semm first introduced the laparoscopic method for appendicectomy in the early 1980s . since then laparoscopic appendicectomy ( la )
was made popular by various surgeons and preferred over the open method due to its inherent advantages .
however , this technically demanding procedure requires increased surgical time and general anesthesia with positive pressure ventilation .
also , this is an expensive procedure and requires an advanced surgical set - up and skilled surgeons , which prevent its use as routine practice in developing countries .
the laparoscopic - assisted appendicectomy ( laa ) technique has all the advantages of the laparoscopic method at less expense than the completely laparoscopic technique , with a shorter operating time as an added advantage .
the aim of our study is to evaluate the feasibility of laparoscopic - assisted appendicectomy ( laa ) using the two - port technique under local anesthesia in adults . as a pilot study we included a selected group of patients with low body mass index ( bmi ) and uncomplicated appendicitis .
we conducted a prospective study over a two - month period where laa was performed on 12 patients ( seven female and five male ) of asa grade i or ii , who presented with acute appendicitis .
inclusion criteria included  pain in the right iliac fossa , with muscle guarding , tenderness at mcburney 's point , vomiting , fever , leukocytosis , and age more than 18 years .
all the patients had a plain abdominal radiograph , routine blood tests , and a sonographic examination .
patients with generalized peritonitis , appendicular abscess or perforation , and a palpable mass were excluded from the study .
the patients who were found to have gangrenous or perforated appendicitis under laparoscopic view were excluded from this study and converted into the open technique .
all the patients were explained about the procedure and the possible conversion into open technique and written consent was taken . in the operation theater ( ot ) , an intravenous catheter was placed in the patients and ringer lactate infusion was started .
ondansetron ( 100 g / kg . ) , diazepam ( 200 g / kg . ) , and pentazocine ( 500 g / kg ) were used as premedication .
all patients were monitored for blood pressure ( non - invasive ) , heart rate , electrocardiogram , and oxygen saturation by pulse oximetry .
the infra - umbilical area and the mcburney 's point area were infiltrated with 1% lignocaine with adrenalin , keeping the dose under 6 mg / kg of body weight , to avoid lignocaine toxicity .
the pneumoperitoneum was created using carbon - di - oxide and the pressure was kept at 11 mmhg .
a 0 telescope was introduced through the umbilical port for complete examination of the abdomen .
a 10 mm trocar in the mcburney 's point area was introduced under vision , for holding the tip of the appendix .
the pneumoperitoneum was deflated after the exteriorization of the appendix through the trocar placed at the mcburney 's point .
the cut end was painted with betadine ( aqueous solution of 10% povidone - iodine ) . the appendicular stump was then reposed within the abdomen .
the patients were started oral feed immediately postoperatively and solid food on the next day .
twelve patients underwent laa with a mean age of 22.5 years ranging from 18 to 30 years , with a mean bmi of 19.25 kg / m ranging from 16.18 to 24.15 kg / m .
the appendix was in the normal position in nine patients and retro - cecal in three patients .
two cases required a 5 mm extra port to free the appendix from the adhesion .
one case was converted to open procedure due to the presence of adhesions of inflammatory origin .
no patients required conversion to general anesthesia with positive pressure ventilation or spinal anesthesia , and no patient developed signs of toxicity due to lignocaine .
two patients needed supplementation of injection ketamine 10 mg for analgesia . no postoperative complications , including wound infection ,
use of local anesthesia for surgical procedures has been steadily refined since its introduction by koller in 1884 , and it is now widely used in several surgical procedures like cholecystectomy , thyroid surgeries , and appendicectomy .
limited access for exploration , systemic toxicity due to excess amount of local anesthetics , limited duration of anesthesia , fear of failure are the reasons for avoidance of using local anesthesia for surgical procedures .
simplicity in using is the most important attraction for local anesthesia , provided the surgical procedure is limited in exploration and duration , and does not disturb the internal milieu of the human body .
it avoids the complications related to spinal , epidural or general anesthesia as well as the patients fear about the stated procedures .
the feasibility of open appendicectomy under local anesthesia was already established by sharma et al .
they found it to be cost - effective , and it also carried little morbidity and could be safely used for all age groups .
we performed laa under the mac technique , where local anesthesia was combined with sedation and analgesia .
local anesthesia was used for inserting the trocars , and sedation analgesia for creating pneumoperitoneum and excision of the appendix .
mac required less anesthesia time and avoided the related complications and cost burden of spinal or general anesthesia .
it requires less postoperative analgesia and is associated with faster recovery leading to shortened postoperative hospital stay when compared with the open technique .
it is associated with lower postoperative complications including wound infection , and better cosmetic effect than the open technique .
however , other studies where the laa technique was adopted , reported a varied number of wound infection rates .
however , it was more expensive than the open technique . performing laa under local anesthesia with the sedation analgesia technique made it even cheaper . due to its short surgical time and also shortened time requirement for administration of anesthesia ( mac ) , its overall ot engagement duration was less , which allowed more number of operations to be taken up within the stipulated time limit
. one important advantage of the laparoscopic proceeding was the outstanding overview of the abdominal cavity with the possibility of more accurate diagnosis and proper decision - making .
two - port laa is a safe and effective alternative for the management of uncomplicated appendicitis .
however , the results can not be generalized to overweight patients . when compared with the three port technique
the overall cost is less with two - port laa and it produces an even better cosmetic effect , due to the lesser number of punctures involved .
the two port technique under local anesthesia is safe in uncomplicated appendicitis among low bmi patients and should now be rigorously evaluated in a randomized controlled trial , to investigate any potential advantage of this method over the conventional laa techniques .
 aim : nowadays laparoscopic - assisted appendicectomy using the two - port technique is gaining popularity due to its certain benefits over the open version . 
 general anesthesia with positive pressure ventilation is the preferred mode of anesthesia in this technique . 
 we conducted a pilot study using the two - port technique in adult patients , with uncomplicated appendicitis under local anesthesia , to evaluate its feasibility.materials and methods : in this prospective study 12 consecutive patients of asa grade i and ii , with a mean age of 22.5 years , suffering from acute appendicitis , were included . 
 all the patients received ondansetron , diazepam , and pentazocine as premedication . 
 monitored anesthesia care was given . 
 the site of trocar insertions were infiltrated with 1% lignocaine with adrenalin . 
 the pneumoperitoneum was created using carbon - di - oxide . 
 after exteriorization of the appendix using the trocar , appendicectomy was performed as in the open procedure.resultseleven out of twelve patients were successfully operated using this method without converting it into an open method . 
 two cases required an extra port to free the appendix from the adhesion . 
 there were no intra- or post - operative complications present.conclusion:two-port laparoscopic - assisted appendicectomy under local anesthesia is a safe and effective method for uncomplicated appendicitis in adults , and the procedure is suitable where limited set - up for anesthesia is present . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION