito C, Borzi P, Valla JS, et al. Laparoscopic versus open appendectomy in
children: a retrospective comparative study of 2,332 cases. World J Surg 2007;31:
750–5.
[7] Taqi E, Al Hadher S, Ryckman J, et al. Outcome of laparoscopic appendectomy for
perforated appendicitis in children. J Pediatr Surg 2008;43:893–5.
[8] Yagmurlu A, Vernon A, Barnhart DC, et al. Laparoscopic appendectomy for perforat-
ed appendicitis: a comparison with open appendectomy. Surg Endosc 2006;20:
1051–4.
[9] Lee SL, Stark R, Yaghoubian A, et al. Does age affect the outcomes and management
of pediatric appendicitis? J Pediatr Surg 2011;46:2342–5.
[10] Colvin JM, Bachur R, Kharbanda A. The presentation of appendicitis in preadolescent
children. Pediatr Emerg Care 2007;23:849–55.
[11] Gorter RR, Heij HA, Eker HH, et al. Laparoscopic appendectomy: state of the art. Tai-
lored approach to the application of laparoscopic appendectomy? Best Pract Res
Clin Gastroenterol 2014;28:211–24.
[12] Dingemann J, Metzelder ML, Szavay PO. Current status of laparoscopic appendecto-
my in children: a nation wide survey in Germany. Eur J Pediatr Surg 2013;23:
226–33.
[13] Standard I, Safety C. IPEG guidelines for appendectomy. J Laparoendosc Adv Surg
Tech A 2009;19:vii–ix.
[14] Jain PK, Sedman P. Appendix retrieval after laparoscopic appendectomy: a safe and
inexpensive technique. Surg Laparosc Endosc Percutan Tech 2003;13:322–4.
[15] Bhandarkar D, Shah R. A novel technique for extraction of the appendix in laparo-
scopic appendectomy. Surg Laparosc Endosc Percutan Tech 2002;12:117–8.
[16] Saad M. Fisherman’s technique, introducing a novel method for using the umbilical
port for removal of appendix during laparoscopic appendectomy. Surg Laparosc
Endosc Percutan Tech 2007;17:422–4.
[17] Ganpule AP, Gotov E, Mishra S, et al. Novel cost-effective specimen retrieval bag in
laparoscopy: Nadiad Bag. Urology 2010;75:1213–6.
[18] Moore P. Re: appendix retrieval after laparoscopic appendectomy: a safe and inex-
pensive technique. Surg Laparosc Endosc Percutan Tech 2004;14:101.
[19] Gett R, Johnston M. Re: appendix retrieval after laparoscopic appendectomy: a safe
and inexpensive technique. Surg Laparosc Endosc Percutan Tech 2006;13:322–4.
Surg Laparosc Endosc Percutan Tech 2006;16:378.
[20] Yau KK. Re: appendix retrieval after laparoscopic appendectomy: a safe and inex-
pensive technique. Surg Laparosc Endosc Percutan Tech 2003;13:322–4.
Surg Laparosc Endosc Percutan Tech 2003;15:184.