Single-port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture

Using the endoscopic snare to facilitate two-port laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy is now the gold-standard treatment for acute appendicitis, requiring three ports for a classic procedure. Recent laparoscopy improvements aim to minimize surgical trauma and improve cosmetic quality through smaller, fewer portal incisions, such as two-port laparoscopic appendectomy, resulting in reduced postoperative pain. We aimed in this study to describe a novel technique to facilitate two-port laparoscopic appendectomy using the endoscopic snare.

PATIENTS AND METHODS

The data for a total of 85 patients, who underwent the two-port laparoscopic appendectomy using the endoscopic snare, at two research centers in Zagazig city, Egypt, from July 2022 till July 2023, is retrospectively analyzed. Overall length of hospital stay was the primary outcome, and the duration of operation and patient cosmetic satisfaction were secondary endpoints.

RESULTS

All the 85 laparoscopic procedures were completed without difficulty. The mean operative time was 43.78 ± 8.46 min (minimum: 34 min, maximum: 57 min). Length of hospitalization was 1.12 ± 0.74 days (min: 1 day, max: 2 days). No major complications were encountered. Four cases of minor postoperative complication occurred, in which the patient developed port site infection, which was completely resolved at one week postoperatively.

CONCLUSION

Laparoscopic appendectomy, using only two ports and endoscopic snare, is generally feasible and has been linked to high patient satisfaction and excellent cosmetic outcomes.

Single-incision versus conventional multi-incision laparoscopic appendicectomy for suspected uncomplicated appendicitis

BACKGROUND

Appendicectomy is a well-established surgical procedure to manage acute appendicitis. The operation was historically performed as an open procedure and is currently performed using minimally invasive surgical techniques. A recent development in appendicectomy technique is the introduction of single-incision laparoscopic surgery. This incorporates all working ports (either one multi-luminal port or multiple mono-luminal ports) through a single skin incision; the procedure is known as single-incision laparoscopic appendicectomy or SILA. Unanswered questions remain regarding the efficacy of this novel technique, including its effects on patient benefit and satisfaction, complications, and long-term outcomes, when compared to multi-incision conventional laparoscopy (CLA). This is an update of a review published in 2011.

OBJECTIVES

To assess the effects of single-incision laparoscopic appendicectomy compared with multi-incision laparoscopic appendicectomy, on benefits, complications, and short-term outcomes, in patients with acute appendicitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled trials (CENTRAL, the Cochrane Library 2018 Issue 2), Ovid MEDLINE (1983 to January 2024), Ovid Embase (1983 to January 2024), the WHO International Clinical Trial Register (January 2024), and Clinicaltrials.gov (January 2024). We also searched reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases. The searches were carried out on 20 January 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the single-incision procedure SILA against CLA for patients (male and female) over the age of 10 years, diagnosed with appendicitis, or symptoms of appendicitis, and undergoing laparoscopic appendicectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data into a standardised form, and assessed the risk of bias in the studies. We extracted data relevant to the predetermined outcome measures. Where appropriate, we calculated a summary statistic: odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous data and mean difference (MD) with 95% CI for continuous data. We used Review Manager Web for our statistical analysis.

MAIN RESULTS

This review was first published in 2011, when there was no RCT evidence available. For this update, we identified 11 RCTs involving 1373 participants (689 in the SILA groups and 684 in the CLA groups). The participants were similar at baseline in terms of age (mean 31.7 (SILA) versus 30.9 years (CLA)) and sex (female: 53.0% (SILA) versus 50.3% (CLA)). Diagnosis of appendicitis was based on clinical assessment; none of the studies used a diagnosis confirmed by imaging as part of their inclusion criteria. The certainty of the evidence was low to moderate, and the outcomes were predominately reported in the short term. Pain scores at 24 hours after surgery may be similar between the SILA and CLA groups (mean score SILA 2.53 versus CLA 2.65; mean difference (MD) in pain score -0.12, 95% CI -0.52 to 0.28; 294 participants, 4 RCTs; low-certainty evidence). SILA probably had superior cosmetic results as indicated by patients using the Body Image questionnaire (5 to 20) (mean score SILA 14.9 versus CLA 12.4; cosmesis score MD 1.97, 95% CI 1.60 to 2.33; 266 participants, 3 RCTs; moderate-certainty evidence). The rate of visceral and vascular injury was probably similar with both techniques (SILA 0/168 versus 4/169; OR 0.20, 95% CI 0.02 to 1.79; 337 participants, 3 RCTs; moderate-certainty evidence). The conversion rate to CLA or open surgery may be higher for SILA procedures than the conversion rate from CLA to open surgery (SILA 32/574 versus CLA 7/569; OR 2.95, 95% CI 1.36 to 6.42; 1143 participants, 9 RCTs; low-certainty evidence). Use of an additional port site was probably more likely with SILA compared to CLA (SILA 28/328 versus CLA 4/336; OR 3.80, 95% CI 1.13 to 12.72; 664 participants, 5 RCTs; moderate-certainty evidence). The recovery time was probably similar for both interventions for hospital stay (mean length of stay in hospital for SILA 2.25 days versus 2.29 days for CLA patients; MD -0.13, 95% CI -0.23 to 0.03; 1241 participants, 10 RCTs; moderate-certainty evidence) and time to return to normal activities (SILA 9.28 days versus CLA 10.0 days; MD -0.59, 95% CI -1.99 to 0.81; 451 participants, 4 RCTs; moderate-certainty evidence). We have low-to-moderate confidence in our findings due to differences in the measurement of certain outcomes, and lack of blinding in the studies, which makes them prone to performance bias.

AUTHORS' CONCLUSIONS

There is low-to-moderate certainty evidence that single-incision laparoscopic appendicectomy is comparable to conventional laparoscopic appendicectomy in terms of complications, length of hospital stay, return to normal activities, and postoperative pain in the first 24 hours. The disadvantage of SILA may be a higher conversion rate, but SILA is probably associated with better patient cosmetic satisfaction.

Addition of Transfixation Suture to Purse String Suture During Intraperitoneal Inguinal Hernia Repair Increases Peri-Hernia Sac Neck Collagen Formation

BACKGROUND

The worldwide accepted repair for indirect inguinal hernia in children is high ligation of the hernia sac with open herniotomy. However, laparoscopic pediatric inguinal hernia repair (IHR) has been gaining popularity in the last two decades. An experimental study was conducted to investigate the effects of different intraperitoneal IHR suture techniques on the collagen formation at the hernia sac neck.

METHODS

Present study was conducted on thirty-five male adult (3-6 months old) Wistar-Albino rats (260-300 g). Intraperitoneal IHR with different hernia sac neck suturing techniques (purse string suture only, transfixation suture only and purse string suture plus transfixation suture) were performed through median laparotomy using open operative techniques. Non-absorbable 2/0 braided polyester suture with 16 mm 1/2 curved round needle (Ti-cron, Covidien, MN) was used as suture material.

RESULTS

The highest collagen thickness around the suture was detected in intraperitoneal IHR with purse-string plus transfixation suture group. The collagen thickness of the intraperitoneal IHR with purse string suture only and IHR with tranfixation suture only groups were not statistically significantly different. The collagen thickness of the intraperitoneal IHR with purse string suture plus transfixation suture group was statistically significantly higher compared with the intraperitoneal IHR with purse string suture only and intraperitoneal IHR with transfixation suture only groups.

CONCLUSIONS

The combined usage of purse string suture and transfixation suture during laparoscopic intraperitoneal inguinal hernia repair further stimulates mesothelial fibrosis at the hernia sac neck compared with mesothelial fibrosis induced by purse string suture only or transfixation suture only.

