K Ashok et al: Advantage Button hole, Non-laparoscopic over Laparoscopy ORIGINAL ARTICLE 

Button hole, Single stitch, Non-laparoscopic Appendectomy in a 

Tribal District Hospital, Advantage over Laparoscopy 
K Ashok 1, K Rashmi2, Goveen M3, V Pramod Kumar4 
1. Director and Medical Superintendent Rajiv Gandhi Institute of Medical Sciences (RIMS) Adilabad. 2. 2nd year P G (M D 
Radiology) Datta Meghe Institute of Medical Sciences Wardha. 3 & 4. Interns Rajiv Gandhi Institute of Medical Sciences 
(RIMS) Adilabad. 
Abstract Background: The purpose of the study is to analyze, feasibility, utility and advantage of using Single Stitch 
Non-Laparoscopic Appendectomy for patients with acute appendicitis in a Hospital located in Tribal District. 
Methods: A total number of 1000 cases diagnosed as acute appendicifis, 100 cases selected for this technique by 
following inclusion criteria who where then operated with a special technique from July 2012 to December 2015. 
All these cases were operated under Spinal Anesthesia. Results: There were no complications and post operative 
mortality, except wound infecfion in two cases out of 100 and post operafive stay was only for 2 days. Conclusion: 
The technique had no significant difference in peri-operative complications, post operative pain and patient 
satisfaction. Hence Single stitch Non laparoscopic appendectomy is a safe and advantageous technique in 
performing appendectomy in Hospitals where there is generally lack of sophisticated equipments. Keywords: Acute 
Appendicitis, Single Stitch Technique, Laparoscopic appendectomy 
Address for correspondence: Dr K Ashok, Director and Medical Superintendent Rajiv Gandhi Institute of Medical 
Sciences (RIMS) Adilabad. Email- srinivasanhadilabad@gmail.com Mobile No-= +919849644591 
DOI:10.18049/jcmad/332 Received on : 18/01/2016 Revised : 29/01/2016 Accepted : 30/01/2016 

Introduction 
Appendicitis  is  the  most  common  cause  of  an  acute  surgical  abdomen,  in  spite  of  recent  advances  in 
diagnosis  and  treatment  it  is  still  associated  with  significant  morbidity  (10  %) and mortality (1–5 %). [1] 
The  decision  to  perform  surgical  exploration  in  suspected  appendicitis  involves  diagnostic  accuracy, 
patient  age  and  co-morbidity,  the  surgeon’s  core  medical  values,  expected  natural  course  of  non- 
operative  treatment  and  priority  considerations  regarding  the  use  of  limited  resource.  [2]  Open 
appendectomy  is  accepted  as  a  standard  treatment.  Open  appendectomy  that  was  first  described  by 
McBurney  in  1894  has  long  been  applied  as  the  gold  standard  procedure  [3].  Since  Semm  in  1983 
introduced  laparoscopic  appendectomy,  it  is  now  becoming  more  accepted.  [4]  Many  advantages  of 
laparoscopic appendectomy have been shown such as lower 
J  Cont  Med  A  Dent January-April 2016 Volume 4 Issue 1 4 hospital stay, shorter recovery period, shorter 
period  for  returning  to  daily  activities, lower postoperative pain, and lower postoperative infections. With 
the  widespread application of laparoscopy, more useful hand-tools were developed and it became possible 
to  perform  all  gastrointestinal  surgical  procedures  laparoscopically  over  time  with  increasing  clinical 
experience.  In  spite  of  these  advantages,  there  is  controversy  over  the  best  model  of  appendectomy 
technique  in  the  literature.  [5]  Despite  the  given  facts  Open  appendectomy  is  still  most  common 
procedure  adopted  in  cases  of  appendicitis  especially in rural areas. [6] This study was aimed to show the 
superiority  of  this  particular  technique  called  Button  hole  single  stitch  technique  compared  to 
laparoscopic  appendectomy,  highlighting  the  advantages  in  a Hospital located in Tribal areas where there 
is a lack of sophisticated equipments. 
 
