McBurney's Point Research Articles

Comparison of Sensitivity and Specificity of Alvarado Score and Tzanakis Score in Enforcement of Acute Appendicitis Diagnosis

Appendicitis is inflammation of the appendix that occurs due to fecalitis, fibrosis, foreign bodies, or neoplasia. Based on WHO data in 2014, appendicitis is ranked 8th as the cause of death and is expected to continue to increase in the upcoming years. In the Southeast Asian region, the incidence of acute appendicitis is found in almost all Southeast Asian countries. Indonesia with a prevalence of 0.05% ranks first as the country with the highest incidence of acute appendicitis. Appendicitis has clinical manifestations in the form of visceral pain that is felt around the umbilicus, which within a few hours will move to the right under McBurney's point, fever, nausea, and vomiting as the result of infection. Difficulties in diagnosing acute appendicitis arise especially in pediatric patients, the elderly, and women of reproductive age because the symptoms they cause often overlap with other conditions.

Simplifying Retroperitoneal Robotic Single-port Surgery: Novel Supine Anterior Retroperitoneal Access

BackgroundMultiport robotic surgery in the retroperitoneum is limited by the bulky robotic frame and clashing of instruments. Moreover, patients are placed in the lateral decubitus position, which has been linked to complications. ObjectiveTo assess the feasibility and safety of a supine anterior retroperitoneal access (SARA) technique with the da Vinci Single-Port (SP) robotic platform. Design, setting, and participantsBetween October 2022 and January 2023, 18 patients underwent surgery using the SARA technique for renal cancer, urothelial cancer, or ureteral stenosis. Perioperative variables were prospectively collected and outcomes were assessed. Surgical procedureWith the patient in a supine position, a 3-cm incision is made at the McBurney point and the abdominal muscles are dissected. Finger dissection is used to develop the retroperitoneal space for the da Vinci SP access port. After docking, the first step is to dissect retroperitoneal tissue to reveal the psoas muscle. This allows identification of the ureter, the inferior renal pole, and the hilum. MeasurementsA descriptive statistical analysis was performed. Data collected included demographics, operative time, warm ischemia time (WIT), surgical margin status, complications, length of hospital stay, 30-d Clavien-Dindo complications, and postoperative narcotic use. Results and limitationsTwelve patients underwent partial nephrectomy (PN) and two each underwent pyeloplasty, radical nephroureterectomy, and radical nephrectomy. In the PN group, mean age was 57 yr (interquartile range [IQR] 30–73), median body mass index was 32 kg/m2 (IQR 17–58), and 25% had stage ≥3 chronic kidney disease. The median Charlson comorbidity index was 3 (IQR 0–7) and 75% of PN patients had an American Society of Anesthesiologists score ≥3. The median RENAL score was 5 (IQR 4–7). The median WIT was 25 min (IQR 16–48) and the median tumor size was 35 mm (IQR 16–50). The median estimated blood loss was 105 ml (IQR 20–400) and the median operative time was 160 min (IQR 110–200). Positive surgical margins were found in one patient. In the overall cohort, one patient was readmitted and managed conservatively; 83% of the PN group were discharged on the same day as their surgery, with the remainder discharged the next day. At 7 d after surgery, no patients reported narcotic use. ConclusionsThe SARA approach is feasible and safe. Larger studies are needed to confirm this approach as a one-step solution for upper urinary tract surgery. Patient summaryWe assessed initial outcomes of a novel approach for accessing the retroperitoneum (the space behind the abdominal cavity and in front of the back muscles and spine) during robot-assisted surgery in the upper urinary tract. The patient is placed on their back and surgery is performed with a single-port robot. Our results show that this approach was feasible and safe, with low complication rates, less postoperative pain, and earlier discharge. This is a promising start, but larger studies are needed to confirm our findings.

