Single incision versus conventional multiport laparoscopic appendectomy: a systematic review and meta-analysis of randomized controlled trials

Perioperative pain management for appendicectomy: A systematic review and Procedure-specific Postoperative Pain Management recommendations

BACKGROUND

Despite being a commonly performed surgical procedure, pain management for appendicectomy is often neglected because of insufficient evidence on the most effective treatment options.

OBJECTIVE

To provide evidence-based recommendations by assessing the available literature for optimal pain management after appendicectomy.

DESIGN AND DATA SOURCES

This systematic review-based guideline was conducted according to the PROSPECT methodology. Relevant randomised controlled trials, systematic reviews and meta-analyses in the English language from January 1999 to October 2022 were retrieved from MEDLINE, Embase and Cochrane Databases using PRISMA search protocols.

ELIGIBILITY CRITERIA

We included studies on adults and children. If articles reported combined data from different surgeries, they had to include specific information about appendicectomies. Studies needed to measure pain intensity using a visual analogue scale (VAS) or a numerical rating scale (NRS). Studies that did not report the precise appendicectomy technique were excluded.

RESULTS

Out of 1388 studies, 94 met the inclusion criteria. Based on evidence and consensus, the PROSPECT members agreed that basic analgesics [paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs)] should be administered perioperatively for open and laparoscopic appendicectomies. A laparoscopic approach is preferred because of lower pain scores. Additional recommendations for laparoscopic appendicectomies include a three-port laparoscopic approach and the instillation of intraperitoneal local anaesthetic. For open appendicectomy, a preoperative unilateral transverse abdominis plane (TAP) block is recommended. If not possible, preincisional infiltration with local anaesthetics is an alternative. Opioids should only be used as rescue analgesia. Limited evidence exists for TAP block in laparoscopic appendicectomy, analgesic adjuvants for TAP block, continuous wound infiltration after open appendicectomy and preoperative ketamine and dexamethasone. Recommendations apply to children and adults.

CONCLUSION

This review identified an optimal analgesic regimen for open and laparoscopic appendicectomy. Further randomised controlled trials should evaluate the use of regional analgesia and wound infiltrations with adequate baseline analgesia, especially during the recommended conventional three-port approach.

REGISTRATION

The protocol for this study was registered with the PROSPERO database (Registration No. CRD42023387994).

Is transumbilical laparoscopic-assisted appendectomy feasible for complicated appendicitis? A single-center experience

PURPOSE

Transumbilical laparoscopic-assisted surgery (TULS) mixed benefits of laparoscopic and open surgeries. Transumbilical laparoscopic-assisted appendectomy (TULAA) is a well-known procedure, accepted and currently used by pediatric surgeons for treatment of uncomplicated appendicitis (UA). There is no current agreement in its use for the complicated appendiceal infections (CA). We reported our results using TULAA for both UA and CA.

METHODS

We retrospectively collected TULAA performed between April 2017 and April 2022. Appendicitis were classified in UA and CA. We analyzed conversion rate, operative time, length of stay, surgical site infections (SSIs) rate, postoperative intra-abdominal abscess and costs.

RESULTS

Over 5 years, 316 children underwent TULAA. Conversion rate was 3%. Mean age at surgery was 9.36 years (IQR 2-16). Forty-nine appendicitis were CA. Operative time and hospital stay was higher in CA than in UA group (38.33 vs. 60.73 min, p < 0.00001; 4 vs. 7 days, p < 0.00001). SSIs rate showed no statistically significant difference between two groups. Incidence of postoperative intra-abdominal collections was 11% in CA and 1% in UA. TULAA's cost was 192.07 €.

CONCLUSION

In our series, TULAA seems to be safe, feasible and cost-effective for both uncomplicated and complicated appendicitis, with no disadvantage in terms of outcomes compared to what is reported in literature for CLS.

