Apendicectomía laparoscópica mediante incisión única transumbilical: experiencia inicial

Single-incision laparoscopic appendectomy versus conventional laparoscopy in adults. A systematic review

PURPOSE

To determine the best treatment option for not complicated acute appendicitis (AA) in adult patients, between single incision laparoscopy (SIL) and conventional laparoscopy (CL), measured by morbidity associated with disease.

METHODS

Systematic review. Articles of adults diagnosed with AA treated by SIL or CL were analyzed. Databases included: MEDLINE, LILACS, IBECS, Web of Science, Scopus and Cochrane, using MeSH terms and free words. The studies were analyzed using the MINCIR methodology. Variables included: conversion rate, morbidity, hospital stay, surgery duration, and methodological quality (MQ) of primary studies. Averages, medians and weighted averages were calculated.

RESULTS

Thirteen articles were analyzed. For SIL and CL the conversion rate were 3.4% and 0.7 %, the morbidity were 8% and 6.5%, the hospital stay were 2.5 and 2.8 days, the surgery duration were 53.4 and 53.8 minutes, and the MQ were 14.3±6.6 and 16.0±6.9 points, respectively.

CONCLUSION

With the exception of the conversion rate, there are no differences between single incision laparoscopy and conventional laparoscopy for the treatment of acute appendicitis in adults.

Acute appendicitis can be treated with single-incision laparoscopy: a systematic review of randomized controlled trials

AIM

Single-incision laparoscopic surgery (SILS) has been proposed as the next step in minimally invasive surgery for appendicectomy. Previous reviews have summarized the results of low-evidence comparative studies, suggesting that the two approaches are comparable in terms of outcomes but showing the need for randomized controlled trials (RCTs). This review offers a meta-analyses of RCTs on this topic to evaluate the safety and efficacy of single-incision laparoscopic appendectomy (SILA).

METHOD

A comprehensive research of electronic databases was performed. Primary outcomes (overall and access-specific morbidity) were designated as safety issues. Secondary outcomes were pain, cosmesis, operative time, conversion rate and length of hospital stay.

RESULTS

After exclusions, five RCTs satisfied the inclusion criteria. They included a total of 761 patients [379 SILA and 382 conventional three-port laparoscopic appendectomies (CLA)]. No significant differences were found in overall morbidity, early wound morbidity or length of stay between SILA and CLA. Cosmesis and pain were not comparable due to different scales and time records. Conclusions on the incisional hernia rate were not reliable due to short follow-up periods.

CONCLUSION

SILA can be considered an acceptable alternative to CLA in the treatment of acute appendicitis, but an economic evaluation of the various techniques for single access must be performed before its widespread clinical introduction. Better-designed RCTs are necessary to define a population in which SILA could have major benefits.

Trans-umbilical Laparoscopic Appendectomy for Acute Appendicitis without Raising Skin-flaps: An Easy-to-use Modification Applied to the Series of 164 Patients from a Rural Institute of Central India

Background:

Laparoscopic appendectomy (LA) is widely used and generally an accepted method for managing appendicitis. And the recent invention of laparoscopic trans-umbilical-appendectomy is a further improvement of LA. However, it requires expensive instruments with the requisite expertise. We discuss a useful modification of trans-umbilical appendectomy for acute appendicitis using routine instruments.

Materials and Methods:

From August 2009 to March 2011, 164 patients were operated by this method at our rural center. Out of them, 102 were males and 62, females. Mean age for males was 27.5 years (range, 14-51) and females, 31.2 years (range, 17-48). Mean body mass index was 21.7 kg/m² (range, 16.2-29) and 23.2 kg/m² (range, 17.4-30) for males and females respectively. Acute appendicitis patients wherein surgery was deemed essential were offered this technique. Three umbilical ports (one 10 mm and two 5 mm) were strategically placed to dissect out appendix. Routine laparoscopic instruments were used for all.

Results:

Mean operativetime was 45 min (range, 30-90) with 1.8% conversion-rate to conventional laparoscopy. Average blood-loss was 15 ml (range, 10-25). We had one caecal electrosurgical injury, which was managed expectantly. Umbilical sepsis and seroma were 3% and 6.1% respectively. Patients were discharged after an average 1.3 days (range, 1-4). The scars had receded in the umbilicus giving a near-scarless abdomen.