Laparoscopic Appendicectomy Using "Mian Waleed's (MW) Ultragrasper

Introduction: The two Port Laparoscopic Appendectomy (TPLA) methods sits between the single port laparoscopic surgery and traditional three port trocar. Though TPLA, the appendix is held with sutures, which creates a risk of perforation and trouble in exploration. Objective: The paper represents our experience with the usage of needle grasper in two Ports Laparoscopic Appendectomy to manipulate and suspend the appendix. Methods: 36 (11 women, 25 men) who endured TPLA were retrospectively analyzed in terms of duration of surgery, patient demographics, conventional laparoscopy or the need for laparotomy, complications, drain use and extent of hospital stay. The MW ultragrasper was placed just below the quadrant of abdomen at McBurney's point without giving incision to manipulate and hang the appendix. Results: 26.80 ± 7.61 years was the mean age with 22.68 ± 3.88 kg / m2 mean body mass index (BMI). The ASA score was 1 and 2. In 34 patients, the operation was accomplished deprived of an extra trocar. 58.11 ± 3.29 mints were the mean operative time. No patient has any intraoperative complications. Drains were obligatory in three patients; They were all discharged after removing the drain. 31 subjects were discharged on the first day after surgery; 3 patients were discharged with drains on 2nd day. 1.42 ± 0.49 days were the mean stay in hospital. Conclusion: By means of a MW ultra grasper, the appendix was suspended and held, and the meso-appendix was successfully skeletonized and cauterized in two Ports Laparoscopic Appendectomy. To manipulate the appendix, it is helpful to insert the MW ultra grasper into the cavity of abdomen at the McBurneys point and leave no visible scarring. Keywords: Minimally invasive surgery, MW ultra grasper and laparoscopic appendectomy.

Comparison of Two Different Accesses Single Orifice Percutaneous Endoscopic Surgery in Diagnosis of Ascites of Unknown Origin: A Retrospective Study.

Background Ascites is a common clinical finding caused by many different diseases, so we developed a technique termed single orifice percutaneous endoscopic surgery (SOPES) which can access peritoneal cavity through the contralateral McBurney's point or umbilicus to seek the underlying causes. In this study, we describe the initial clinical experience of SOPES and compare the application of two accesses. Methods This is a retrospective study performed between 2007 and 2018. Patients with ascites of unknown origin who underwent these two kinds of SOPES were included. Main outcomes were measured by diagnostic accuracy, complication rate, procedure time, time till stitches removal, length of hospital stay, and hospital cost. Results 148 patients successfully undergone SOPES via the contralateral McBurney's point (IM group, n = 70) or the umbilicus (UM group, n = 78). 63 patients in the IM group and 71 patients in the UM group reached clear diagnosis (90.0% vs. 91.0%, p = 0.831). The overall complication rate was 5.4%, while the UM group was higher than the IM group (10.3% vs. 0%, p = 0.017). All complications were resolved after medical treatment, and no mortality resulted from this procedure. The procedure time and the time until stitches removal in the UM group were longer than that in the IM group. There were no significant differences in length of hospital stay and hospital cost between the two groups. Conclusions SOPES, which combines the strength of minimally invasive single orifice incision and flexible angles of examination and instrumentation, is a newly developed flexible endoscopic surgical modality that provides new important clinical valuable in evaluation of ascites of unknown origin. Moreover, SOPES via the contralateral McBurney's point was safer than the umbilicus approach.

Adolescent Male With Abdominal Pain

A 15-year-old boy presented to emergency department (ED) with abdominal pain without fever for 2 days. Local peritoneal signs were found over the McBurney point. Laboratory findings showed a WBC count of 22,800/μL and c-reactive protein level of 2.06 mg/dL (normal <0.5 mg/dL). Abdominal ultrasonography failed to visualize the appendix. However, it detected multiple marblelike objects with hypoechoic rims and hyperechoic centers (Figure 1) over the epigastrium. Abdominal computed tomography (CT) showed an engorged appendix, which confirmed the diagnosis of acute appendicitis.