Hybrid Appendectomy in Pediatric Appendicitis: A Comparative Analysis of Single-Port and Multiport Laparoscopic Appendectomy

Background: Hybrid appendectomy (HA) has the technical advantages of the excellent visual field provided by laparoscopic surgery and is fast and easy similar to open surgery. We aimed to compare the safety and effectiveness of HA with single- and multiport laparoscopic appendectomy (SPLA and MPLA) in pediatric patients with acute appendicitis. Materials and Methods: This retrospective study compared the short-term operative outcomes between HA, SPLA, and MPLA groups. From January, 2010 to December, 2019, 239 patients aged <12 years who underwent laparoscopic appendectomy for acute appendicitis were included. The primary outcome was the 30-day postoperative complication rate, stratified according to the modified Clavien-Dindo classification. Results: In 239 patients, HA was more frequently performed in patients with a low body mass index (17.42 versus 18.97 kg/m² in the SPLA group versus 18.44 kg/m² in the MPLA group, P = .029) and tended to be more frequently adopted in uncomplicated appendicitis. In uncomplicated appendicitis, the HA group had a significantly shorter operation time than the MPLA group (31.77 versus 40.09 min, P < .001), but had a comparable operation duration with the SPLA group. The rate of 30-day postoperative complications was not significantly different between the groups (HA 7.6% versus SPLA 7.8% versus MPLA 5.4%, P = .841). The postoperative time to resume water intake was significantly longer in the SPLA group than in the HA and MPLA groups (P = .008). Conclusions: HA showed a short operation time, fast functional recovery, and acceptable postoperative complication rate in patients with uncomplicated appendicitis and can be safely and effectively performed in these patients.

Left Paraduodenal Hernia Treated With Single-Incision Laparoscopic Surgery: Report of a Case

Paraduodenal hernia is traditionally repaired via conventional laparotomy. Recently, several reports described the repair of paraduodenal hernia via laparoscopic surgery with multiple ports. Due to development of the technique and devices for laparoscopic surgery, single-incision laparoscopic surgery (SILS) has been applied to various operations, including cholecystectomy, appendectomy, and procedures for colorectal cancer. Here, we report treatment of a left paraduodenal hernia via SILS. A 23-year-old man presented with abrupt onset of abdominal pain, nausea, and vomiting. Computed tomography revealed a mass of intestinal loops enveloped by a thin capsule on the left of the abdominal cavity. Blood circulation in the jejunal loops was preserved, and no dilatation of the jejunum was observed. Physical and radiographic examination indicated the possibility of left paraduodenal hernia; we performed paraduodenal hernia repair using SILS. After we confirmed that there was no strangulation or gangrenous change in the bowel on laparoscopic examination, we reduced the incarcerated jejunum loops via an atraumatic method. The postoperative course was uneventful, and the patient was discharged 8 days after the operation. This disease affects relatively young patients, rendering this operation attractive from the viewpoint of cosmetic benefits and minimal invasion. Paraduodenal hernia repair via SILS is feasible, safe, and may constitute an alternative method for paraduodenal hernia without necrotic change.

Single-Incision Versus Conventional Laparoscopic Appendectomy: A Multi-Center Randomized Controlled Trial (SCAR trial)

Introduction:

Although single-incision laparoscopic appendectomy (SILA) was introduced decades ago, it is still considered a difficult technique to perform compared to conventional laparoscopic appendectomy (CLA). In addition, controversy about the benefits of SILA compared to CLA abound and no definite criteria for choosing SILA over CLA in patients with appendicitis currently exist. Therefore, we have planned a multi-center randomized controlled trial to compare SILA with CLA in terms of cosmetic satisfaction and pain reduction.

Methods and analysis:

Patients diagnosed with appendicitis at the participating centers will be recruited and allocated into either a CLA or an SILA groups using a 1:1 randomization. Patients in the CLA group will receive a conventional 3-port laparoscopic appendectomy and patients in the SILA group will receive a laparoscopic appendectomy using a single-incision at the umbilicus. The primary trial endpoint is cosmetic satisfaction assessed using the Patients and Observer Scar Assessment Scale (POSAS) administered 6 weeks post-surgery. Secondary trial endpoints include cosmetic satisfaction assessed via the Body Image Questionnaire, pain levels assessed via the Visual Analog Scale and International Pain Outcomes questionnaire, and the presence of postoperative complications. The target sample size of this superiority trial is 120 patients, as this will provide 80% power at the 2.5% level of significance to detect a 3-point difference in POSAS.

Discussion:

The results of this planned multi-center randomized controlled trial will provide substantive evidence to help surgeons choose when to use SILA over CLA in patients with appendicitis.

Ethics and dissemination:

This trial was approved by the institutional review board at Daegu joint on February 27, 2020 (No: 19-12-001-001) and registered with the clinical research information service (CRIS) (KCT0005048). The results of the study will be published and presented at appropriate conferences.

Highlights

Successful outcomes in adolescent varicocele treatment with high-level laparoscopic varicocelectomy

PURPOSE

In this study, we aimed to compare the effects of testicular vein ligation level on complications encountered; i.e. high-level ligation cranial to the linea terminalis vs ligation caudal to the linea terminalis.

METHODS

A total of 47 unilateral adolescent patients, treated with laparoscopic varicocelectomy between January 2004 and December 2017, were reviewed retrospectively. Patients were divided into two groups in terms of ligation level: caudal to the linea terminalis as group 1 and cranial to the linea terminalis as group 2. Symptoms, varicocele grades, preoperative testicular growth arrest, operative method, hydrocele formation, postoperative recurrence and testicular catch-up growth were recorded.

RESULTS

The mean operation time was 38.6 ± 10.2 min (34-53 min) in group 1 and was 33.6 ± 6.4 min (29-42 min) in group 2. Single hydrocele occurred in the laparoscopic nonselective varicocelectomy in group 1 (4.5%) and was successfully treated with open hydrocelectomy. Single varicocele recurrence was observed in the laparoscopic selective varicocelectomy in group 1 (4.5%) and treated with laparoscopic nonselective varicocelectomy cranial to the linea terminalis.

CONCLUSIONS

The high-level ligation of the spermatic veins cranial to the linea terminalis during laparoscopic varicocelectomy, independent of the technique applied, may contribute to reasonable low hydrocele and recurrence rates.

LEVEL OF EVIDENCE

Level III.

Indirect inguinal hernia repair conducted with single conventional port intracorporeal conventional equipment-endoscopic surgery

PURPOSE

Laparoscopic or laparoscopy-assisted inguinal hernia repair (IHR) can be performed using one port plus two stab wounds. We herein present our experience with laparoscopic IHR conducted using a single conventional port and a single working instrument.

METHODS

The records patients who underwent single conventional port intracorporeal IHR during November 2013-December 2018 were evaluated. The main outcome measurements were patient's demographic characteristics, hernia side, presence of incarceration, operative time, and complications.

RESULTS

A total of 132 inguinal hernias (52 right, 40 left, and 20 bilateral) were repaired in 112 patients (76 boys, 36 girls). The mean ages of the patients were 69.8 ± 53.4 months (3 months to 17 years). In six patients, contralateral processus vaginalis was found to be patent during operation. Incarcerated inguinal hernia was present in two patients. Mean operative time was 17.9 ± 3.8 min (9-30 min) in unilateral hernias and 28.9 ± 6.5 min (24-45 min) in bilateral hernias. No intraoperative and postoperative complications were encountered. The mean hospital stay of the patients was 8.8 ± 5.0 h (4-36 h). Postoperative follow-up was 16.5 ± 5.1 months (6-24 months). No recurrent inguinal hernias were detected during follow-up.

CONCLUSION

Single conventional port intracorporeal IHR obviates additional stab wounds. Additionally, present technique eliminates the risk of skin puckering, subcutaneous granuloma, infection, nerve, and muscle damage development induced by the subcutaneously placed knot in laparoscopy-assisted IHR. Single conventional port intracorporeal IHR in children is a feasible and safe operative technique with low complication rates.

COMPARISON BETWEEN INCIDENCE OF INCISIONAL HERNIA IN LAPAROSCOPIC CHOLECYSTECTOMY AND BY SINGLE PORT

Background:

Surgeries with single port access have been gaining ground among surgeons who seek minimally invasive procedures. Although this technique uses only one access, the incision is larger when compared to laparoscopic cholecystectomy and this fact can lead to a higher incidence of incisional hernias.

