Endoscopic Transceical Appendectomy In this video, we present a novel transceical endoscopic appendectomy approach for the removal of complex appendiceal polyps. So the unique anatomy of the appendix limits the visualization of the lateral margin of the polyps extending inside the appendiceal lumen. EMR and ESD or even EFTR could be used to manage this lesion, but you cannot guarantee 100% removal of the entire polyps simply because the polyp is extending deep in the appendiceal lumen and we don't know the extent of the polyp. Also, appendicitis is a major adverse event associated with these techniques. In this case, we have a 69-year-old female with a history of hypertension and hyperlipidemia who had a sessile serrated polyp which occupying 50% of the circumference and it was extending within the lumen of the appendix. So in the video, we'll find that the sessile lesion is around 15 mm. It's not that large, but upon inspection, you can tell that we cannot see the margin of the lesion and we don't know how deep it is going within the appendiceal lumen. Sometimes injection is used to help us avert the appendix and this maybe allows us to remove the lesion without doing an appendectomy, but the more we inject, the more the polyp gets embedded within the lumen which makes it even harder to remove the lesion. So given the inability to delineate the border of the lesion, the decision was made to perform transceical endoscopic appendectomy. Obviously, this was discussed with the patient before the procedure given the pre-operative picture of the lesion that this might be a possibility and the patient understood that we are doing this technique. As you can see here, we start with circumferential incision around the polyp and around the appendix and we inject first a headspan lifting solution to raise the appendiceal orifice polyp as you can see and we're gradually dissecting the mucosa, submucosa and going all the way to the muscular sprobria serosa in a circumferential manner around the appendix. So by now we can see the outside appendix in some area, so we freed up the right margin of the lesion and we are gradually using the ESD knife to complete the circumferential incision. Now we're going to use traction. This is the first point traction we're using and we're using Kleb with a rubber band traction and we are placing it over the polyp and de-inflate the colon so that later on when we insufflate the colon we can create some sort of dynamic traction. So deflate the colon, place, we can place the Kleb and gradually insufflate and you can see here we are identifying the appendix and the meso-appendix around it. So appendix is not freely flowing outside, it is actually surrounded on one side by the meso-appendix and you have to carefully identify the meso-appendix and separate the meso-appendix from the appendix or take the appendix with part of the middle appendix together. The appendiceal length is variable, sometimes it could be one centimeter and it could be up to 16 centimeters, so having a CT scan before performing this procedure is important. Luckily in our patient here the appendix was around three centimeters which is around the average. We followed the appendix all the way to the end and once we find the distal end and cleared it we're applying another point of traction and that point of traction now is utilizing the base of the appendix, the tip of the appendix and inverting it all the way to the cecum and placing it in another clip up there. So now we inverted the appendix completely and still one part of the circumferential incision was not completely done and once we did it we confirm now that we did complete appendectomy with removal of the polyps. In a situation like that there should be a 14 gauge needle used to deflate the peritoneum, you don't want to have neobrutinium in situations like that and gradually we are placing the clips, so we are using a variety of clips here. Unlike other closures, this closure has to be tightly sealed, you have to ensure that both margins are sealed, we cannot have a room here for any small leak, so we are very, we're not that conservative, we're a little bit slightly aggressive in placing too many clips close to each other. We are using a variety of the clips to approximate the edges as you can see here and once we ensure good approximation when we look at both sides of the lesion and place the clip and we add additional clips in between just for safety and for the possibility if one of these clips was detached you will have another backup clip. Bathogy showed 1.1 centimeter polyp within 3 centimeter appendix, margins were negative, it was sessile serrated polyp, so this was a negative R0 resection. So to summarize our method, it was circumferential injection with lifting solution followed by incision around the appendix using ESD knife, an ESD approach, then the incision is extended to the cirrhosis and then we dissect the appendix from the meso appendix and that's one of the most important aspects and then we use multiple point traction followed by closure. The implication what we're doing is that this is a novel method for removal of appendiceal polyps, it could be also used later on for maybe localized benign appendiceal tumor removal and it is perfect for cases when we don't know the extension of the polyp. So in conclusion endoscopic transceical appendectomy is safe and effective method for management of complex appendiceal polyp and the risk of appendicitis associated with full thickness resection is eliminated with this novel approach. Thank you.

transceical endoscopic appendectomy

complex appendiceal polyps

appendix anatomy

EMR

ESD