Cystic duct dilation through endoscopic retrograde cholangiopancreatography for treatment of gallstones and choledocholithiasis: Six case reports and review of literature

BACKGROUND

Choledocholithiasis removal via endoscopic retrograde cholangiopancreatography (ERCP) then followed by laparoscopic cholecystectomy (LC) has gradually become the principal method in the treatment of gallstones and choledocholithiasis. We use ERCP through the cystic duct to treat gallstones combined with choledocholithiasis, with the aim to preserve the normal function of the gallbladder while simultaneously decreasing risk of biliary tract injury.

CASE SUMMARY

A total of six cases of patients diagnosed with gallstones and choledocholithiasis were treated with ERCP. The efficacy was evaluated via operation success rate, calculus removal rate, postoperative hospital stay and average hospitalization costs; the safety was evaluated through perioperative complication probability, gallbladder function detection and gallstones recrudesce. The calculus removal rate reached 100%, and patients had mild adverse events, including 1 case of postoperative acute cholecystitis and another of increased blood urinary amylase; both were relieved after corresponding treatment, the remaining cases had no complications. The average hospital stay and hospitalization costs were 6.16 ± 1.47 d and 5194 ± 696 dollars. The 3-11 mo follow-up revealed that gallbladder contracted well, without recurrence of gallstones.

CONCLUSION

This is the first batch of case reports for the treatment of gallstones and choledocholithiasis through ERCP approached by natural cavity. The results and effects of six reported cases proved that the new strategy is safe and feasible and is worthy of further exploration and application.

Paramedian incisional complications after prophylactic laparoscopy-assisted gastropexy in 411 dogs

OBJECTIVE

To determine the frequency and types of paramedian incisional complications after prophylactic laparoscopy-assisted gastropexy (LAG) in dogs and to evaluate potential risk factors for complications.

STUDY DESIGN

Multi-institutional retrospective study.

ANIMALS

Client-owned dogs (N = 411).

METHODS

Records for dogs that underwent single-incision-port laparoscopy-assisted gastropexy (SIPLAG) or multiple-port laparoscopy-assisted gastropexy (MPLAG) at five veterinary referral hospitals were reviewed. Information regarding signalment, surgical procedures, perioperative care, and incisional complications was collected. Follow-up information was obtained by review of medical records and/or communication with owners. Potential risk factors for complications were examined statistically.

RESULTS

Paramedian incisional complications were observed in 78 of 411 (19%) dogs. The most common complication was seroma formation, which occurred in 51 (12.4%) dogs. Surgical site infections were observed in 16 (3.9%) dogs, and dehiscence or development of excessive scar tissue at the incision site were each observed in nine (2.2%) dogs. Complications resolved with conservative treatment in 75 of 78 (96.2%) dogs and with surgical treatment in three of 78 (3.8%) dogs. The odds of complications were approximately twice as high in dogs undergoing SIPLAG than in dogs undergoing MPLAG (odds ratio, 2.03; P = .006).

CONCLUSION

Minor paramedian incisional complications, particularly seroma formation, were frequently observed after LAG. Most complications were successfully managed conservatively. Single-incision-port laparoscopy-assisted gastropexy was associated with a higher complication rate compared with MPLAG.

CLINICAL SIGNIFICANCE

Owners should be informed that there is a relatively high rate of minor paramedian incisional complications after LAG. The risk of complications appears to be higher for SIPLAG than for MPLAG.

Conventional Laparoscopic Appendectomy Versus Single-Port Laparoscopic Appendectomy, a Multicenter Randomized Control Trial: A Feasible and Safe Alternative to Standard Laparoscopy

Background: Acute appendicitis represents one of the main causes of surgical emergencies. It can be approached as open appendectomy or laparoscopic appendectomy (LA). LA uses different modalities, such as conventional laparoscopic appendectomy (CLA) or single-port laparoscopic appendectomy (SPLA). The aim of this work is to compare the results of CLA versus SPLA in patients diagnosed with Acute Appendicitis. Materials and Methods: A comparative multicenter prospective study of patients undergoing LA with a clinical diagnosis of acute appendicitis was presented. They were divided into two groups (CLA group and SPLA group). Results: A total of n = 147 patients were included (72 CLA and 75 SPLA). Preoperative and intraoperative times were shorter for patients undergoing CLA (P = .002; P = .068). Postoperative and reinsertion time was lower for SPLA (P = .000; P = .0004). There were no differences in postoperative complications. The type of approach showed statistically significant differences with respect to pain within the first 12 hours of the postoperative period, as well as at discharge, while no differences were observed in relation to cosmetic satisfaction when the two approaches were compared. Conclusion: SPLA technique presented less intraoperative time, shorter time of labor reinsertion, and less postoperative pain. There were no statistically significant differences in postoperative complications.