Aim:

To compare the incidence of incisional hernia after laparoscopic cholecystectomy and by single port.

Methods:

A total of 57 patients were randomly divided into two groups and submitted to conventional laparoscopic cholecystectomy (n=29) and laparoscopic cholecystectomy by single access (n=28). The patients were followed up and reviewed in a 40.4 month follow-up for identification of incisional hernias.

Results:

Follow-up showed 21,4% of incisional hernia in single port group and 3.57% in conventional technique.

Conclusions:

There was a higher incidence of late incisional hernia in patients submitted to single port access cholecystectomy compared to conventional laparoscopic cholecystectomy.

Single-Incision Versus Three-Port Laparoscopic Appendectomy: Short- and Long-Term Outcomes

AIM

To compare the outcome of patients who had undergone single-incision laparoscopic appendectomy (SILA) with others who had undergone three-port laparoscopic appendectomy (3-PORT).

MATERIALS AND METHODS

Data from all adults with uncomplicated appendicitis treated by laparoscopic appendectomy between June 2012 and December 2015 were prospectively collected. Patients with chronic pain, appendix malignancy, at least two previous laparotomies, and those undergoing concomitant surgery for different condition were excluded from analysis. Postoperative pain was assessed by a visual analog scale (VAS). Patients were reviewed postoperatively at 7 days and 1 month in the outpatient clinic. Late complications were assessed with a telephonic interview.

RESULTS

A total of 91 patients were included (46 SILA; 45 3-PORT). There were 16 males and 30 females in the SILA group (mean age = 26.76 ± 10.58 years) and 18 males and 27 females in the 3-PORT group (mean age = 26.84 ± 10.79 years). The mean operative time for SILA was 48.54 ± 12.80 min, for the 3-PORT group the mean operative time was 46.33 ± 15.54 min (P = 0.46). No case required conversion. Mean postoperative hospital length of stay was 1.87 ± 0.69 days for SILA and 2.38 ± 1.11 days for 3-PORT (P = 0.01). VAS value of 3.91 ± 1.96 and mean ketorolac usage of 0.38 ± 0.65 in 3-PORT group and SILA patients reported 3.70 ± 1.58 and 0.39 ± 0.58, respectively (P = 0.91). Our mean follow-up in SILA group was 25.75 ± 10.82 months, for 3-PORT group the mean follow-up was 26.9 ± 11.8 months. Eleven patients missed long-term follow-up. No incisional hernia was found. There is a statistically significant difference in cosmetic evaluation in favor of SILA (P < 0.005).

CONCLUSIONS

There was no difference in operative time, early complications, postoperative pain, analgesia requirement between SILA and 3-PORT laparoscopic appendectomy, but after SILA procedure discharge was quicker and long-term cosmetic satisfaction was superior.

Two-port laparoscopic appendectomy assisted with needle grasper comparison with conventional laparoscopic appendectomy

Purpose

The 2-port laparoscopic appendectomy technique (TLA) is between the conventional 3-port and single-port laparoscopic appendectomy surgeries. We compared postoperative pain and cosmetic results after TLA with conventional laparoscopic appendectomy (CLA) by a 3-port device.

Methods

Patients undergoing TLA were matched with patients undergoing CLA between February 2015 and November 2015 at the same institution. Thirty-two patients underwent TLA with a needle grasper. The appendix was secured by a percutaneous organ-holding device (needle grasper), then removed through a puncture at McBurney's point. Another 38 patients underwent CLA. Patient demographics, operative details, and postoperative outcomes were collected and evaluated.

Results

One patient in the TLA group developed a wound infection and 1 patient in the CLA group developed a postoperative intra-abdominal abscess and 3 wound infections. There was no significant difference between the groups when comparing the length of hospital stay, time until oral intake, and other complications. The pain score in the first 12 hours after surgery was significanly higher in CLA group than the TLA group (P < 0.001). Operative time was significantly shorter in the CLA group compared to the TLA group (P < 0.001).

Conclusion

TLA using a needle grasper was associated with a significantly lower pain score 12 hours after surgery, better cosmetic results, and lower cost, than the CLA 3-port procedure because of the fewer number of ports.

A cost and outcome analysis of pediatric single-incision appendectomy

BACKGROUND

For appendicitis, single-incision laparoscopic appendectomy (SIA) has been proposed as an alternative to 3-port appendectomy (3PA). However, there remains controversy regarding outcomes and cost of SIA. We sought to review our experience with these two techniques to identify differences in these factors.

MATERIALS AND METHODS

The charts of children (0-17 y) who underwent appendectomy at a tertiary pediatric hospital from 2011-2014 were retrospectively reviewed. Appendectomy was either performed through traditional 3PA or SIA (laparoscopically assisted via externalization through an umbilical incision). Demographic data including age, body mass index, comorbidities, and gender were examined. Information on perforation, operative time and cost, length of stay, and infectious complications for both SIA and 3PA was identified. Data were analyzed using student t tests and chi square analysis.

RESULTS

A total of 337 patients underwent appendectomy (141 SIA and 197 3PA), 35.6% of whom (40 SIA, 80 3PA) had perforated appendicitis. For nonperforated appendicitis, SIA had significantly shorter operative times, decreased operative costs, and length of stay. However, these differences were not found for perforated appendicitis. Regardless of appendicitis severity, there was no difference in rates of wound infection, abscess, or readmission between the two techniques.

CONCLUSIONS

Our study suggests that SIA is a faster, more cost effective alternative than 3PA for acute appendicitis. SIA did not result in increased infection rates for acute or perforated appendicitis and can be considered an equivalent alternative to 3PA in the surgical management of appendicitis.

Two-port laparoscopic appendectomy with the help of a needle grasper: better cosmetic results and fewer trocars than conventional laparoscopic appendectomy

INTRODUCTION

The two-port laparoscopic appendectomy technique (TPLA) lays between the conventional three-port trocar procedure and single-port laparoscopic appendectomy surgery. During TPLA, the appendix is suspended with stitches, resulting in perforation risk and difficulty in exploration.

AIM

We used a needle grasper in TPLA to hang and manipulate the appendix.

MATERIAL AND METHODS

Thirty-four patients (10 female, 24 male) who underwent TPLA between February 2015 and November 2015 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. The needle grasper was inserted at the right under the abdominal quadrant (McBurney point) without an incision to hang and manipulate the appendix.

RESULTS

The mean age was 25.19 ±8.464 years; the mean body mass index (BMI) was 23.50 ±3.246 kg/m(2). ASA scores were 1 and 2. The operations were completed without any additional trocar in 34 patients. The mean operation time was 57.03 ±3.814 min. There were no intraoperative complications in any patients. Three patients required a drain; all were discharged after drain removal. Thirty-one patients were discharged on the 1(st) postoperative day; three patients with drains were discharged on the 2(nd) day. The mean hospital stay period was 1.18 ±0.535 days.

CONCLUSIONS

Using the needle grasper, the appendix was held and suspended and the mesoappendix was cauterized and skeletonized successfully in TPLA. Inserting a needle grasper into the abdominal cavity at the McBurney point to manipulate the appendix helps and does not leave a visible scar.

Single-Port Laparoscopic Interval Appendectomy for Perforated Appendicitis With a Periappendiceal Abscess

PURPOSE

Nonoperative management followed by an interval appendectomy is a commonly used approach for treating patients with perforated appendicitis with abscess formation. As minimally-invasive surgery has developed, single-port laparoscopic surgery (SPLS) is increasingly being used to treat many conditions. We report our initial experience with this procedure using a multichannel single-port.

METHODS

The study included 25 adults who underwent a single-port laparoscopic interval appendectomy for perforated appendicitis with periappendiceal abscess by using a single-port with or without needlescopic grasper between June 2014 and January 2016.

