Appendicitis remains one of the most common surgical emergencies worldwide, and laparoscopic appendicectomy (LA) has become the preferred treatment in many centers due to its minimally invasive nature, reduced postoperative pain, quicker recovery, and superior cosmetic outcomes. Traditionally, laparoscopic appendicectomy is performed using a three-port technique. However, innovations in minimally invasive surgery have led to the development of techniques using fewer ports, such as the two-port laparoscopic appendicectomy, which reduces invasiveness while maintaining safety and effectiveness.

This technique offers an attractive alternative for selected patients, particularly young adults and children, where cosmesis and reduced pain are significant considerations.

Evolution of the Two-Port Technique

The conventional three-port laparoscopic appendicectomy involves one umbilical port for the camera and two working ports (usually suprapubic and left iliac fossa). While effective, it requires three abdominal incisions. With advances in instrumentation and growing surgical expertise, surgeons began experimenting with reduced-port techniques:

Single-incision laparoscopic surgery (SILS): Performed through the umbilicus but technically demanding and expensive due to specialized ports and instruments.

Two-port technique: Strikes a balance between standard three-port and single-port approaches by minimizing incisions without requiring specialized equipment.

Patient Selection

The two-port laparoscopic appendicectomy is most suitable for:

Uncomplicated appendicitis.

Non-obese patients (BMI < 30).

Young adults and pediatric patients.

Patients without extensive adhesions or peritonitis.

For complicated appendicitis (perforation, abscess, dense adhesions), the traditional three-port or even open approach may be safer.

Technique of Two-Port Laparoscopic Appendicectomy
Anesthesia and Positioning

The procedure is performed under general anesthesia.

The patient is placed in a supine position with Trendelenburg tilt and left tilt to allow bowel loops to fall away from the right iliac fossa.

Creation of Pneumoperitoneum and Port Placement

A 10 mm umbilical port is inserted for the laparoscope (usually 30°).

A 5 mm working port is introduced in the suprapubic or left iliac fossa region.

This provides two access points: one for visualization and one for dissection.

Retraction of the Appendix

Retraction is achieved using a percutaneous suture loop technique or a suture passer introduced directly through the abdominal wall without a formal port.

A polypropylene suture or endoloop is placed around the appendix base or mesoappendix, and traction is applied externally to elevate the appendix.

Dissection of the Mesoappendix

Using instruments through the working port, the mesoappendix is carefully dissected and divided.

Energy sources like monopolar cautery, bipolar, or advanced devices (Ligasure or Harmonic scalpel) may be used depending on availability.

Securing the Base of the Appendix

The base of the appendix is ligated using an endoloop, extracorporeal knot, or intracorporeal suture.

Two loops are generally placed proximally, and one distally for added safety.

Division and Extraction

The appendix is divided between the ligatures.

It is retrieved via the umbilical port using a glove-finger bag or endobag to prevent contamination.

Closure

Ports are removed under vision.

The umbilical fascial defect is closed with absorbable sutures, and skin incisions are closed for optimal cosmetic results.

Advantages of the Two-Port Technique

Reduced number of incisions – only two formal ports are used, improving cosmetic results.

Less postoperative pain – fewer ports mean less tissue trauma.

Lower cost – avoids specialized single-port devices.

Comparable safety – for uncomplicated appendicitis, outcomes are similar to three-port appendicectomy.

Training value – improves a surgeon’s dexterity and confidence in reduced-port laparoscopy.

Limitations and Challenges

Steeper learning curve: Surgeons must adapt to working with fewer instruments, which limits triangulation.

Patient selection critical: Complicated cases may not be suitable.

Risk of conversion: Surgeons must be ready to insert a third port if exposure or safety is compromised.

Instrument clashing: With only two ports, there is an increased chance of crowding and instrument conflict.

Clinical Outcomes and Evidence

Studies comparing two-port with three-port laparoscopic appendicectomy have shown:

Comparable operative times in uncomplicated cases.

Reduced postoperative pain scores in many patients.

Quicker return to normal activities, especially in young adults and children.

Improved cosmetic satisfaction due to fewer scars.

Conversion to three-port remains necessary in a minority of cases, particularly in obese patients or when complicated pathology is encountered.

Conclusion

The two-port laparoscopic appendicectomy represents a safe, effective, and cosmetically superior alternative to the traditional three-port approach in carefully selected patients with uncomplicated appendicitis. It strikes a balance between minimizing invasiveness and maintaining surgical safety without requiring expensive or specialized equipment.

For surgeons skilled in laparoscopic techniques, this approach expands the armamentarium of minimally invasive appendicectomy and exemplifies the continuous innovation in surgical practice. As training centers emphasize advanced minimal access surgery, the two-port technique will likely gain further popularity for its efficiency, patient satisfaction, and cost-effectiveness.