Modified Vecchietti vaginoplasty using self-made single-port laparoscopy in Mayer-Rokitansky-Küster-Hauser syndrome

To introduce the minimally invasive Vecchietti procedure based on single-port laparoscopy with self-made surgical instruments for the surgical management of Mayer-Rokitansky-Küster-Hauser syndrome (MRKH). Surgical video article. The approval of the Institutional Review Board and written consent from the patient were obtained. University hospital. A 22-year-old woman presented with primary amenorrhea and inability to participate in penetrative sexual intercourse. A gynecological examination revealed a phenotypically normal vulva and absence of the vagina. A normal 46,XX karyotype was expressed. Magnetic resonance imaging and ultrasonic imaging of the abdomen and pelvis indicated that the ovaries were normal in size and there was vaginal agenesis with rudimentary uterus. No other congenital malformations were present. The modified Vecchietti procedure involved a transvaginal operation and laparoscopic surgery. The epidural catheter was stretched and made into two wires that were tucked into the core of the Veress needle and then folded into four strings for perineal puncture. A transverse incision of about 3 cm was made in the center of the navel, layer by layer into the abdomen, and placed in a self-made single port (made of a small wound protector and an 8-inch glove), introducing the laparoscope. Under laparoscopic surveillance, the Veress needle was inserted through the vesicorectal space guided by the index finger, which was placed in the rectum. The epidural catheter was pumped from the core into the abdominal cavity under laparoscopy. Subsequently, cystoscopy was performed to ensure that no bladder perforation occurred during the needle insertion. The ball-shaped acrylic device and the two rubber stoppers were attached to the epidural catheter of the vulva. An epidural puncture needle with wire perforated the peritoneum through McBurney's point and the opposite McBurney's point, pulling the epidural catheter out of the abdominal cavity. The epidural catheter was curled around the gauze rolls until the ball-shaped device could be accommodated into the newly created cavity at a sufficient depth. After the surgery, the top of neovagina was lifted about 1 cm every day by tightening gauze rolls to increase the traction, until a neovagina 9 cm long was achieved. The clinical and anatomical data such as the operative time, intraoperative bleeding, duration of hospitalization, and measurement of the final length of the newly created canal 30 days after surgery and 3 months after surgery. The operative time was 30 minutes, and the intraoperative blood loss was 10 mL. The duration of hospitalization was 10 days. Before discharge, the vaginal depth was 9 cm at 5 days after the surgery, and the self-made traction system was removed. A plastic mold was then inserted using povidone-iodine. The vaginal dilator had to be worn day and night. The patient was advised to sit at the corner of a hard bed or chair from time to time to enhance the dilated effect of the vaginal mold. Three months after the surgery, it could be worn each night until regular sexual intercourse was initiated. The canal length 30 days and 3 months after the surgery was nearly 9 cm. The modified Vecchietti vaginoplasty is a simple, safe, cost-effective, and minimally invasive procedure, offering an anatomic and functional neovagina for MRKH patients.

The efficacy and safety of a novel method of peritoneal dialysis catheter insertion from the McBurney point

BackgroundCatheter dysfunction, especially omental wrapping, is a serious complication of peritoneal dialysis (PD). Although catheter implantation at a lower site was reported to prevent omental wrapping, this method could induce insufficient drainage of the PD solution and cause pain or a persistent desire to defecate, when the intraperitoneal catheter is of insufficient length or when its tip is in direct contact with the pelvic floor, respectively. The aim of this study was to assess the efficacy and safety of a novel PD catheter insertion method of approaching from the McBurney point, from the outer side of the abdomen.MethodsThis retrospective study included 23 patients with end-stage renal disease who were started on PD from January 2017 to July 2018 at Ashikaga Red Cross Hospital, Tochigi, Japan. Among them, 16 patients underwent a PD catheter insertion using a conventional method, whereas 7 patients underwent a novel method of approaching from the McBurney point. Infectious and mechanical complications were evaluated until August 2020.ResultsThere were 18 men and 5 women, with a mean age of 63.1 ± 13.6 years. All patients were followed up postoperatively for a mean duration of 27.2 ± 13.4 months. No patient experienced omental wrapping, insufficient drainage of the PD solution, and pain or persistent desire to defecate in both groups. Both the incidence of infectious and mechanical complications (times per patient-year) were not statistically different between patients undergoing a conventional and a novel PD catheter insertion (0.18 vs. 0.24; p = 0.79 and 0.03 vs. 0.16; p = 0.16, respectively).ConclusionsThis novel method of PD catheter insertion from the McBurney point was safe, caused less discomfort, and was effective in preventing catheter dysfunction.