K Ashok et al: Advantage Button hole, Non-laparoscopic over Laparoscopy Materials & Methods 
identified and Babcock’s forceps is applied for the Taenia Coli. Then it is pulled out with a Objectives of 
Study 
technique called “PULL AND PUSH”. The 1) 
Formulating certain criteria for selection of 
base of appendix is identified and appendix is cases 
to be done with this technique (Single 
delivered through the wound and appendectomy 
Stitch Non Laparoscopic Technique-SSNLT). 2) 
done. The wound is closed in layers. In almost To 
compare the advantages of this technique 
all cases only single stitch was enough to close over 
conventional laparoscopy. A total 1000 
the skin wound. Liquids were allowed orally cases 
of with diagnosis of Acute Appendicitis 
after 6 hours. The patients were discharged on were 
admitted in RIMS Hospital, Adilabad from 
3rd post operative day. A combination of July, 2012 
and December, 2015, out of which 
antibiotics - Cefixime and Metronidazole were 100 
cases were selected for this study. 
given. Pain killers like Diclofenac Sodium and The 
following Inclusion criteria were used in 
Tramadol were given only on day of operation. 
selecting the cases for this technique. [7-9] 
1) Slim individuals 
Results 2) Appendicitis < 24 hours 
duration. 
In all the 100 cases, only single stitch was 3) Marked 
tenderness and guarding at Mc 
enough for closing the abdomen. No extension 
Burney’s point. 
of incision was required as the inclusion criteria 4) 
Palpable appendix after fully relaxation 
were strictly followed. There were no significant of 
abdomen under Anesthesia. 
 postoperative complications except wound 5) Ultra 
Sonographic findings like: 
infection in 2 cases. Early ambulation, less a) Clear visible 
Appendix. 
hospital stay, less analgesics, and the cosmetic b) Diameter 
> 6 mm 
effect of wound was similar to a laparoscopic c) Thickened 
& Edematous Wall. 
appendectomy. The near perfect patient d) Presence of 
faecolith. 
satisfaction score was 9.3 (O = poor satisfaction, e) 
Appendix seen superficial to bowel 
10= excellent satisfaction) were obtained. loops. 
Figure 1: showing the Percentage of Out of 5 
formulated criteria, if any 3 criteria 
complications were met, then case was selected for 
this surgery. By these criteria 100 cases were selected for this study. 
The following ultrasound findings were contraindications for this technique: a) Poor window. b) Early 
mass formation. c) Retrocaecal Appendix d) Perforated Appendicitis with fluid 
collection in Right illac fossa e) With tip of appendix going 
subhepatically into lumbar region. 
Figure 2: showing the age wise distribution of the patients Procedure Under Spinal Anesthesia, 1⁄2 inch 
incision is given at the McBurney’s point, parallel to spino- umbilical line. Skin and Subcutaneous tissues 
incised, and cut is given to external oblique aponeurosis. Then Transverses Abdominis Muscle is split. 
Index finger is introduced and muscles are separated and adequate space is created in the peri-peritoneal 
area. Retraction of muscles is done by opposite end of non-toothed forceps and peritoneum is opened. 
Caecum is 
J Cont Med A Dent January-April 2016 Volume 4 Issue 1 5 
 
K Ashok et al: Advantage Button hole, Non-laparoscopic over Laparoscopy 
Table 1: Post-operative different age groups 
complications in 
and 4% have reported as fair. This clearly shows better outcome and complete patient satisfaction 
Complications 
< 15 Yrs 
J Cont Med A Dent January-April 2016 Volume 4 Issue 1 6 

15– 30 Yrs 
30– 
in this procedure. 
45 
Table 3: Follow up complications in different Yrs 
age groups Follow up status > 45 Yrs 
Wound Infections 
-- -- -- 2 
< 15 
15–30 
30–45 > Yrs 
Yrs 
Yrs 
Yrs 
45 
Intra abdominal abscess 
-- -- -- -- 
At months 
3 
-Nil- -Nil- -Nil- -Nil- 
Mortality -- -- -- -- 
At 6 
The table 1 shows the number of post operative 
months 
complications  encountered  after  the  surgical  procedure  it  is  very  clear  that  there  were no significant post 
operative  complications  reported  except  2  cases  were  of  suture  abscess  which  were  conservatively 
managed with antibiotics and it successfully resolved completely. 
Table 2: Patient Satisfaction in different age groups 
Success 
-Nil- -Nil- -Nil- -Nil- 
At months 
12 
-Nil- -Nil- -Nil- -Nil- 
Table  3  shows  that  there  were  no  follow  up  complication  reported  by  any  patient  after  15  days  and one 
month follow up after the surgical procedure. This denotes excellent outcome of the procedure. 