RESULTS

Of the 25 patients, 9 (36%) required percutaneous drainage for a median of 7 days (5-14 days) after insertion, and 3 (12%) required conversion to reduced-port laparoscopic surgery with a 5-mm port insertion because of severe adhesions to adjacent organs. Of 22 patients undergoing SPLS, 13 underwent pure SPLS (52.0%) whereas 9 patients underwent SPLS with a 2-mm needle instrument (36.0%). Median operation time was 70 minutes (30-155 minutes), and a drainage tube was placed in 9 patients (36.0%). Median total length of incision was 2.5 cm (2.0-3.0 cm), and median time to soft diet initiation and length of stay in the hospital were 2 days (0-5 days) and 3 days (1-7 days), respectively. Two patients (8.0%) developed postoperative complications: 1 wound site bleeding and 1 surgical site infection.

CONCLUSION

Conservative management followed by a single-port laparoscopic interval appendectomy using a multichannel single-port appears feasible and safe for treating patients with acute perforated appendicitis with periappendiceal abscess.

One-trocar versus multiport hybrid laparoscopic appendectomy: What's the best option for children with acute appendicitis? Results of an international multicentric study

BACKGROUND

One-trocar laparoscopic appendectomy (OTA) is routinely adopted in children with acute appendicitis. In case of a difficult appendectomy, it is necessary to add additional trocar/s to safely complete the procedure. This technique is called multiport hybrid laparoscopic appendectomy (HLA). We aimed to compare the outcome of multiport HLA versus OTA.

METHODS

We retrospectively reviewed the data of 1,092 patients underwent LA in 5 European centers of pediatric surgery in the last 5 years. We compared 2 groups: G1 of 575 patients (52.6 %) (average age 10 years) underwent OTA and G2 of 517 patients (47.4 %) (average age 8.2 years) underwent multiport HLA.

RESULTS

No intra-operative complications occurred in both groups. An additional pathology was treated in 12 cases (8 Meckel's diverticulum, 2 carcinoids, 2 ovarian cysts) in G2. Operative time was significantly shorter in G2 compared to G1 (47.8 vs 58.6 min; p < .001). The average analgesic requirement was significantly shorter in G2 compared to G1 (44 vs 56 h; p < .001). As for postoperative complications, the incidence of port-site infections was similar between the two groups, while the incidence of postoperative abdominal abscesses (PAA) was significantly higher in G1 compared to G2 (4.7 vs 0.2 %; p < .001). The cosmetic outcome was excellent in all patients of both groups. A subgroup analysis between complicated and uncomplicated appendicitis showed that only in complicated cases, the average operative time, the average VAS pain score, the average analgesic requirements and the incidence of PAA were significantly higher in OTA group compared to multiport HLA group (p < .001).

CONCLUSIONS

Our results suggest that OTA is a valid and safe procedure for the uncomplicated cases, while additional trocars are required in case of complicated appendicitis. Multiport HLA significantly reduces the operative time, the incidence of abdominal abscesses and the analgesic requirements compared to OTA.

Conventional single-port laparoscopic appendectomy for complicated appendicitis in children: Efficient and cost-effective

BACKGROUND:

Laparoscopic appendectomy (LA) is gradually gaining popularity among paediatric surgeons for complicated appendicitis. A retrospective study was conducted to compare conventional single port LA, multiport LA and open appendectomy (OA) for complicated appendicitis in children.

PATIENTS AND METHODS:

From January 1995 from December 2014, 1,408 patients (604 girls, 804 boys) underwent surgery for uncomplicated and complicated appendicitis. The patient characteristics, operation times, duration of hospitalization, operative costs, and postoperative complications were recorded. A 10-mm 0^° scope with a parallel eye piece and an integrated 6 mm working channel were inserted through an 11-mm “conventional umbilical port” for single port LA.

RESULTS:

A total of 314 patients with complicated appendicitis (128 girls, 186 boys) underwent appendectomy. Among these, 102 patients (32.4%) underwent single port LA, 17 patients (5.4%) underwent multiport LA and 195 patients (62.1%) underwent OA. The hospital stay of the single port LA group was significantly less (3.88 ± 1.1) compared with multiport LA (5.41 ± 1.2) and OA groups (6.14 ± 1.1) (P < 0.001). Drain usage, wound infection and adhesive intestinal obstruction rates were significantly high in the OA group. There was no significant difference between the groups in postoperative intraabdominal abscess formation. Single-port LA performed for complicated appendicitis was cheaper compared with the other groups.

CONCLUSIONS:

The present study has shown that single-port LA for complicated appendicitis can be conducted in a reasonable operative time; it shortens the hospitalization period, markedly reduces postoperative wound infection and adhesive intestinal obstruction rates and does not increase the operative cost.

A Novel and Scarless Laparoscopic Appendectomy Technique: Two Ports in a Single Incision Plus One Puncture Without Trocar

Single-port laparoscopic appendectomy (SILS-A) is now being performed in a great number of patients. However, SILS-A requires extended operation time and does not markedly decrease postoperative pain or improve cosmesis. To solve these problems, we developed a new technique for laparoscopic appendectomy that relies on 2 ports in a single incision plus 1 puncture (POP-SILS), and we can prove that this useful technique allows SILS-A to be easier and more cosmetic. The cases of 112 patients treated by laparoscopic appendectomy (LA) at our hospital between 2010 and 2013 were studied retrospectively. Forty-one were cases of locally complicated appendicitis, and 71 were cases of simple appendicitis. In laparoscopic appendectomy with POP-SILS, we maintain instrument triangulation using two 5-mm ports in the umbilicus and needle instruments that are introduced by puncture above the pubic bone. We studied the safety and usefulness of this method from the standpoint of operation time, postoperative stay, and complications. From 2010 to 2013, we performed 77 POP-SILS-LAs. Thirty-five patients required 1 or more additional ports or underwent conventional LA. The time required for POP-SILS-LA was 54 minutes (range, 23–209) in cases of simple appendicitis. Even in 17 cases of locally complicated appendicitis, POP-SILS-LA was successful. There was no statistical difference in surgical complications between POP-SILS-LA and multiport LA. Both the umbilical scar and the puncture scar eventually became invisible. The outcomes in our patient series showed POP-SILS-LA to be a safe and beneficial, minimally invasive approach to laparoscopic appendectomy.

The SCARLESS Study Group. Single port/incision laparoscopic surgery compared with standard three-port laparoscopic surgery for appendicectomy: a randomized controlled trial

BACKGROUND AND OBJECTIVE

The aim of this study was to compare the effectiveness of single port/incision laparoscopic surgery (SPILS) with standard three-port laparoscopic surgery for appendicectomy in adults. Feasibility data was collected to evaluate generalizability to other single-port techniques such as cholecystectomy.

METHODS

This was a single-center, randomized controlled trial. Participants were randomized to receive either SPILS or standard three-port laparoscopic appendicectomy. The primary patient-reported outcomes were body image and cosmesis at 6 weeks. The primary clinical outcome was pain at 1-7 days. Secondary outcomes included duration of operation, conversion rates, complication rates, use of analgesia, hospital re-admission rates, re-operation rates, and time to return to normal activities.

RESULTS

Seventy-nine patients were randomized. Sixty-seven completed the day 1-7 diary and 53 completed the 6-week follow-up. SPILS patients answered significantly more favorably to the items in the body image scale [mean (SD) 5.6 (1.0) vs. 7.0 (3.3); -1.4 (95 % CI -2.8 to 1.5; p = 0.03)] and the cosmetic scale [18.9 (4.1) vs. 15.3 (5.8); 3.6 (95 % CI 0.7-6.5; p = 0.016)] compared with patients in the Standard group. The duration of operation was shorter for SPILS, and patients required less morphine in recovery; however, there were no statistically significant differences in other outcomes.

CONCLUSIONS

Patient-reported body image and cosmesis outcomes were better, and surgical outcomes were similar following SPILS. However, the SPILS procedure is more technically demanding and may not be achievable or necessary in routine clinical care. Further assessment of the findings is needed through larger multicenter studies.