“High absorption area in the pelvis”

A 42-year-old man presented to our emergency room with epigastric pain. He had undergone a barium examination 6 weeks previously for gastric cancer screening. He was apyrexial. Physical examination revealed slight tenderness in the epigastric region and McBurney's point. However, there were no signs of peritoneal irritation such as percussion tenderness. A plain radiographic study of the abdomen revealed high-absorption areas in the pelvis (Fig. 1A). Abdominal computed tomography revealed metal artifact-like findings in the appendix (Fig. 1B and Fig. 1C).

ACCURACY OF CLINICAL AND LABORATORY PARAMETERS IN THE DIAGNOSIS OF ACUTE APPENDICITIS

Introduction: The diagnosis of acute appendicitis is generally clinical and once it is diagnosed, operative management ensues. Abdominal pain is the main presenting complaint of patients with acute appendicitis. The diagnostic sequence of colicky central abdominal pain which is followed by vomiting with migration of the pain to the right iliac fossa. The site of maximal tenderness is often said to be over McBurney's point. Specialist investigations are rarely needed to confirm a diagnosis of acute appendicitis, and the diagnosis is predominantly a clinical one. Judicious use of urine and blood tests, for inflammatory response variables, allow exclusion of other pathologies and provide additional evidence to support a clinical diagnosis of appendicitis.&#x0D; Material and Methods: Every patient with acute onset of right lower quadrant abdominal pain and without previous history of appendectomy was considered as suspected of having acute appendicitis. Every patient with right iliac fossa pain and without history of appendectomy is suspected of having appendicitis until proven otherwise were included in the study. All Clinical and laboratory tests relevant to acute appendicitis were done among study participants. In Clinical parameters appetite, diarrhea, dysuria, vomiting, signs of localized peritonitis i.e. rebound tenderness and or guarding and pain migration was observed.in laboratory parameters, CRP, complete blood count (CBC) were measured and analysed. Patient’s demographic characteristics were noted.&#x0D; Results: A total of 100 patients were included in the study of which 50 were included in the control and 50 in case group. Mean age in control group was 29±7.23 years while in acute appendicetomy group was 29 ±8.77 years. In control group 44% were male and 56 % were female while in acute appendicitis 42% were male and 58 % were female. All clinical presentations were statistically significant in case and control group. CRP was positive in 8 (16%) in control group while in Acute appendicitis group it was 21 (42%) (P=0.0071).&#x0D; Conclusion: CRP did not contribute to the overall diagnostic accuracy. The successful diagnosis of acute appendicitis can be done through proper clinical examination and adequate evaluation of laboratory parameters&#x0D; Keywords: Acute Appendicitis, CRP, appendicetomy

An Uncommon and a Rare Presentation of Acute Appendicitis with Calculus Cholecystitis in a 12-Year-Old Girl: A Case Report

