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 Table of Contents     
Year : 2021  |  Volume : 17  |  Issue : 4  |  Page : 573-575

“Misra's appendicular hitch” stich – Innovative technique for simplifying endo-suturing during laparoscopic appendectomy

Department of Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission30-Sep-2020
Date of Decision22-Jan-2021
Date of Acceptance08-Feb-2021
Date of Web Publication23-May-2021

Correspondence Address:
Dr. Krishna Asuri
Room No. 5014C, Teaching Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_248_20

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 ¤ Abstract 

Laparoscopic suture transfixation and free tie ligation are the most commonly used cost-effective technique of managing the base of the appendix during laparoscopic appendectomy in low resource settings such as India. This becomes technically cumbersome especially in the presence of the long friable appendix and for novice surgeons. We hereby describe an innovative technique of suspending the appendix using a transfacial suture to ease the placement of suture at the base of the appendix during laparoscopic appendectomy.

Keywords: Endoloop, laparoscopic appendectomy manuscript, laparoscopic suturing

How to cite this article:
Asuri K, Jain M. “Misra's appendicular hitch” stich – Innovative technique for simplifying endo-suturing during laparoscopic appendectomy. J Min Access Surg 2021;17:573-5

How to cite this URL:
Asuri K, Jain M. “Misra's appendicular hitch” stich – Innovative technique for simplifying endo-suturing during laparoscopic appendectomy. J Min Access Surg [serial online] 2021 [cited 2022 Jul 3];17:573-5. Available from:

 ¤ Introduction Top

Appendectomy is one of the most commonly performed general surgery procedures. Laparoscopic appendectomy has now become one of the standard of care for acute appendicitis.[1] The most critical step of laparoscopic appendectomy is the division of the base of appendix. There are presently the number of techniques of dividing the base of appendix including the use of commercially available endoloops, endoscopic linear stapler, clips and suture trans fixation, and free tie ligation. Literature has shown that there is no difference in the above techniques in terms of patient outcome.[2] Use of stapler, clips and endoloops is technically much easier than suture ligation (transfixation and free tie) which requires good suturing skills. However, suture ligation is the most cost-effective technique especially in low resource setting such as India. One of the common technical problems encountered during suture ligation of the appendicular base during laparoscopic appendectomy is that invariably the left hand of the surgeon is engaged in holding and providing traction to the appendix while the suturing is done by the right-hand instrument. This is cumbersome and especially in patients with long and friable appendix may result in crushing of the appendix and spillage of contents and also add to the time taken for suturing. When such technical difficulty arises most surgeons resort to placing an additional port or using other techniques (stapler, clips and endoloops).

We hereby describe our innovative technique of suspending and fixing the appendix using a trans facial suture which is passed through the mesoappendix. This technique makes suture trans fixation and ligation technically very simple specially for beginners. We would like to name this as “Misra's appendicular hitch” stich in honour of our mentor who taught us all the skills of laparoscopy.

 ¤ Technique Top

After creation of pneumoperitoneum using Veress needle, a 10 mm trocar is inserted just above the umblicus as a camera port for a 10 mm 30degree scope. Two additional 5 mm working ports are inserted, one in the right pararectus position at the level of umblicus and second suprapubic in the midline as shown in [Figure 1]. After performing a diagnostic laparoscopy, the appendix is identified. The mesoappendix is divided using Harmonic© ultrasonic shears (or bipolar alternatively) and the base of appendix is identified. Following this a 1-0 silk suture with a straightened needle is inserted just to the right of the suprapubic port [Figure 2]. The needle is drawn into the peritoneal cavity, passed through the mesoappendix and again drawn outside through the abdominal wall [Figure 3] and [Figure 4]. Gentle traction is applied to the suture from outside to suspend the appendix [Figure 5]. In this position the appendix is fixed and both the hands of the surgeon are free to transfix (or ligate) the base without handling the appendix [Figure 6]. After transfixation/ligation with an absorbable suture, the base of appendix is divided and retrieved through the 10 mm umbilical port using a 5 mm scope. Saline lavage is given and drain placed at the discretion of the surgeon.
Figure 1: Port placement

