The learning curve of single-port laparoscopic appendectomy performed by emergent operation

Single-port laparoscopic appendectomy using new surgical procedure versus conventional three-port laparoscopic appendectomy

The aim of this study was to compare the clinic outcomes between new single-port laparoscopic appendectomy (NSLA) and conventional three-port laparoscopic appendectomy (CTLA) for patients with acute appendicitis. Patients who were diagnosed with acute appendicitis and underwent appendectomy were retrospectively collected from a single clinical center from September 2021 to June 2023. Baseline characteristics, surgical information, and postoperative information were compared between the NSLA group and the CTLA group. Univariate and multivariate logistic regression analyses were used to find out the predictors of overall complications. A total of 296 patients were enrolled from a single clinical medical center. There were 146 (49.3%) males and 150 (50.7%) females. There were 54 (18.2%) patients in the NSLA group and 242 (81.8%) patients in the CTLA group. After data analysis, we found the patients in the NSLA group had a shorter postoperative hospital stay (P < 0.01) than the CTLA group. The other outcomes including intraoperative blood loss (P = 0.167), operation time (P = 0.282), nature of the appendix (P = 0.971), and overall complications (P = 0.543) were not statistically different. After univariate and multivariate logistic regression analysis, we found that age (P = 0.018, OR = 1.039, 95% CI = 1.007-1.072), neutrophil percentage (P = 0.018, OR = 1.070, 95% CI = 1.011-1.132), and fever (P = 0.019, OR = 6.112, 95% CI = 1.340-27.886) were the predictors of overall complications. However, the surgical procedure (NSLA versus CTLA) was not a predictor of overall complications (P = 0.376, OR = 1.964, 95% CI = 0.440-8.768). Compared with CTLA, there was no significant increase in postoperative overall complications with NSLA, making it a safe and feasible new surgical procedure. More studies are needed to evaluate the long-term results.

Laparoscopic appendectomy with single port vs conventional access: systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Conventional three-access laparoscopic appendectomy (CLA) is currently the gold standard treatment, however, Single-Port Laparoscopic Appendectomy (SILA) has been proposed as an alternative. The aim of this systematic review/meta-analysis was to evaluate safety and efficacy of SILA compared with conventional approach.

METHODS

Per PRISMA guidelines, we systematically reviewed randomised controlled trials (RCTs) comparing CLA vs SILA for acute appendicitis. The randomised Mantel-Haenszel method was used for the meta-analysis. Statistical data analysis was performed with the Review Manager software and the risk of bias was assessed with the Cochrane "Risk of Bias" assessment tool.

RESULTS

Twenty-one studies (RCTs) were selected (2646 patients). The operative time was significantly longer in the SILA group (MD = 7,32), confirmed in both paediatric (MD = 9,80), (Q = 1,47) and adult subgroups (MD = 5,92), (Q = 55,85). Overall postoperative morbidity was higher in patients who underwent SILA, but the result was not statistically significant. In SILA group were assessed shorter hospital stays, fewer wound infections and higher conversion rate, but the results were not statistically significant. Meta-analysis was not performed about cosmetics of skin scars and postoperative pain because different scales were used in each study.

CONCLUSIONS

This analysis show that SILA, although associated with fewer postoperative wound infection, has a significantly longer operative time. Furthermore, the risk of postoperative general complications is still present. Further studies will be required to analyse outcomes related to postoperative pain and the cosmetics of the surgical scar.

Assessing the learning curve for transumbilical single-site laparoscopy for endometrial cancer

Introduction

Applying transumbilical laparoendoscopic single-site surgery to endometrial cancers is worldwide, and the depiction of the learning curve is rarely described, which leads to the vagueness of young clinical practitioners. We accumulated the data to identify the completion of the learning curve by analyzing the operative and postoperative outcomes of the patients with endometrial cancer for transumbilical laparoendoscopic single-site surgery (TU-LESS).

Methods

This was a retrospective, consecutive single-center study of patients with endometrial cancer undergoing standard endometrial cancer comprehensive staging surgery (extrafascial hysterectomy, bilateral salpingectomy, and pelvic lymphadenectomy) through TU-LESS by an experienced surgeon from December, 2017 to June, 2021 in the Department of Gynecologic Oncology, West China Second Hospital, Sichuan University, China.