Acute appendicitis is very common general surgical emergency in teenagers while cholecystitis is common in middle-aged females but cholecystitis at the age of twelve year is very rare and along with acute appendicitis is even rarer. We describe a case of 12-year-old female who came to the outpa- tient department of Abbasi Shaheed Hospital with the complain of on and off pain in the right iliac fossa for the last one year. Abdominal examination was positive for rebound tenderness in right iliac fossa at the McBurney's point. Computed Tomography scan of whole abdomen showed gallstones with normal looking appendix. Impression of acute calculus cholecystitis with recurrent acute appen- dicitis was made. Laparoscopy along with laparoscopic cholecystectomy was planned. On Laparoscopy appendix was found to be inflamed so laparoscopic cholecystectomy along with laparoscopic appendectomy was done via the same ports. Acute appendicitis along with cholecystitis due to cholelithiasis is very uncommon and very few cases have been reported in literature.

Initial experience of modified transperitoneal laparoscopic pyeloplasty combined with a rigid ureteroscope with a deflectable tip( Sun’s ureteroscope) for the treatment of ureteropelvic junction obstruction with renal calculi

Objective To evaluate the efficacy and safety of Institution Urology of Peking University modified technique for transperitoneal laparoscopic pyeloplasty combined with deflectable tip rigid ureteroscope(the Sun's ureteroscope) in ureteropelvic junction obstruction(UPJO) complicated with renal calculi. Methods From January 2018 to September 2018, eight patients, including five males and three females, were diagnosed as UPJO with coexistent ipsilateral renal calculi in Peking University First Hospital and Changzheng Hospital of Second Military Medical University. The age ranged from 14 to 50 years(mean 28 years). Four patients had flank pain and one patient had flank pain with hematuria, while the other three patients came without clinical symptom.The BMI ranged from 16.8 to 26.2 kg/m2(mean 22.0 kg/m2). The lesion located on the left side in 4 cases and on the right side in 4 cases. One patient suffered with multiple pelvis stones. Four patients suffered with multiple lower calyceal stones, and 3 patients had solitary lower calyceal stone. The stone size ranged from 2 mm to 10 mm (mean 6.4 mm). 3 cases had slight hydronephrosis and 5 cases had moderate hydronephrosis. Two patients combined with crossing vessels. All patients underwent modified transperotoneal laparoscopic dismembered pyeloplasty with pyelolithotomy. In cases with left lesion, an incision was made for the veress needle 5mm inferior to the costal margin in the left midclavicular line to establish pneumoperitoneum . A 12-mm camera port was placed 30 mm inferior to the umbilicus and 10 mm lateral to the border of left rectus muscle. Then, a 5 mm operative trocars was inserted at 30mm superior to the umbilicus 10 mm lateral to the border of left rectus muscle. Another 12 mm operative trocar was inserted at the opposite McBurney point. The last 5 mm operative trocar was placed at the veress needle point. After visualizing the pelvis and the proximal ureter at the lower pole of the kidney, a 1.0 cm transverse incision on the lower pole of the pelvis above the obstruction site was made. The Sun’s ureteroscope was introduced into the renal pelvis through the 1.0 cm transverse incision via the 12-mm trocar below the umbilicus. Stones in the renal pelvis and calyces were extracted with basket catheters and removed via the port. After the pyelo-nephroscopy, a modified transperitoneal laparoscopic pyeloplasty was made. A F6 double-J stent was inserted into the ureter during the surgery. Result All surgeries were finished successfully without conversion. The surgical duration ranged from 111 to 185 min(mean 135 min). The estimated blood ranged from 10 to 50 ml(mean 38.8 ml). The hospital stay ranged from 3 to 7 days(mean 4 days). The intraoperative stone free rate was 100%(8/8). No perioperative complications occured. With the follow-up from 6 to 14.4 months(mean 8.9 months), there was no evidence of obstruction in all patients, as confirmed by symptoms or radiological improvement of hydronephrosis, and two patients found recurrence of renal calculi. Conclusions Our modified technique for transperitoneal laparoscopic pyeloplasty combined with deflectable tip rigid ureteroscope(the Sun′s ureteroscope) is a safe, effective method to manage ureteropelvic junction obstruction with renal calculi. Key words: Ureteroscope; Laparoscopic pyeloplasty; Ureteropelvic junction obstruction; Renal calculus

