Single-incision laparoscopic appendectomy using conventional instruments: an initial experience using a novel technique

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.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis: A systematic review, meta-analysis and trial sequential analysis of randomised controlled trials

AIMS

The aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters.

RESULTS

Sixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD -0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD -2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection.

CONCLUSION

Although SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required.

Single incision laparoscopic surgery using conventional laparoscopic instruments versus two-port laparoscopic surgery for adnexal lesions

Single incision laparoscopic surgery (SILS) has emerged as least invasive interventions for gynecologic disease. However, SILS is slow to gain in popularity due to difficulties in triangulation and instrument crowding. Besides, the costly instruments may influence patients' will to have this procedure, and limit other medical expense as well. To optimize outcome and reduce cost, the objective of this study is to evaluate the feasibility and safety for patients undergoing adnexal surgeries using conventional laparoscopic instruments with SILS (SILS-C), and to compare with those of patients subject to TP using conventional laparoscopic instruments (TP-C). This is a retrospective case-control study. The data dated from April 2011 to April 2018. Patients who received concomitant multiple surgeries, were diagnosed with suspected advanced stage ovarian malignancy, or required frozen sections for intraoperative pathologic diagnosis were excluded. Demographic data, including the age, body weight, height, previous abdominal surgery were obtained. The surgical outcomes were compared using conventional statistical methods. 259 patients received SILS-C. The operating time was 63.83 ± 25.31 min. Blood loss was 2.38 ± 6.09 c.c. 58 patients (24.38%) needed addition of port to complete surgery. 384 patients received TP-C. Compared with SILS-C, the operating time was shorter (57.32 ± 26.38 min, OR = 0.984, CI = 0.975-0.992). The patients were further divided into unilateral or bilateral adnexectomy, and unilateral or bilateral cystectomy. Other than the operating time in unilateral cystectomy (66.12 ± 19.5 vs. 58.27 ± 23.92 min, p = .002), no statistical differences were observed in the subgroup analysis. Single incision laparoscopic surgery using conventional laparoscopic instruments is feasible and safe as initial approach to adnexal lesions. In complex setting as unilateral cystectomy or pelvic adhesions, two-port access may be considered.

Easily Applicable Single-incision Laparoscopic Appendectomy Using Straightforward Instrumental Alignment and Conventional Laparoscopic Instruments

BACKGROUND

Laparoscopic appendectomy is one of the most frequently performed operations. As such, single-incision laparoscopic appendectomy (SILA) is indicated as a feasible and safe procedure comparable to conventional laparoscopic appendectomy (CLA). However, novice surgeons face challenges in performing SILA, because the role of the surgeon's hands is reversed. We introduce an easily applicable technique of SILA by adapting the alignment of CLA.

METHODS

A series of 61 consecutive patients underwent SILA between January 2019 and December 2019 by 4 surgeons at Bundang CHA Medical Center. Acute appendicitis was diagnosed preoperatively by abdomino-pelvis computed tomography or ultrasonography. During the operation, a 3-channel Glove port was used with conventional laparoscopic instruments.

RESULTS

The study participants consisted of 32 males and 29 females, with a mean age of 26.8 years (range, 4 to 66 y). The mean body mass index was 20.79 kg/m2 (range, 11.89 to 27.04 kg/m2). The mean operation time was 37.5±17.0 minutes. There was only 1 case of conversion with 1 additional port. Eight patients (13.1%) experienced postoperative complications defined by Dindo-Clavien-Strasberg classification: grade 1 wound complication in 7 patients and grade 2 postoperative bowel obstruction in 1 patient. The mean postoperative hospital stay was 2.5±1.3 days.

CONCLUSION

Alignment of the instruments during CLA was successfully implemented into a SILA. Our new, easily applicable SILA technique will decrease the learning curve for novice surgeons in performing single-incision laparoscopic surgery.

Single-incision laparoscopy surgery: a systematic review

Background

Laparoscopic surgery is a modern surgical technique in which operations are performed far from their location through small incisions elsewhere in the body.