Comparison of postoperative pain between single-incision and conventional laparoscopic appendectomy in children

INTRODUCTION

The aim of this study was to evaluate differences in postoperative pain between single-incision laparoscopic appendectomy (SLA) and conventional laparoscopic appendectomy (CLA) for uncomplicated appendicitis in children.

METHODS

In total, 30 patients underwent CLA, and 12 patients underwent SLA. Patients with perforated appendicitis or an abscess were excluded. We evaluated the length of hospital stay, the frequency of postoperative analgesic requirement, and the duration of postoperative pain.

RESULTS

The mean length of hospital stay was 3.67 ± 0.75 days for the CLA group and 4.0 ± 0.70 days for the SLA group. The mean frequency of postoperative analgesic requirement was 1.93 ± 1.63 times for the CLA group and 2.00 ± 1.00 times for the SLA group. The mean duration of postoperative pain was 52.63 ± 20.82 hours for the CLA group and 55.91 ± 18.45 hours for the SLA group. These postoperative outcomes were similar between the two groups.

CONCLUSION

Our study suggests that SLA, which results in similar postoperative pain as CLA, is a feasible technique for uncomplicated appendicitis in children.

Single-incision videolaparoscopic appendectomy with conventional videolaparoscopy equipment

Background

Acute appendicitis is the most common surgical emergency in daily practice, and is approached laparoscopically in many centers. Efforts have been undertaken for the development of minimally invasive techniques that reduce tissue trauma and offer improved cosmetic results, one of such being the single-incision laparoscopic surgery (SILS).

Aim

To present a minimally invasive technique for appendectomy (SILS) undertaken with conventional instruments.

Method

Eleven patients were treated in the emergency care center presenting abdominal pain in the right iliac fossa that was suggestive of appendicitis. Diagnostic investigation was subsequently conducted, including physical examination, laboratory and imaging exams (CT scan with intravenous contrast or total abdominal ultrasound), and the results were consistent with acute appendicitis. Thus, after consent, these patients underwent SILS appendectomy under general anesthesia with three trocars (two 10 mm and one 5 mm), using conventional and optical laparoscopic tweezers (10 mm, 30º). The base and pedicle of the appendix were ligated with titanium LT 400 clips. The procedure occurred uneventfully. Inclusion criteria were absence of diffuse peritonitis, BMI (body mass index) less than 35 and absence of serious comorbidities or sepsis.

Results

Seven men and four women were operated with average age of 25.7 years and underwent appendectomy through this technique. Mean procedure duration was of 37.2 min. Regarding surgical findings, three had appendicitis in stage 1, four in stage 2 and four in stage 3. All patients improved well, without surgical complications, and did not require conversion to open surgery or conventional laparoscopy technique.

Conclusion

Appendectomy conducted through Single Incision Laparoscopic Surgery is a feasible and promising technique that can be performed with conventional laparoscopic instruments.

Outcomes of a single-port laparoscopic appendectomy using a glove port with a percutaneous organ-holding device and commercially-available multichannel single-port device

Purpose

A laparoscopic appendectomy is now commonly performed. The push in recent years toward reducing the number of ports required to perform this surgery has led to the development of a single-port laparoscopic appendectomy (SPA). We compared postoperative pain after an SPA using a glove port with a percutaneous organ-holding device (group 1) with that of an SPA using a commercially-available multichannel single-port device (group 2).

Methods

Between March 2010 and July 2011, a retrospective study was conducted of a total of 77 patients who underwent an SPA by three surgeons at department of surgery, Kangbuk Samsung Medical Center. Thirty-eight patients received an SPA using a glove port with a percutaneous organ-holding device. The other 39 patients received an SPA using a commercially-available multichannel single port (Octo-Port or SILS Port). Operative details and postoperative outcomes were collected and evaluated.

Results

There were no differences in the mean operative times, times to pass gas, postoperative hospital stays, or cosmetic satisfaction scores between the two groups. The pain score in the first 24 hours after surgery was higher in group 2 than group 1 patients (P < 0.001). Furthermore, the trocar used in group 2 was more expensive than that used in group 1.

Conclusion

An SPA using a glove port with a percutaneous organ-holding device was associated with a lower pain score during the first 24 hours after surgery because of the shorter fascia incision length and a cheaper cost than an SPA using a commercially-available multichannel single-port device.

Two-port laparoscopic appendectomy as transition to laparoendoscopic single site surgery

BACKGROUND:

According to the precepts of reduced surgical trauma and better cosmesis, an intermediate laparoscopic appendectomy technique between the conventional three-trocar procedure and Laparoendoscopic Single Site Surgery (LESS) was performed, based on literature review and experience of the surgical team.

PATIENTS AND METHODS:

Patients with early stage acute appendicitis and a favourable anatomical presentation were selected. The procedure was performed with two ports: A 10 mm trocar at the umbilicus site for laparoscope and a 5 mm one just above the pubic bone for grasper. The appendix was secured by external wire traction through a right iliac fossa puncture with 14-gauge intravenous catheter.

RESULTS:

From August 2009 to December 2012, we performed 42 cases; two required conversion to a conventional laparoscopic technique. There were no complications in the remaining, no wound infections and a mean operation time of 64.5 minutes.

CONCLUSION:

The use of two-port laparoscopic appendectomy can act as a LESS intermediate step procedure, without loss of instrumental triangulation and maintenance of appropriate counter-traction. This technique can be used as an alternative to the three-port laparoscopic procedure in patients with initial presentation of appendicitis and a favourable anatomical position.

Laparoscopic appendectomy: State of the art. Tailored approach to the application of laparoscopic appendectomy?

Acute appendicitis is the most common surgical emergency in developed countries. The treatment of acute appendicitis is either open or laparoscopic appendectomy. The latter has gained wide acceptance in the past years, although the debate on the true merits of laparoscopic appendectomy is still on going. Some authors prefer this approach as the gold standard for all patients, but in our opinion a tailored approach is warranted for specific patient groups. In addition, a standardised guideline on the technical aspects is still lacking. In the current article, open versus laparoscopic appendectomy and several technical aspects, such as stump closure, appendix extraction and single incision are discussed laparoscopic appendectomy are being addressed. In the future perspectives we will briefly discuss the third 'newly' introduced antibiotic treatment.

Overview of single-port laparoscopic surgery for colorectal cancers: past, present, and the future

Single-port laparoscopic surgery (SPLS) is implemented through a tailored minimal single incision through which a number of laparoscopic instruments access. Introduction of operation-customized port system, utilization of a camera without a separate external light, and instruments with different lengths has brought the favorable environment for SPLS. However, performing SPLS still creates several hardships compared to multiport laparoscopic surgery; a single-port system inevitably leads to clashing of surgical instruments due to crowding. To overcome such difficulties, investigators has developed novel concepts and maneuvers, including the concept of inverse triangulation and the maneuvers of pivoting, spreading out dissection, hanging suture, and transluminal traction. The final destination of SPLS is expected to be a completely seamless operation, maximizing the minimal invasiveness. Specimen extraction through the umbilicus can undermine cosmesis by inducing a larger incision. Therefore, hybrid laparoscopic technique, which combined laparoscopic surgical technique with natural orifice specimen extraction (NOSE)--i.e., transvaginal or transanal route-, has been developed. SPLS and NOSE seemed to be the best combination in pursuit of minimal invasiveness. In the near future, robotic SPLS with natural orifice transluminal endoscopic surgery's way of specimen extraction seems to be pursued. It is expected to provide a completely or nearly complete seamless operation regardless of location of the lesion in the abdomen.

Transumbilical single-incision laparoscopic appendectomy using conventional instruments: the single working channel technique

BACKGROUND

This study aimed to evaluate the feasibility, safety, and cosmetic results of a novel technique, transumbilical single-incision laparoscopic appendectomy (TSILA), using a single working channel with conventional instruments.

PATIENTS AND METHODS

The study enrolled 84 consecutive patients undergoing laparoscopic appendectomy for acute appendicitis. To test the advantages of TSILA on the management of patients with acute appendicitis, a prospective randomized clinical trial was conducted. Surgical outcomes such as operation time, complication, and hospital stay of 42 patients undergoing TSILA were analyzed and compared with those of 42 patients undergoing classic 3-port appendectomy. All patients received a follow-up visit for 3 to 12 months.