Results

After applying the inclusion and exclusion criteria, 42 patients were included in the study. The learning curve for this study was evaluated using both cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Applying CUSUM and RA-CUSUM has grouped 42 cases into three phases. The prior five cases represented the learning period. The following six cases were needed to lay a technical foundation (cases 6-11). The third phase was regarded as achieving proficiency (cases 12-42). The operative time decreased drastically with the learning curve. There were no significant differences in terms of postoperative complications and lymph node retrieval among the three phases. More difficult patients were confronted in the third phase.

Discussion

In our study, the learning curve was composed of three phases. According to the results of our study, 11 cases were required for experienced surgeons to achieve a technical foundation.

Efficacy of transumbilical laparoendoscopic single-site surgery versus multi-port laparoscopic surgery for endometrial cancer: a retrospective comparison study

Background

Although single-port laparoscopy surgery has been evaluated for several years, it has not been widely adopted by gynecologic oncologists. The objective was to compare the perioperative outcomes and survival of endometrial cancer (EC) patients undergoing transumbilical laparoendoscopic single-site surgery (TU-LESS) with multi-port laparoscopic surgery (MLS).

Materials and methods

This is a retrospective comparative monocentric study including patients treated between December 2017 and October 2021. The perioperative outcomes and survival of EC patients who had surgery via TU-LESS or MLS were compared, by propensity matching.

Results

A total of 156 patients were included (TU-LESS vs. MLS: 78 vs. 78). The conversion rate of TU-LESS and MLS was 5.13% and 2.56%, respectively (P=0.681). The operation time was comparable between the two groups [207.5min (180-251) vs. 197.5min (168.8-225), P=0.095]. There was no significant difference between the two groups in exhaustion time, perioperative complications, or postoperative complications. While, the TU-LESS group had a shorter out-of-bed activity time [36 hours (24-48) vs. 48 hours (48-72), P<0.001] and a lower visual analog pain scale 36 hours after surgery [1 (1-2) vs. 2 (1-2), P<0.001] than the MLS group. The length of hospital stay was similar in the two groups [5(4-6) vs. 5(4-5), P=0.599]. Following surgery, 38.5% of the TU-LESS patients and 41% of the MLS patients got adjuvant therapy (P=0.744). The median follow-up time for TU-LESS and MLS cohorts was 45 months (range: 20-66) and 43 months (range: 18-66), respectively. One TU-LESS patient and one MLS patient died following recurrence. The 4-year overall survival was similar in both groups (98.3% vs. 98.5%, P=0.875).

Conclusion

TU-LESS is a feasible and safe option with comparable perioperative outcomes and survival of MLS in endometrial cancer. With the growing acceptance of sentinel lymph node biopsy, TU-LESS of endometrial cancer may be a viable option for patients and surgeons.

Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper

BACKGROUND

Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS.

METHODS

This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements.

RESULTS

Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20-107) depending on the initial surgeon's experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon's proficiency.

CONCLUSIONS

Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research.

Conventional three-port laparoscopic appendectomy versus transumbilical and suprapubic single-incision laparoscopic appendectomy using only conventional laparoscopic instruments

PURPOSE

Single-incision laparoscopic appendectomy (SILA) is usually performed using single-port instruments, which may restrict its development and application. This study explored the performance of transumbilical SILA (TSILA) and suprapubic SILA (SSILA) using only conventional laparoscopic instruments and compared them with conventional three-hole/port laparoscopic appendectomy (CLA).

METHODS

This retrospective study included 174 patients who underwent CLA, TSILA, or SSILA for acute appendicitis at our hospital between June 2019 and July 2021. Demographic data and clinical outcomes were compared among the three groups.

RESULTS

Compared with CLA, TSILA was associated with significant reductions in postoperative pain, length of hospital stay, and hospital cost, while SSILA was associated with significant reductions in length of hospital stay and hospital cost (all P < 0.05). Significantly more patients in the two SILA groups were cosmetically satisfied than those in the CLA group (all P < 0.05). However, compared with CLA, SSILA required a significantly longer operative time (65.3 ± 24.1 vs 56.5 ± 20.9, P = 0.039). Besides, compared with TSILA, SSILA showed significantly higher postoperative pain score (2 ± 2 vs 3 ± 2, P = 0.006). Mild incisional or intraabdominal infections were noticed in 2 (3.0%) patients in the CLA group, 3 (5.1%) in the TSILA group, and 3 (6.3%) in the SSILA group (P = 0.69).

CONCLUSION

SILA performed with only conventional laparoscopic instruments was associated with reduced hospital stay and cost and higher cosmetic satisfaction in comparison to CLA. However, it is technically demanding and may increase operative time.

