Post written by Takashi Muramoto, MD, PhD, from the Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan.

We presented endoscopic transcecal appendectomy under laparoscopic single-port assistance for a flat-elevated tumor completely covering the appendiceal orifice in the video. The lesion was a flat-elevated tumor completely covering the appendiceal orifice, measuring 15 mm in diameter. Our strategy was to use a single port for introducing the laparoscope to guide the endoscope and safely endoscopically resect the tumor and close the defect. After making a circumferential mucosal incision, a ring-thread made of dental floss was applied to the opposite side of the cecum to obtain sufficient traction. Then, it was intentionally perforated using the tip of DualKnife (Olympus, Tokyo, Japan), and a circumferential full-thickness incision was made. After advancing the endoscope into the abdominal cavity, the mesoappendix was dissected using ITKnife nano (Olympus, Tokyo, Japan) and the lesion, along with the appendix, was resected en bloc. Bleeding from the appendicular artery was observed during the dissection, and hemostasis was accomplished endoscopically. After complete resection, the appendix was pulled into the colonic lumen and removed through the anus. Finally, the 2-channel scope was reinserted and the endoscopic purse-string reefing method using Endoloop2 (HX-400U-30, Olympus, Japan) was applied to close the defect completely. The total procedure time was 90 minutes, and there were no adverse events. The patient was discharged 8 days after the treatment. Histological examination confirmed sessile-serrated adenoma/polyp (SSA/P), and curative resection was achieved.

Laparoscopic surgery is the most commonly used treatment for tumors completely invading the appendix whose margins cannot be visualized endoscopically, but at least 3 ports are required. In addition, ileocecal resection may be required depending on the tumor size, which inevitably increases the degree of invasiveness. There are a few case reports of endoscopic transcecal appendectomy, although its safety has not yet been established. From that point of view, endoscopic transcecal appendectomy under laparoscopic single-port assistance is less invasive than conventional laparoscopic resection and can be conducted more safely and efficiently than endoscopy alone.

Endoscopic transcecal appendectomy under laparoscopic single-port assistance has the potential to be one of the minimally invasive treatment options for appendiceal tumors. In addition, we were able to clarify the feasibility of endoscopic transcecal appendectomy and future issues, by laparoscopic observation of the abdominal cavity.

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