RESULTS

The study consisted of 42 patients undergoing TSILA and 42 patients undergoing classic 3-port laparoscopic appendectomy with an average age of 34.1 and 34.9 years, respectively. The mean operative time of TSILA did not show any difference when compared with the classic procedure (84.8 vs. 77.9 min, P=0.271). No operative complications occurred in patients undergoing TSILA, whereas 2 patients undergoing the classic procedure showed incisional infection. The average postoperative hospital stay was 2.7 days in the TSILA group and 2.9 days in the classic procedure group with no difference (P=0.316). At the follow-up visit, no patient showed any evidence of incisional hernia. The transumbilical incisions were visible minimally, and the cosmetic scores given by patients undergoing TSILA was higher than that given by patients undergoing the classic procedure (4.5 vs. 3.9, P<0.001).

CONCLUSIONS

The results of the study demonstrate that laparoscopic appendectomy can be achieved through a single umbilical incision and a single working channel using conventional instruments and that this approach is successful, safe, economic, and esthetic.

Laparoscopy utilization and outcomes for appendicitis in small children

PURPOSE

To examine the trends in laparoscopic appendectomy (LA) utilization and outcomes for children 5 years or younger.

METHODS

We studied 16,028 inpatient admissions for children 5 years of age or less undergoing an appendectomy for acute appendicitis in 2000, 2003, and 2006 using the Kids' Inpatient Database (KID). Laparoscopy frequency, hospital length of stay, and complications were reviewed.

RESULTS

In 2000, 2003 and 2006 appendectomies were done laparoscopically 11.4%, 18.7% and 31.3% of the time, respectively. Children were more likely to undergo LA at a children's hospital (P<0.001). LA complications were less likely overall (OR: 0.80, CI: 0.70-0.92, P=0.002) and in perforated cases (OR: 0.78, CI: 0.67-0.91, P=0.001). LA decreased hospital length of stay by 0.54 days for all patients and 0.70 days for perforated cases (P<0.001).

CONCLUSIONS

Open appendectomy has historically been the standard in children 5 years of age and younger. Laparoscopic appendectomy has slowly gained acceptance for the treatment of appendicitis in smaller children. The use of laparoscopy has increased significantly at all facilities. Furthermore, laparoscopic appendectomy in this age group has a comparatively low complication rate and short hospital length of stay, and is safe in complicated perforated appendicitis cases.

Is single port incisionless-intracorporeal conventional equipment-endoscopic surgery feasible in patients with retrocecal acute appendicitis?

Purpose

Since laparoscopic appendectomy was first described, various modifications, such as single port incisionless-intracorporeal conventional equipment-endoscopic surgery (SPICES), have been described for reducing pain and improving cosmetic results. In the retrocecal and retrocolic positions, attachments to the lateral peritoneum and cecum may lead to difficulties during SPICES, which is performed with only one port. Here, we present the effects of variations in the position of the vermiform appendix in treating acute appendicitis with SPICES.

Methods

We retrospectively reviewed 52 children who underwent SPICES for acute appendicitis between March 2010 and November 2011 in our institution. One group (group A) consisted of 30 patients (mean age, 10.5 ± 2.5 years) with retrocecal appendix, while the other group (group B) included 22 patients (mean age, 10.9 ± 2.3 years) with the appendix lying free in the peritoneal cavity.

Results

There were no significant differences between groups in terms of patient age, gender, success rate of SPICES, mean operating time, mean follow-up period, overall complication rates or mean postoperative hospitalization period.

Conclusion

These results suggest that SPICES is a safe and feasible approach even in patients with retrocecal acute appendicitis.

Transumbilical single-incision laparoscopic multiple organ procedures: initial experience of 20 cases

BACKGROUND

Cure of disease with the least possible injury is an ideal of surgery. Herein we share our experience with transumbilical single-incision laparoscopic multiple organ procedures using conventional instruments.

SUBJECTS AND METHODS

We reviewed data from 20 patients who underwent transumbilical single-incision laparoscopic surgery of multiple organs between May 2009 and March 2012 at Shengjing Hospital. All 20 patients had laparoscopic cholecystectomy, which was combined with appendectomy in 16 patients, resection of hepatic hemangiomas in 2 patients, and partial gastrectomy for gastric mesenchymal tumor in 2 patients. All procedures were successful with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus.

RESULTS

All the operations were successfully completed without conversion to conventional laparoscopic or open surgery. No intraoperative complications occurred. Patients were satisfied with the therapeutic and cosmetic outcomes.

CONCLUSIONS

Transumbilical single-incision laparoscopic combined procedures appear to be a technically feasible alternative to standard laparoscopic procedures in simultaneous management of two different coexisting pathologies. Larger studies are required to confirm these findings.

Application of design rationale for a robotic system for single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery

Current endoscopes and instruments are inadequate in some respects for complex intra-abdominal surgery because they are too flexible and cannot provide robust grasping and anatomic retraction. Minimal invasive surgery devices represent a sophisticated class of mechanical instruments making use of a range of mechanisms integrated into modular platforms that can be combined to undertake complex medical procedures. Although the machine elements concerned represent classic mechanical engineering devices, issues of miniaturization, surgical procedure compliance and location control conspire to present a design challenge. In order to capture, document and resolve the design requirements for this complex application, quality functional deployment has been applied in combination with design rationale, captured through issue-based information system mapping. This article reports the use of these tools to produce robot designs with improved dexterity and triangulation that are basic requirements in laparoscopy.

Single-incision pediatric endosurgery: a systematic review

BACKGROUND

Single-incision pediatric endosurgery (SIPES) is defined as minimally invasive surgery performed through a unique incision in the abdomen, chest, or retroperitoneum. Several publications exist, but no previous systematic review has been made to evaluate the real benefits of this approach in terms of feasibility and clinical outcomes.

MATERIALS AND METHODS

We performed an electronic search in PubMed up to March 2012 with the terms "single AND incision OR site OR port OR trocar AND children" including related articles and obtained 197 articles. After applying our inclusion criteria, 78 articles were reviewed.

RESULTS

We identified prospective controlled trials (n=1), case-control studies (n=12), case series (n=49), and case reports (n=16). In total, 4212 patients had been operated on by SIPES and were separated by systems: gastrointestinal (n=2888), urologic (n=390), gynecologic (n=27), other abdominal (n=874), and thoracic (n=33) procedures. The most common procedure was SIPES appendectomy, and a unique prospective controlled trial supports its safety and effectiveness. Technically demanding surgeries such as hepatojejunostomy and colonic surgeries were described. Multichannel ports and multiple ports, standard and articulated instruments, transparietal instruments, retraction sutures, and magnets were used. Operative times, length of stay, and complications similar to standard laparoscopic surgery were described. A low conversion rate (to a reduced port, standard laparoscopy and open procedures) was also mentioned. No comparable measure for pain and cosmesis assessment was used.

CONCLUSIONS

A wide experience in SIPES and feasibility has already been described with good clinical outcomes and low rate of conversion. Appendectomy is the unique procedure in which SIPES has been demonstrated to be safe and effective. It is pending the execution of prospective controlled trials for other operations to demonstrate, with objective evidence, the real benefits of this less invasive approach.

One, two or three port appendectomy - a rational approach

Introduction

Laparoscopic appendectomy is a safe and feasible technique accepted by many surgeons as the gold standard approach for the treatment of acute appendicitis in children. Traditionally laparoscopic appendectomy requires the use of three ports. However, surgical techniques with fewer ports have been reported.

Aim

To evaluate the efficacy of laparoscopic appendectomy in children according to the proposed 3-step protocol using one, two or three ports.