Charles Heber McBurney—McBurney and His Point to Make

<i>Charles Heber McBurney—McBurney and His Point to Make</i>

The Case Files

The Case Files

The application of improved abdominal wall punctures technique in ventriculoperitoneal shunt for hydrocephalus: a retrospective analysis versus open mini-laparotomy

Purpose: Ventriculoperitoneal shunt (VPS) remains as one of the main treatment for hydrocephalus. The traditional technique for placing the distal ends of shunts is via a mini-laparotomy. However, laparotomies are relatively time consuming. Trocars to penetrate abdominal wall by blind puncture have been used. Here, we report on the abdominal wall puncture technique, and compare the possible complications and outcomes with traditional mini-laparotomy.Materials and methods: We use a 5mm incision at the inverse McBurney point. The abdominal wall on both sides of the incision point is lifted with two towel clips prior to puncture to create a potential gap between the abdominal wall and viscera. After the puncture, a guide wire is inserted followed by a dilator, introducer and the distal shunt tubing using a Seldinger technique. In this process, the operator feels resistance give with breakthrough of parietal peritoneal. After the insertion of introducer, a negative pressure injection test helps confirm whether the introducer is inside the peritoneum.Results: Operative time is less than with mini-laparotomies. Postoperative abdominal symptoms are mild. Out of 29 patients there were no puncture related complications.Conclusion: The improved abdominal-wall puncture technique is a simple, fast, economical and effective method. Patients, who are treated by the method, generally experience rapid postoperative recoveries.

Hybrid appendectomy with classic trocar on McBurney's point.

IntroductionAppendectomy is still the most commonly performed intra-abdominal operation worldwide. Interestingly, it has not reached the same popularity as other laparoscopic surgical procedures. Although multiple techniques have been described, a standard approach has not been described for the laparoscopic technique yet.AimTo perform hybrid appendectomy for acute appendicitis on McBurney’s point, aiming to perform an easier and quicker procedure while limiting the trauma to the abdominal wall by obtaining the advantages of both laparoscopic and open techniques.Material and methodsWe retrospectively evaluated the results of 24 patients on whom we had performed hybrid appendectomy with an optical trocar on McBurney’s point for acute appendicitis in 1 year in terms of demographics, operative time, complications, hospital stay and cosmetic results.ResultsTwenty-one of the patients underwent hybrid appendectomy with a one-optic trocar on McBurney’s point. The mean operative time was 21.4 ±6.2 min. We did not encounter any postoperative complications in any of the patients. The median hospital stay was 1.2 ±1.0 days. The postoperative scar was minimal.ConclusionsThis technique is defined in the literature for the first time, and it is easy and feasible for the surgeons. It may reduce the operative time and costs when compared to the conventional laparoscopic technique, but prospective studies with more patients are needed for more certain results.

The Case Files

The Case Files

Two-port laparoscopic appendectomy with the help of a needle grasper: better cosmetic results and fewer trocars than conventional laparoscopic appendectomy.

IntroductionThe two-port laparoscopic appendectomy technique (TPLA) lays between the conventional three-port trocar procedure and single-port laparoscopic appendectomy surgery. During TPLA, the appendix is suspended with stitches, resulting in perforation risk and difficulty in exploration.AimWe used a needle grasper in TPLA to hang and manipulate the appendix.Material and methodsThirty-four patients (10 female, 24 male) who underwent TPLA between February 2015 and November 2015 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. The needle grasper was inserted at the right under the abdominal quadrant (McBurney point) without an incision to hang and manipulate the appendix.ResultsThe mean age was 25.19 ±8.464 years; the mean body mass index (BMI) was 23.50 ±3.246 kg/m2. ASA scores were 1 and 2. The operations were completed without any additional trocar in 34 patients. The mean operation time was 57.03 ±3.814 min. There were no intraoperative complications in any patients. Three patients required a drain; all were discharged after drain removal. Thirty-one patients were discharged on the 1st postoperative day; three patients with drains were discharged on the 2nd day. The mean hospital stay period was 1.18 ±0.535 days.ConclusionsUsing the needle grasper, the appendix was held and suspended and the mesoappendix was cauterized and skeletonized successfully in TPLA. Inserting a needle grasper into the abdominal cavity at the McBurney point to manipulate the appendix helps and does not leave a visible scar.