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Figure 2: Introducing the transfacial suture on a straightened needle

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Figure 3: Passing the suture through the divided mesoappendix

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Figure 4: Taking out the suture through the abdominal wall

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Figure 5: Traction to suspend the appendix

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Figure 6: Transfixation of base of appendix

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 ¤ Discussion Top

Acute appendicitis is one of the most common indications for emergency surgical intervention worldwide and laparoscopic appendectomy is a well-established standard of care in all age groups.[1] With the increasing use of laparoscopic appendectomy, many variations to the technical details of the procedure have been described.[2] Different techniques of management of base of appendix have been described such as endoloops ligature,[3] linear endoscopic stapler,[4] endoclips/hemlock clips[5],[6] and laparoscopic suturing.[7] All techniques have been found to have comparable results.[2] However, the use of staplers, endoclips and endoloops adds to the cost of the procedure which becomes significant in low resource settings such as in India where cost constraints prevent the surgeon from doing laparoscopy let alone using staplers. Based on the technique described by Schroeder and Lobe,[8] the cost of endoclips technique is %412 (approx., 30,000 INR), cost of endoloops is %348 (approx. 25,000 INR) and the cost of the stapler is %312 (approx. 22,000 INR). Thus laparoscopic suturing along with liagtion with a free tie continues to be the preferred low-cost techniques in the Indian scenario. However, some technical challenges are encountered while suturing especially in patients with long friable appendix which not only entails placement of extra trocar and use of alternate techniques but sometimes even conversion to open. Excessive handling of the appendix during suturing results in the crushing of the appendix and spillage of contents.

Our simple technique of suspending and fixing the appendix using a trans facial suture simplifies the overall laparoscopic suturing as well as ligation. We believe this innovative technique may add to the ease of laparoscopic suturing especially for beginners and trainees.

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Conflicts of interest

There are no conflicts of interest.

 ¤ References Top

Bliss LA, Yang CJ, Kent TS, Ng SC, Critchlow JF, Tseng JF. Appendicitis in the modern era: Universal problem and variable treatment. Surg Endosc 2015;29:1897-902.  Back to cited text no. 1
Gorter RR, Heij HA, Eker HH, Kazemier G. Laparoscopic appendectomy: State of the art. Tailored approach to the application of laparoscopic appendectomy? Best Pract Res Clin Gastroenterol 2014;28:211-24.  Back to cited text no. 2
Beldi G, Muggli K, Helbling C, Schlumpf R. Laparoscopic appendectomy using endoloops: a prospective, randomized clinical trial. Surg Endosc 2004;18:749-50.  Back to cited text no. 3
Daniell JF, Gurley LD, Kurtz BR, Chambers JF. The use of an automatic stapling device for laparoscopic appendectomy. Obstet Gynecol 1991;78:721-3.  Back to cited text no. 4
Hanssen A, Plotnikov S, Dubois R. Laparoscopic appendectomy using a polymeric clip to close the appendicular stump. JSLS 2007;11:59-62.  Back to cited text no. 5
Ates M, Dirican A, Ince V, Ara C, Isik B, Yilmaz S. Comparison of intracorporeal knot-tying suture (polyglactin) and titanium endoclips in laparoscopic appendiceal stump closure: A prospective randomized study. Surg Laparosc Endosc Percutan Tech 2012;22:226-31.  Back to cited text no. 6
Matyja M, Strzałka M, Rembiasz K. Laparosocopic appendectomy, cost-effectiveness of three different techniques used to close the appendix stump. Pol Przeglad Chir 2015;87:634e637.  Back to cited text no. 7
Schropp KP, Lobe TE. Laparoscopic appendectomy. In: Holcomb GW 3rd, editor. Pediatric Laparoscopic Surgery. Norwalk, CT: Appleton & Lange; 1994. p. 21-7.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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