Material and methods

A total of 100 children with the diagnosis of acute appendicitis underwent laparoscopic appendectomy. Patients were treated according to the following protocol: transumbilical access with one 10 mm port using the laparoscope with working channel. The appendix was mobilized and delivered through the umbilical port and tied extracorporeally and removed. If the appendix was placed retrocecally or had adhesions, a second port was introduced. The appendix was mobilized and finally retrieved from the abdominal cavity through the camera port, and resected extracorporeally. In the cases of very short and gangrenous appendix and immobile colon, a third port was introduced and totally intra-abdominal appendectomy was performed. Patients were evaluated regarding the duration of the operation, and operative and postoperative complications.

Results

During the study period 100 children (58 males, 42 females) had laparoscopic appendectomy: 48 children by one-port technique (group I), 27 children by two-port technique (group II) and 25 children by three-port technique (group III). The mean operative time was 33 min (20-55 min) in group I, 39 min in group II (23-60 min), and 49 min (30-75 min) in group III. There were no intraoperative complications. Wound infections were recorded in 4 (8.3%) patients in group I, three (11.1%) in group II and four (16.0%) in group III. One patient in group III developed an abdominal abscess managed conservatively.

Conclusions

One-port laparoscopic appendectomy is a feasible technique in children. It allows 48% of children to have the operation. The addition of a second port allows one to mobilize the appendix and perform extracorporeal resection in an additional 27% of cases. These approaches have shorter operative time compared to 3-port technique. Laparoscopic extracorporeal appendectomy, especially one-port, is found to be cost effective and have excellent cosmetic results.

Single-port laparoscopic appendectomy versus conventional laparoscopic appendectomy: a prospective randomized controlled study

OBJECTIVE

To compare surgical outcomes and quality of life between single-port laparoscopic appendectomy (SPLA) and conventional laparoscopic appendectomy (CLA) in patients with acute appendicitis.

BACKGROUND

A prospective randomized single center study was performed to compare the outcome of SPLA and CLA in patients with acute appendicitis.

METHODS

A total of 248 patients were randomized, but because of 18 withdrawals, the outcome of 224 is analyzed, 116 in CLA and 114 in SPLA.

RESULTS

There was no significant difference in the overall complication rate (P = 0.470). There were no significant differences in infectious complications between the SPLA group and the CLA group (10.2% and 12.4%, respectively). The wound complication rate between the 2 groups was not significant (5.1% and 10.6%, respectively; P = 0.207). Cosmetic satisfaction score, 36-item short-form health survey, and postoperative pain scores were not significantly different between 2 groups.

CONCLUSIONS

SPLA failed to show any advantages over CLA relative to pain and cosmesis. However, SPLA is as safe as CLA (RCT number 01348464).

Conventional Laparoscopic Appendicectomy and Laparoscope-Assisted Appendicectomy: a Comparative Study

Laparoscopic procedures for removal of the appendix by the three-port technique as an alternative to conventional appendicectomy have gained wide popularity, but they have been criticized for technical difficulty, more time consumption, and high cost. We have compared conventional three-port laparoscopic appendicectomy (LA) and laparoscope-assisted appendicectomy (LAA). In period from August 2010 to January 2012, 77 patients underwent appendicectomy by a minimally invasive procedure (39 LA and 38 LAA), at Medical College and Hospital, Kolkata. All the 39 cases of LA were completed successfully, but of the 38 cases, LAA could be completed only in 32 cases. Of the six cases where LAA could not be completed, five were converted to LA [three because of excessive body mass index (BMI) and two because of bleeding]. One case had to be converted to open appendicectomy because of excessive bleeding. In LA, the mean duration of surgery was less than that in LAA (18.18 versus 24.39 min). Wound infections were more common in LAA compared to LA (six versus two). Severe postoperative pain was present in eight cases in LAA compared to two in LA. On day 2, 79.487 % patients undergoing LA were discharged compared to 28.947 % in LAA. LA is better as a minimally invasive procedure. LAA can only be done in patients with lower BMI, is more time consuming, has more complications, more incidence of postoperative pain, wound infections, and longer hospital stay.

A review of minimally invasive single-port/incision laparoscopic appendectomy

INTRODUCTION

Single-port/incision laparoscopic appendectomy (SPILA) is a modern advancement toward stealth surgery, using a single point of entry. Despite the paucity of clinical data, it is increasingly being used to minimize scarring and, potentially, pain associated with the multiple entry points. We aimed to summarize and present available data on this new approach.

METHODOLOGY

All available databases until December 2010 including the Cochrane Controlled Trials Register, MEDLINE, and EMBASE were searched and cross-referenced for studies describing single-incision laparoscopic appendectomy. Case and experimental reports, series with fewer than 5 patients, and non-English articles were excluded. Outcome measures were operative time, postoperative hospital stay, pain scores, complications, conversion, and mortality, stratified according to type of SPILA approach. SPSS version 18.0.0 software was used for data collection.

RESULTS

Database query yielded 79 articles; 45 were included (1 randomized controlled trial, 44 case series). Total cases were 2806, with mean patient age for studies ranging from 7.0 to 37.5 years. No mortality was reported. The overall complication rate was 4.13%. The overall weighted mean operating time was 41.3 minutes (range, 15.0-95.9 minutes). The weighted mean hospital stay was 2.79 days (range, 1.0-6.6 days).

CONCLUSIONS

Although the incidence of complications with SPILA remains low and operating times between new and traditional approaches are comparable in case-based literature, adequately powered randomized trials are required to assess its effectiveness. Occurrence of long-term complication types remains unexplored.

Single incision laparoscopic colorectal resection: Our experience

BACKGROUND:

A prospective case series of single incision multiport laparoscopic colorectal resections for malignancy using conventional laparoscopic trocars and instruments is described.

MATERIALS AND METHODS:

Eleven patients (seven men and four women) with colonic or rectal pathology underwent single incision multiport laparoscopic colectomy/rectal resection from July till December 2010. Four trocars were placed in a single transumblical incision. The bowel was mobilized laparoscopically and vessels controlled intracorporeally with either intra or extracorporeal anastomosis.

RESULTS:

Three patients had carcinoma in the caecum, one in the hepatic flexure, two in the rectosigmoid, one in the descending colon, two in the rectum and two had ulcerative pancolitis (one with high grade dysplasia and another with carcinoma rectum). There was no conversion to standard multiport laparoscopy or open surgery. The median age was 52 years (range 24-78 years). The average operating time was 130 min (range 90-210 min). The average incision length was 3.2 cm (2.5-4.0 cm). There were no postoperative complications. The average length of stay was 4.5 days (range 3-8 days). Histopathology showed adequate proximal and distal resection margins with an average lymph node yield of 25 nodes (range 16-30 nodes).

CONCLUSION:

Single incision multiport laparoscopic colorectal surgery for malignancy is feasible without extra cost or specialized ports/instrumentation. It does not compromise the oncological radicality of resection. Short-term results are encouraging. Long-term results are awaited.

Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery

INTRODUCTION:

The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA).

MATERIALS AND METHODS:

All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot.

RESULTS:

A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay.

CONCLUSION:

This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.

Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a novel area of minimally invasive surgery that uses a single incision to minimize all ports to one site. The end result is an incision that can be strategically placed in the umbilicus for a perceived scarless abdomen. The authors rationalized that a randomized controlled trial was important given the rapid popularization of this approach.

METHODS

An institutional review board-approved prospective randomized trial compared patients undergoing SILS (SILS-A) and conventional laparoscopic (LAP-A) appendectomy at a free-standing children's hospital during a median follow-up period of 2.2 years.

RESULTS

A total of 50 patients (50 % boys and 67 % Hispanics) were randomized equally to SILS-A and LAP-A. The patients ranged in age from 3 to 15 years without a difference between the two groups. Half (50 %) of these patients were younger than 8 years. The technique for SILS-A involved a single supraumbilical curvilinear skin incision with three fascial incisions. Ports were inserted to varying depths to minimize restriction of instrument movement. Coaxial visualization was improved by the use of a 30° scope. To achieve technical comparability with the LAP-A, a stapler device was used, which required upsizing a 5 mm port to a 12 mm port. The mean duration of the operation was 46.8 ± 3.7 min (range, 22-120 min) compared with 34.8 ± 2.5 min (range, 18-77 min) for standard LAP-A (p = 0.010). No conversions occurred, and the two groups did not differ in hospital length of stay. The postoperative complications consisted of one wound seroma in the SILS-A group (nonsignificant difference), and no hernias were seen. No difference in readmissions, diet tolerance, fever, or postoperative pain was noted between the two groups.