Acute tubercular appendicitis: A rare presentation

Tuberculosis is a common disease in developing countries like India but gastrointestinal involvement comprises only 3% of all extrapulmonary cases. Primary tubercular appendicitis is rare. We report a case of a 15-year-old girl who presented with complaints of acute abdominal pain, vomiting, and fever for 1 day along with tenderness at the McBurney's point suggestive of acute appendicitis. She underwent laparoscopic appendicectomy. Histopathological report of appendix revealed presence of many epitheloid cells with central necrosis compatible with tuberculosis; hence, antitubercular treatment was started postoperatively. We wish to highlight that primary tubercular appendicitis mimics acute appendicitis in general but requires additional antitubercular treatment along with appendicectomy to avoid complications.

Two-port laparoscopic appendectomy assisted with needle grasper comparison with conventional laparoscopic appendectomy.

PurposeThe 2-port laparoscopic appendectomy technique (TLA) is between the conventional 3-port and single-port laparoscopic appendectomy surgeries. We compared postoperative pain and cosmetic results after TLA with conventional laparoscopic appendectomy (CLA) by a 3-port device.MethodsPatients undergoing TLA were matched with patients undergoing CLA between February 2015 and November 2015 at the same institution. Thirty-two patients underwent TLA with a needle grasper. The appendix was secured by a percutaneous organ-holding device (needle grasper), then removed through a puncture at McBurney's point. Another 38 patients underwent CLA. Patient demographics, operative details, and postoperative outcomes were collected and evaluated.ResultsOne patient in the TLA group developed a wound infection and 1 patient in the CLA group developed a postoperative intra-abdominal abscess and 3 wound infections. There was no significant difference between the groups when comparing the length of hospital stay, time until oral intake, and other complications. The pain score in the first 12 hours after surgery was significanly higher in CLA group than the TLA group (P < 0.001). Operative time was significantly shorter in the CLA group compared to the TLA group (P < 0.001).ConclusionTLA using a needle grasper was associated with a significantly lower pain score 12 hours after surgery, better cosmetic results, and lower cost, than the CLA 3-port procedure because of the fewer number of ports.

Diverticulitis of the appendix: is it clinically significant?

We represent here, a case of male patient aged 32 years coming complaining of diffuse periumbilical pain since 2 days that shifted to the right iliac fossa and suprapubic areas within 6 h from onset. The condition was accompanied by vomiting (once), constipation, and fever. Abdominal examination revealed tender Mc-Burney point with rebound tenderness in the right iliac fossa; he had a pulse of 97 beats/min, temperature of 38.1΀C, and total leukocytic count of 9000 c/m. Ultrasonography revealed minimal free fluid with noncompressible tubular blind structures, indicating acute appendicitis [Figure 1]. The patient was prepared for appendectomy in the usual manner through Lan's incision. On operation, two bulges were found arising from the antimesenteric border of the distal half of the appendix [Figure 2] as diverticulae with impending rupture of one of them [Figure 3]. Both the appendix and diverticulae are seats of inflammation [Figure 4]. Appendectomy was performed and the specimen was sent for histopathologic examination, revealing diverticulitis of an inflamed appendix (type 2 diverticulosis of the appendix). We reviewed the literature to study cases on such a clinical entity and determine whether appendectomy was sufficient in all cases and whether there was actual increased risk for another diverticulae elsewhere.