Discussion:

Recently developed technique of single-port appendectomy has primarily been used for chronic appendicitis. Moreover, >1 inch incision inducted per-umbilicum rises the attendant morbidity. We study a surgeon-friendly simple technique applied to acute appendicitis.

Conclusion:

Method described here is feasible and safe for managing acute appendicitis. It can be learnt rather easily (learning curve of 15 cases) by a laparoscopic surgeon and avoids expensive instrumentation. Thus, it may stand out in providing benefits of modern surgery to population of developing countries.

Randomized prospective study to compare laparoscopic appendectomy versus umbilical single-incision appendectomy

INTRODUCTION

The use of single-incision laparoscopic surgery may represent an improvement over conventional laparoscopic surgery. In recent years, more and more articles have been published demonstrating the feasibility of this approach. Hence, for this reason, we present this randomized prospective study to compare the 2 techniques.

METHODS

Between September 2009 and December 2010, a total of 184 patients with a diagnosis of acute appendicitis and indicated for surgery were included in the study, of whom, 91 received an appendectomy via a single umbilical incision and 93 via conventional laparoscopy. The study protocol was approved by the ethical committee of the Virgen de la Arrixaca University Hospital (Murcia). The study was registered on ClinicalTrials.gov with inscription number NCT0151529. All the operations were performed by the same team of surgeons.

RESULTS

As far as the demographical results of the study population are concerned, there were no significant differences between the 2 groups for age, weight, sex, body mass index, and removed appendix type. Operating time was longer with the single-port approach: 38.13 ± 13.49 versus 32.12 ± 12.44 minutes (P = 0.02). Significant differences were observed for postoperative pain, which was measured on the visual analog scale, with less pain reported in the single-incision group: 2.76 ± 1.64 versus 3.78 ± 1.76 (P < 0.001). There were no significant differences between the 2 groups for early and late complications and lengths of hospital stay measured in postoperative hours.

CONCLUSIONS

The transumbilical single-port approach is seen as a feasible technique for performing appendectomy. It does not increase the rate of complications and represents a possible alternative to conventional laparoscopic appendectomy.

Abordaje transumbilical en pacientes pediátricos con diagnóstico de apendicitis aguda. Una serie de 424 pacientes

Antecedentes: El tratamiento de la apendicitis aguda implica su extirpación; es frecuente la solicitud de cicatrices postquirúrgicas del mejor tamaño posible. Una de las estrategias disponibles es el abordaje transumbilical. Objetivo: Describir las características clínicas y los desenlaces operatorios de los pacientes pediátricos en quienes se realiza apendicectomía vía transumbilical. Metodología: Estudio prospectivo de 424 pacientes sucesivos en cuanto a los desenlaces operatorios a corto plazo. Resultados: El tiempo promedio de intervención quirúrgica fue de 22 minutos; 95.8% de los pacientes presentaron evolución satisfactoria del postquirúrgico; 1.4% de los pacientes se reintervinieron para drenar un absceso intracavitario residual y 0.2% presentó infección de sitio operatorio sin más complicaciones. Conclusión: El abordaje transumbilical de la apendicitis es una alternativa mínimamente invasiva para todos los estados de apendicitis aguda e implica disminución del tiempo de realización, menor estancia del posquirúrgico, menor incidencia de complicaciones y mayor conformidad con los resultados estéticos.

Single port laparoscopic appendectomy: are we pursuing real advantages?

Single port appendectomy, due to its cosmetic appeal and to a technique similar to classic laparoscopic appendectomy, is provoking an increasing number of publications and case series to explore its feasibility and effective improvements for patients with acute appendicitis. The margins for improvement are not so large, as laparoscopic appendectomy is, after 20 years from its beginning, still debated. A literature search has been accomplished to investigate the outcomes of the operation. 23 case series or retrospective comparisons with classic laparoscopy have been found. The numbers and low quality of the published data do not permit to draw evidence based conclusions. Still, trends seem to evidence an increase in complications especially in complicated appendicitis, which suggests caution in its dissemination outside clinical trials.