Single incision laparoscopic surgery from a caribbean perspective

Conventional laparoscopy with multiple ports has recently gained a strong foothold in the Caribbean, but single incision laparoscopic surgery (SILS) has lagged behind. In this paper, we compare the data on SILS and conventional multi-port laparoscopy in the English-speaking Caribbean.

A Prospective Randomized Controlled Trial of Single-Port and Three-Port Laparoscopic Appendectomy in Children

Background: This study aimed to evaluate single-port laparoscopic appendectomy (SPLA) in comparison with three-port laparoscopic appendectomy (3PLA) in children about the extent of surgical trauma after SPLA and 3PLA measured by serum interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations. Materials and Methods: A total of 50 patients with a median age of 11.5 were randomized to two groups. Experts in both methods performed the surgeries. The decision on the type of planned surgery was randomly determined. Serum IL-6 and CRP levels were measured using an enzyme-linked immunosorbent assay before, and at 12 and 36 hours after surgery. Furthermore, we compared operating time, hospital stay, postoperative pain, and complication rates. Results: The operative time in the 3PLA group was shorter than that in the SPLA group (P < .05). Preoperative IL-6 levels were not different between the two groups, but the rise (pre- versus postoperative) of IL-6 in the SPLA group was remarkably higher when compared with the 3PLA group (P < .05). Similar results were obtained for CRP; basal serum CRP levels were not different between the two groups, but the rise of CRP in the 3PLA group was significantly lower compared with that in the SPLA group. During the first 12 hours postoperative, the SPLA patients reported more severe postoperative pain and longer inpatient opiate usage was noted that after 3-PLA. Only one SPLA case was converted to 3PLA. There were no conversions to open surgery. The length of hospital stay and complication rate were not different between the two groups. Conclusions: SPLA in children is associated with longer operative times, increased pain level, and more severe surgical trauma as measured by postoperative CRP and IL-6 levels in comparison with a 3PLA. The two approaches were comparable regarding the length of hospital stay and complication rate.

Safety of single-incision laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) is a common procedure performed worldwide. In this study, we evaluated the safety and efficacy of SILC for acute cholecystitis.

METHODS

Patients who underwent SILC between September 2012 and December 2016 were retrospectively enrolled and divided into acute and chronic groups. Demographic, operative and outcome data were obtained by reviewing medical records, physical examination and telephone follow-up.

RESULTS

In total, 1435 patients were included in this study: 220 (15.3%) in the acute group and 1215 (84.7%) in the chronic group. The mean operative time was longer in the acute group than in the chronic group (44.7 ± 21.6 versus 32.8 ± 9.8 min; P < 0.001). Insertion of additional ports was performed in 17 patients: six in the acute group and 11 in the chronic group. Conversion to abdominal laparotomy was performed in eight patients: one in the acute group and seven in the chronic group. The mean post-operative hospital stay was 31.7 ± 20.4 h in the acute group and 27.7 ± 13.7 h in the chronic group. The complication rate was similar between the acute (n = 8, 3.6%) and chronic (n = 33, 2.7%) groups.

CONCLUSION

SILC does not increase the complication rate and is a safe and feasible technique for both chronic and acute cholecystitis.

Comparison of single-incision and conventional laparoscopic surgery for benign adnexal masses

BACKGROUND

Our aim was to compare single incision and conventional laparoscopic surgeries performed for benign adnexal masses with regard to their intraoperative characteristics and postoperative pain levels.