Single-incision compared with conventional laparoscopy for appendectomy in acute appendicitis: a systematic review and meta-analysis

OBJECTIVE

A meta-analysis of the relevant literature evaluated the feasibility, safety, and potential benefits of single-incision laparoscopic appendectomy (SILA) relative to those of conventional laparoscopic appendectomy (CLA).

METHODS

The major biomedical databases, including ClinicalTrials.gov, were searched up to January 2022 for relevant randomized controlled trials (RCTs). SILA and CLA were compared regarding patient body mass index, operative time, and perioperative complications. The Cochrane Handbook and RevMan 5.3 were used to judge trial quality and perform the meta-analysis, respectively.

RESULTS

The 17 included RCTs comprised 2068 patients, of whom 1039 and 1029 patients underwent SILA and CLA, respectively. The operative time for SILA was longer than that for CLA (MD = 8.35 min, 95% CI = 6.58 to 10.11, P < 0.00001), but the cosmetic results from SILA were superior (SMD = 0.81, 95% CI = 0.58 to 1.03, P < 0.00001). However, the incidence rates were similar in terms of patient body mass index; postoperative pain scores; and rates of abdominal abscess, conversion to open surgery, ileus, surgical site infection, and overall perioperative complications between the two groups.

CONCLUSION

SILA is a safe technique for acute appendicitis, and its cosmetic outcomes are superior to those of CLA.

Single-port laparoscopic appendectomy using a needle-type grasping forceps compared with conventional three-port laparoscopic appendectomy for patients with acute uncomplicated appendicitis: a single-center retrospective study

Objective

To compare the clinical outcomes between single-port laparoscopic appendectomy using a needle-type grasping forceps (SLAN) and conventional three-port laparoscopic appendectomy (CLA) for patients with uncomplicated appendicitis.

Methods

We retrospectively collected clinical data of patients with uncomplicated appendicitis who underwent SLAN or CLA from May 2019 to May 2021 in our center. The patients’ baseline characteristics, perioperative outcomes, and follow-up data were compared between the two groups. Additionally, baseline characteristics were compared with postoperative outcomes in the SLAN group.

Results

Ninety-six patients were enrolled (SLAN group, n = 32; CLA group, n = 64). The SLAN group had a shorter hospital stay, lower 24-hour postoperative visual analogue scale scores, shorter postoperative fasting time, lower frequency of antibiotic administration, and longer operative time than the CLA group. In the SLAN group, younger patients had a longer appendix and male patients had a thicker appendix; additionally, patients with an appendiceal diameter of 0.6 to 1.0 cm had a longer postoperative hospital stay and higher frequency of antibiotic administration.

Conclusions

Compared with CLA, SLAN may be less invasive, provide faster postoperative recovery, and result in better cosmesis for patients with uncomplicated appendicitis. Further research should be performed to evaluate the long-term outcomes.

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

Evaluating the Feasibility of Single Incision Laparoscopic Appendectomy Performed by a Resident Based on Propensity Score Matching

PURPOSE

Conventional laparoscopic appendectomy (CLA) has been considered the standard for the treatment of acute appendicitis. Recently, single incision laparoscopic appendectomy (SILA) has become an alternative option. There are few reports on the results of SILA performed by residents during the training period. The present study, we report our residents' experience.

MATERIALS AND METHODS

We reviewed clinical characteristics and outcomes of 1005 patients who underwent appendectomy between October 2013 and April 2016. Every operation was performed by only residents. Clinical characteristics and operative outcomes between SILA and CLA group were reviewed after propensity score matching.

RESULTS

SILA was used more frequently in younger patients (23.3 versus 36.4 years, P = .000), women (66.4% versus 45.9%, P = .000), and patients with lower body mass index (20.2 versus 22.9 kg/m², P = .043). After propensity score matching, the rate of complicated appendicitis was lower (12.9% versus 15.5%, P = .573), and the mean operative time was slightly shorter in the SILA group than in the CLA group (56.68 versus 59.09 minutes, P = .068), although these differences were not statistically significant. There were no significant differences between the two groups in hospitalization period (2.7 versus 2.9 days, P = .380), the use of analgesics (2.0 versus 2.1 times, P = .128), and wound complication rate (10.3% versus 14.6%, P = .333).

CONCLUSION

It is a safe and relatively easy procedure with an acceptable postoperative cosmetic outcome that can be incorporated into the routine surgical training.