Discussion 
There  is  general  increase  in  trend towards laparoscopic appendectomies because its advantages. However 
carefully  selected  and  well  performed  Single  Stitch  Non  Laparoscopic  Technique  SSNLT  can  achieve 
remarkable  success  on  par  with  Laparoscopic  Technique  and  especially  in  Tribal  areas  where  there  are 
limited  resources  and  equipments  present  such  as  Laparoscope  this  technique  is  viable  alternative.  With 
the above study we found the following advantages of this technique over LAP. 
Table 4: showing comparison between LAP (Laparoscopic Appendectomy) with SSNLT (Single Stitch 
Non Laparoscopic Technique of appendectomy) Sl. No. 
< 15 Yrs 
15– 30 Yrs 
30– 45 Yrs 
> 45 Yrs 
Total % 
Excellent 20 40 10 07 77 Good 04 10 04 01 19 Fair 01 -- 01 02 04 
Table  2  shows  the  patient  satisfaction  sheet  which  was  given  to  individual  patient  to  complete  in  their 
own  language  during  the  time of their discharge. It shows that about 77% of patients have given excellent 
grade to the surgical procedure and 19% have given good 
Description LAP SSNLT 
1 Anesthesia 
General Anesthesia (Most of the cases) 
Spinal 
2 Duration of procedure More Less 3 Equipment Costly Routine instruments 4 Training & Experience 
Required Routine procedure 5 Staff Specialized trained staff is required Routine staff 6 Hospital Stay 2 to 
3 days (min) Same 7 Overall Expenditure Costly Cost effective 
8 Complications 
i) Complications of Anesthesia ii) Bowel injuries iii) Burn of Bowel due to defective 
instruments 
NIL 
9 
Cosmetic Appearance of 
3 ports are introduced with three 
Only single small the wound 
incisions 
incision 
 
K Ashok et al: Advantage Button hole, Non-laparoscopic over Laparoscopy 
In this study, 100 patients of acute appendicitis were selected based on age, sex and above mentioned 
criteria. These 100 patients underwent elective SSTNL surgery. Patients Detailed History, Physical 
Examination, Operative Details, Post operative complications, Length of Hospital stay, Pain scores, 
Analgesic requirements and Patient satisfaction scores were collected. There were 60 males and 40 
females in the study, and with different age groups 32 were of < 15 yrs, 35 were of 15-30 yrs, 20 were of 
20-30 yrs, 13 were of >45 yrs. And they were operated and there are no perioperative complications. The 
post operative pain score was measured by a scale from 0 to 10 (0 = No Pain, 10 = Severe Pain). The 
Hospital stays of patients were recorded. The near patient satisfaction score Average was 9.31 (O=Poor, 
10=satisfied). There was only wound infection in 2 of 100 patients on 3rd post operative day, rest of 
patients recovered with no complications. The patients were discharged on day-3 and followed for 12 
months. No complications were noticed till 12 months. This study was performed to find the advantages 
of SSTNL over LAP Appendectomy in Tribal Areas, where the infrastructure and training facilities are 
generally low. In a similar study by AC Moberg et al; they compared the recovery time after 
Laparoscopic Vs Open appendectomy on one hundred and sixty three patients found no difference in 
recovery time, complication rates and mean hospital stay in the patients. [10] It agrees with our findings 
where we found mean hospital stay of 2 days. This shows that if this surgical procedure is performed by 
experienced surgeons its results are often comparable to Laparoscopic procedures. In another study by 
Raphael SC et al; found that Laproscopic appendectomy takes 31% longer time to perform but post 
operative pain and lower wound infection rates by 60%. [11] In tribal areas like ours where lack of 
sophisticated equipments of Laparoscopy we innovated this modified open appendectomy procedure 
SSTNL surgery. The results obtained are comparable to Laparoscopic appendectomy. Another interesting 
finding by Kristen Hall et al; found that while the laproscopic appendectomy is associated with 
statistically significant but questionable advantage over open appendectomy. This shows that although 
J  Cont  Med  A  Dent  January-April  2016  Volume  4  Issue  1  7  Laparoscopic  appendectomy  has  advantage 
over  the  conventional  appendectomy.  [12]  It  indicates  that  a  well  performed  and  carefully  done  open 
appendectomy  is  often  comparable  with  Laparoscopic  procedures.  Although  strictly  speaking  our 
procedure  is  not  a  conventionally  done  open  procedure  but it is a modified version of the open procedure 
where  a  very  small  incision  like  Button  hole  is  given  and  procedure  is  followed.  However  we  have  to 
bring  to  the  fact  that  our  surgeons  were  very  experienced  and  we  strictly  followed  the  selection  criteria 
which  are  of  utmost  importance in this kind of procedure. It may be very well considered as alternative to 
Laparoscopic  procedures  in  areas  where  there  is  lack  of  sophisticated equipments and facilities like ours. 
This  SSTNL  technique  appears  to  be  more  beneficial  in  terms  of  cost,  training,  post  operative 
complications and hospital stay over laparoscopic appendectomy. 
Conclusion The results of single stitch appendectomy where comparable to LAP 
appendectomy in terms of training, cost and hospital stay and post operative complications. The technique 
had no significant difference in peri-operative complications, post operative pain and patient satisfaction. 
Hence Single stitch Non laparoscopic appendectomy is a safe and advantageous technique in performing 
appendectomy in Hospitals where there is generally lack of sophisticated equipments. 
Conflict of Interest: None declared Source of Support: Nil Ethical Permission: Obtained 
References 
1. Prystowsky JB, Pugh CM, Nagle AP. Current problems in surgery. Appendicitis. Curr Probl Surg 
2005; 42(10):688–742. 2. Sandell E, Berg M, Sandblom G, Sundmanj, franneby U, Bostrium L, Andren 
Sandberg A. Surgical decision – making in acute appendicitis. BMC Surg 2015; 15(69):1-6. 3. McBurney 
C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method 
of operating. Ann Surg 1894; 20:38-43. 
 