CONCLUSIONS

The findings show the SILS approach to be feasible in the pediatric population despite the limited abdominal domain in younger children. Although SILS operating room times currently are longer than for LAP-A, they are comparable, and no other outcomes differed appreciably between the two techniques at the time of hospitalization or during the follow-up period.

Single-access laparoscopic colectomy utilizing gravity in the lateral decubitus position

BACKGROUND

Only a limited number of instruments can be used in single-access laparoscopic colectomy, and triangulation must be forfeited to avoid instrument collision. We investigated whether this problem could be overcome by performing laparoscopic colectomy by the use of the lateral decubitus position, making full use of gravity.

OBJECTIVE

The aim of this study was to determine whether single-access laparoscopic colectomy could be achieved while maintaining patients in the lateral decubitus position.

DESIGN

This was a prospective study.

SETTING

This single-center study was conducted in a hospital.

PATIENTS

Ten consecutive patients (4 men and 6 women) with stage II or III colon cancer were included.

INTERVENTIONS

Each patient was placed in the lateral decubitus position. Single-port access to the abdomen was provided by a 3.0-cm incision at the umbilicus. The roots of the supplying or draining vessels were isolated and divided for lymphadenectomy. Next, the colon was dissected from a lateral approach, without the help of the assistant. The specimen was extracted from the single-access incision. Extracorporeal or intracorporeal anastomosis was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was the feasibility of single-access laparoscopic colectomy in the lateral decubitus position.

RESULTS

There were no intraoperative complications and no need for conversions to conventional laparoscopic surgery, open surgery, or the supine position. The median total surgical time was 154 minutes (interquartile range, 135-220 minutes). Surgical blood loss was slight (<20 mL) in all patients. No postoperative complications occurred. The median postoperative hospital stay was 7 days (interquartile range, 5-7 days).

LIMITATIONS

The sample size was small.

CONCLUSIONS

Our results show that single-access laparoscopic colectomy in the lateral decubitus position is safe and feasible.

Single port/incision laparoscopic surgery compared with standard three-port laparoscopic surgery for appendicectomy - a randomised controlled trial

BACKGROUND

Laparoscopic surgery has become the preferred approach for many procedures because of reduced post-operative pain, better recovery, shorter hospital stay and improved cosmesis. Single incision laparoscopic surgery is one of the many recent variants where either standard ports or a specially designed single multi-channel port is introduced through a single skin incision. While the cosmetic advantage of this is obvious, the evidence base for claims of reduced morbidity and better post-operative recovery is weak. This study aims to compare the effectiveness of single port/incision laparoscopic appendicectomy with standard three-port laparoscopic appendicectomy in adult patients at six weeks post-surgery. We also wish to assess the feasibility of a multicentre randomised controlled trial comparing single port/incision laparoscopic surgery with standard three-port laparoscopic surgery for other surgical techniques.

METHODS AND DESIGN

Patients diagnosed with suspected appendicitis and requiring surgical treatment will be randomised to receive either standard three-port or single incision laparoscopic surgery. Data will be collected from clinical notes, operation notes and patient reported questionnaires. The following outcomes will be considered:1. Effectiveness of the surgical procedure in terms of:•patient reported outcomes•clinical outcomes•resource use2. Feasibility of conducting a randomised controlled trial (RCT) in the emergency surgical setting by quantifying:•patient eligibility•randomisation acceptability•feasibility of blinding participants to the intervention received•completion rates of case report forms and patient reported questionnaires

TRIAL REGISTRATION

ISRCTN66443895 (assigned 10 March 2011, first patient randomised 09 January 2011).

Single-scar laparoscopic colectomy with intracorporeal attachable and detachable instruments

BACKGROUND

In single-access laparoscopic colectomy, the number of instruments that can be inserted through the single-access site is limited by instrument collision. To compensate, triangulation is necessary, but the operative field becomes inadequate. To overcome this problem, intracorporeal attachable and detachable instruments can broaden the field of visceral tissue by retracting from at least 2 points.

OBJECTIVE

We tested this new procedure for colon cancer surgery.

DESIGN

This is a prospective study.

SETTING

This study was conducted at a single-center hospital.

PATIENTS

Ten consecutive patients (3 male and 7 female) with stage II or III colon cancer underwent the procedure.

INTERVENTIONS

All patients received a 3.0-cm incision at the umbilicus or right iliac fossa. At least 2 clips and a suspending bar were inserted through a 12-mm port in a multiport access device. The clips grasped the mesocolon at different points and were retracted with either an extracorporeal magnet or fine-loop retractors; this broadened the operative field in the mesocolon by at least 2 points. The mesocolon was dissected with a medial to lateral approach. The suspended bar was tied to 2 fine-loop retractors and manipulated to enlarge the operative field in the mesocolon. The roots of the vascular pedicles were isolated and divided during lymph node dissection. After extracting the specimen, an anastomosis was performed.

MAIN OUTCOME MEASURES

Intra- and postoperative complications due to inadequate access were the primary outcomes measured.

RESULTS

There were no intraoperative complications and no need for conversions to open surgery or second access ports. The median total surgical time was 182 minutes (range, 122-245). Surgical blood loss was slight (range, 1-20 mL) in all patients. No postoperative complications occurred. The postoperative hospital stay was 5 to 7 days.

LIMITATIONS

The sample size was small.

CONCLUSIONS

This study showed that intracorporeal attachable and detachable instruments were safe and feasible for this procedure.

Single-port laparoscopic surgery in children: concept and controversies of the new technique

Single-incision laparoscopic surgery (SILS) is emerging as an alternative technique to conventional laparoscopy for the treatment of common surgical diseases. Despite its wide use, the adoption of SILS in children has been slower since the broad application of minimally invasive techniques in children, in general, has historically lagged behind those in adults. This paper reviews the evolution of SILS from its original conception and its application in the field of pediatric surgery.

Comparison of endoscopic task performance with crossed versus uncrossed straight and curved instruments through a single port

BACKGROUND

Despite advancing technology for single-incision minimal access surgery, there have been no reports on the optimal operating setup and the instruments for use through a single port. This study therefore aimed to compare task performance in single-port surgery between crossed and uncrossed instruments (straight and distally coaxially curved).

METHODS

A dedicated trainer box was used to investigate the performance of two tasks (pick-transfer-place and dissection) by 18 surgical residents using two randomly allocated manipulating systems: (1) a conventional, uncrossed manipulation system (UCMS), with surgery through a cone-shaped 40-mm port using coaxially curved or straight instruments subtending a 30° manipulation angle, and (2) a crossed manipulation system (CMS), with surgery through a cylindrical miniport (25 mm) using coaxially curved instruments.

RESULTS

The pick-transfer-place task performed with the UCMS enabled comparison between straight and curved coaxial instruments and showed that although the participants moved the same number of objects with either type (p = 0.464), they dropped a significantly more objects with straight instruments (1.5 ± 1.33 vs. 0.61 ± 0.85; p = 0.013). The execution of this task with the CMS (curved instruments only) provided a performance (dropped objects and error rates) equal to that obtained by the UCMS with curved instruments (p = 0.521, p = 0.989). The dissection task with the UCMS showed no difference between straight and curved coaxial instruments in dissection accuracy (75.6 vs. 75.5%; p = 0.950) or execution times (258 vs. 302 s; p = 0.367). The performance of this task by the CMS and the UCMS (with curved coaxial instruments) was equivalent with regard to dissection accuracy (p = 0.849) and execution time (p = 0.402).

CONCLUSIONS

Using the UCMS, task performance is better with distally curved coaxial instruments. The CMS (with curved instruments) gives a task performance equivalent to that obtained with UCMS.