Johan Forceps As a Knot Pusher for Extracorporeal Roeder Knot: An Inexpensive Alternative to an Endoloop Ligature in Laparoscopic Appendicectomy.

Background: Securing of the appendix stump is one of the key steps in performing laparoscopic appendicectomy (LA). This can be achieved by a variety of methods including endoloops, stapler, and clips. An alternative technique, previously described by authors, is the use of Johan forceps as a knot pusher, to deploy an extracorporeal Roeder knot at the base of appendix. We aimed to evaluate the safety and cost-effectiveness of our technique. Patients and Methods: A single surgeon's, prospective cohort, and multicenter study was undertaken at three different hospitals in the United Kingdom. We collected data of all patients, who underwent LA by this technique between 2014 and 2019. Demographics, operative findings, postoperative complications and readmissions were recorded and analyzed. Results: In total, 227 appendicectomies were performed. Median age was 24 years (interquartile range [IQR]: 16-58) with 58% male preponderance. Operative findings were 57% (n = 130) acutely inflammatory appendicitis, 16.74% (n = 38) were complicated appendicitis (perforated, gangrenous). Rest of the operative findings were macroscopically normal appendix (with no other pathology in 18.06% (n = 41), and macroscopically normal appendix but with gynecological pathologies in 7.9% (n = 18). Postoperatively, there were no cases to report complication of blow out stumps neither clinically nor radiologically. Surgical site infections rate has been 3.5% (n = 8). One patient had small intra-abdominal abscess (0.4%), treated by IV antibiotics. Mean hospital stay was 1.89 days (standard deviation [SD] 1-5 days). Thirty days readmissions rate was 4.8%. None of the complications or readmissions was related to the surgical technique. There were no deaths recorded in this series. Cost of handmade endoloop was $0.69. Conclusion: Use of Johan forceps as knot pusher for extracorporeal Roeder knot is a safe, feasible, cost-effective, and easily reproducible technique for carrying out LA.

Chronic Umbilical Discharge: An unusual presentation of endometriosis.

Umbilical endometriosis is an important differential diagnosis of any umbilical lesion. A 35-year-old type 2 diabetic woman presented with intermittent umbilical discharge which failed to respond to various antibiotics. An ultrasound scan and MRI scan failed to show any obvious abnormality. The umbilicus was excised and histology confirmed endometriosis. Surgical excision provides a definitive diagnosis and curative treatment for isolated endometriosis.