K Ashok et al: Advantage Button hole, Non-laparoscopic over Laparoscopy 4. Semm K. Endoscopic appendectomy. 
Endoscopy 1983;15: 59-64. 5. Barış Mantoglu1, Bora Karip, Metin Mestan, Yalın İscan, Birol Agca, 
Hasan Altun, Kemal Memisoglu. Should appendectomy be performed laparoscopically? Clinical 
prospective randomized trial. Ulus Cerrahi Derg 2015; 31: 224-28. 6. Ciftci F. Laparoscopic Vs 
mini-incision open appendectomy. World J Gastrointest Surg 2015; 27;7(10):267-72. 7. Özsan İ, 
Karabuğa T, Yoldaş Ö, Alpdoğan Ö, Aydın Ü. Laparoscopic Appendectomy versus Mini-Incision 
Appendectomy in Patients with Lower Body Mass Index and Noncomplicated Appendicitis. 
Gastroenterology Research and Practice 2014;2014:1-4. 8. Cranen PW, Lunsford ML, Gitaldi AS, Gore 
LR. Economic impact of Laparoscopic Appendectomy in a Rural Hospital. Am Surg 2015; 81 (7): 277 – 
78. 
J Cont Med A Dent January-April 2016 Volume 4 Issue 1 8 9. Walczak DA, Pawel Czak D, Zoltuzek A, 
Jaguscik R, Falek W, Ferwonska M, Ptassinska K, Tozciak PW1 Paseka Z. Pol prezegl Chir The value of 
scoring systems for the diagnosis of Acute Appendicitis: Pol Przegl Chir 2015;87(2):65-70 2015 Feb; 
87(2):65-70.[Pubmed] 10. A.C. Moberg, F. Berndsen, I. Palmquist, U. Petersson, T. Resch and A. 
Montgomery. Randomized clinical trial of laparoscopic versus open appendicectomy for confirmed 
appendicitis. British Journal of Surgery 2005; 92(3): 298-304. 11. Raphael S C, Douglas YR, Paul Li and 
Jose D. A Meta analysis of randomized controlled trials of laparoscopic versus conventional 
appendectomy. Am J of Surgery 1998; 177(3): 250-256. 12. Kristen HL, Micheal PB, Scott PZ, Eva RH, 
William SH, C Daniel S, et al. A prospective randomized comparison of laparoscopic appendectomy with 
open appendectomy: clinical and economic analysis. Surgery 2001;129(4):390-400.