True single-port appendectomy: first experience with the "puppeteer technique"
Related Experiment Video
Updated: Jun 26, 2026
Robotic Spleen-Preserving Distal Pancreatectomy: The Warshaw and Kimura Techniques
Published on: July 26, 2024
1Department of Surgery, Section of Gastrointestinal Surgery, Yale University School of Medicine, 40 Temple Street, Suite 7B, New Haven, CT 06510, USA. kurt.roberts@yale.edu
Background:
Laparoscopic appendectomy is one of the most commonly performed minimally invasive surgeries worldwide. In recent years, successful attempts to reduce the number of the traditionally used three ports have been reported. Specifically, two-port techniques, hybrid approaches, and single-port assisted techniques have been described.
Methods:
In this case series, the author describes for the first time a successful and uncomplicated true single-port appendectomy (TSPA) technique. Between July and December of 2007, 14 consecutive patients were assigned to undergo TSPA for presumed appendicitis at Yale-New Haven Hospital. The novel approach involves an innovative "puppeteer technique," which uses a "pulley" in the form of an intraabdominally placed loop to the abdominal wall as an axle to elevate the appendix with a string. The thread is pulled by the surgeon extracorporeally, similar to a puppeteer moving the limbs of his or her puppets.
Results:
Of the 14 patients, 13 (8 women and 5 men) underwent a successful TSPA. One patient was converted to a two-port appendectomy. The average age of the patients was 37.5 years (range, 22-59 years), and the average body mass index (BMI) was 27.4 kg/m(2) (range, 19.4-39 kg/m(2)). The mean operative time was 87.5 min (range, 54-128 min). No major complications were observed. One minor postoperative complication occurred, involving urinary retention, which resolved within 24 h.
Conclusions:
The novel "puppeteer technique" seems to be a safe and easily reproducible alternative to previous laparoscopic appendectomy techniques. It uses only one single 11-mm port without any additional skin incisions or transdermally traversing needles. It is performed entirely intracorporeally, resulting in presumably less postoperative pain and improved cosmesis. Randomized controlled trials are necessary to investigate this novel technique. The TSPA technique, the first of its kind in the treatment of appendicitis, minimizes the minimally invasive approach to a new level.