MATERIAL AND METHODS

The main outcome measures were laparoscopic entry time, total operation time, amount of bleeding, intraoperative complications, post-operative pain scores, additional analgesic requirements, and length of hospital stay.

RESULTS

A total of 71 women, 39 in the conventional laparoscopy group and 32 in the SILS group, participated in the study. Demographic findings did not differ between the two groups. Similarly, rates of intraoperative complications, rates of conversion to laparotomy, pre- and postoperative hematocrit levels were not significantly different between the groups. Laparoscopic entry time was shorter in the SILS group (10.4 ± 5.9 min. vs. 5.28 ± 1.7 min.). However, total operation time was similar in the two groups. The groups did not show significant differences regarding additional analgesic requirements, or postoperative pain scores after 24 h. However, pain scores in the recovery room and after six and 12 h were lower in the SILS group.

CONCLUSION

SILS seems to be effective and safe for the treatment of benign adnexal masses. SILS appears to be advantageous regarding postoperative pain especially in the early period.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Transumbilical laparoscopic appendectomy performed by residents is safe and feasible

INTRODUCTION

The aim of this study was to compare the clinical outcomes of single-incision transumbilical laparoscopy-assisted appendectomy performed by surgical residents and attending surgeons.

METHODS

We reviewed the clinical outcomes of 131 transumbilical laparoscopy-assisted appendectomies performed from January 2011 to June 2014. During the study period, 13 residents and 6 board-certified attending surgeons performed the procedures. For all operations performed by residents and attending surgeons, we reviewed and compared gender, age, BMI, body temperature, white blood cell count, C-reactive protein serum level, and the presence of a fecalith or abscess. Clinical outcomes including operative time, estimated blood loss, need for additional ports, conversion to open surgery, intraoperative complications, postoperative complications, and postoperative hospital stay were compared between the two groups.

RESULTS

The mean preoperative white blood cell count in the resident-operated group was significantly higher than in the attending-operated group (14.0 vs 10.8 ×10³ /mm³ , P = 0.007). There were no other significant differences in clinical variables between the two groups. Outcomes show that estimated blood loss was significantly higher (23.4 vs 9.8 mL, P = 0.031) and operative time tended to be longer (86.0 vs 72.0 min, P = 0.056) in the resident-operated group. No other significant differences were observed.

CONCLUSION

Transumbilical laparoscopy-assisted appendectomy performed by residents is feasible and safe. It is an acceptable as a part of routine surgical training.

Feasibility of single-incision laparoscopic cholecystectomy for acute cholecystitis

AIM: To assess the safety of single-incision laparoscopic cholecystectomy (SILC) for acute cholecystitis.

METHODS: All patients who underwent SILC at Sano Hospital (Kobe, Japan) between January 2010 and December 2014 were included in this retrospective study. Clinical data related to patient characteristics and surgical outcomes were collected from medical records. The parameters for assessing the safety of the procedure included operative time, volume of blood loss, achievement of the critical view of safety, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and duration of postoperative hospital stay. Patient backgrounds were statistically compared between those with and without conversion to laparotomy.

RESULTS: A total of 100 patients underwent SILC for acute cholecystitis during the period. Preoperative endoscopic treatment was performed for suspected choledocholithiasis in 41 patients (41%). The mean time from onset of acute cholecystitis was 7.7 d. According to the Updated Tokyo Guidelines (TG13) for the severity of cholecystitis, 86 and 14 patients had grade I and grade II acute cholecystitis, respectively. The mean operative time was 87.4 min. The mean estimated blood loss was 80.6 mL. The critical view of safety was obtained in 89 patients (89%). Conversion laparotomy was performed in 12 patients (12%). Postoperative complications of Clavien-Dindo grade III or greater were observed in 4 patients (4%). The mean duration of postoperative hospital stay was 5.7 d. Patients converted from SILC to laparotomy tended to have higher days after onset.

CONCLUSION: SILC is feasible for acute cholecystitis; in addition, early surgical intervention may reduce the risk of laparotomy conversion.