Objective

This systematic review is aimed to overview single-incision laparoscopy surgery.

Methods

This systematic review was carried out by searching studies in PubMed, Medline, Web of Science, and IranMedex databases. The initial search strategy identified about 87 references. In this study, 54 studies were accepted for further screening and met all our inclusion criteria [in English, full text, therapeutic effects of single-incision laparoscopy surgery and dated mainly from the year 1990 to 2016]. The search terms were “single-incision,” “surgery,” and “laparoscopy.”

Results

Single-incision laparoscopy surgery is widely used for surgical operations in cholecystectomy, sleeve gastrectomy, cholecystoduodenostomy, hepatobiliary disease, colon cancer, obesity, appendectomy, liver surgery, rectosigmoid cancer, vaginal hysterectomy, vaginoplasty, colorectal lung metastases, pyloroplasty, endoscopic surgery, hernia repair, nephrectomy, rectal cancer, colectomy and uterus-preserving repair, bile duct exploration, ileo-ileal resection, lymphadenectomy, incarcerated inguinal hernia, anastomosis, congenital anomaly, colectomy for cancer.

Conclusion

Based on the findings, single-incision laparoscopy surgery is a scarless surgery with minimal access. Although it possesses lots of benefits, including less incisional pain and scars, cosmesis, and the ability to convert to standard multiport laparoscopic surgery, it has some disadvantages, for example, less freedom of movement, fewer number of ports that can be used, and the proximity of the instruments to each other during the operation.

Exclusion criteria for assuring safety of single-incision laparoscopic cholecystectomy

Despite increasing popularity of single-incision laparoscopic cholecystectomy (SILC), indication criteria assuring safety of SILC has yet to be established. In the present study, the subjects consisted of 146 consecutive patients undergoing conventional laparoscopic cholecystectomy (CLC) or SILC. SILC was indicated after excluding patients who met following criteria: age > 75 years, obesity, operative scar, cardiopulmonary diseases, acute cholecystitis, choledocholithiasis and abnormal bile duct anatomy. Thirty-four patients were excluded from the SILC candidates (moderate/high-risk CLC group). Among the 112 potential candidates, SILC was indicated for 23 patients (21%, SILC group) and the remaining 89 patients (79%) underwent CLC (low-risk CLC group). In the SILC group, operation time was longer than in the low-risk CLC group (171 [113-286] vs. 126 [72-240] min, p < 0.01), but the periods requiring painkiller was shorter. That led to reduced length of hospital stay compared to low-risk CLC group (2 [2-4] vs. 4 [2-12] days, p < 0.01). Between the low-risk CLC and moderate/high-risk CLC group, operation time was significantly longer and amount of blood loss was larger in the latter group. No complications were encountered in the SILC group. SILC can be indicated safely as far as appropriate criteria is adopted for excluding patients in whom complicated laparoscopic procedures are needed.

Expanding the indications for single-incision laparoscopic cholecystectomy to all patients with biliary disease: is it safe?

PURPOSE

The safety of single-incision laparoscopic cholecystectomy (SILC) has been proven in well-selected patients. The objective of this study was to determine whether SILC can be offered to all patients with any indication for cholecystectomy.

METHODS

A total of 173 consecutive SILCs were performed between January 2010 and November 2012 with no exclusion criteria. Demographic data, operative, and postoperative outcomes were prospectively collected and analyzed.

RESULTS

Patients with acute cholecystitis and gallstone pancreatitis had longer operative times and a higher conversion to 4-port cholecystectomy than patients with biliary colic. Similar relationships were seen when comparing patients with obesity to nonobese patients. There were no differences in complication rates between the groups.

CONCLUSIONS

SILC can be safely offered to patients with a wide spectrum of biliary disease with the understanding that this may result in increased operative times and a higher likelihood of conversion to multiport laparoscopy.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Comparison and efficacy of LigaSure and rubber band ligature in closing the inflamed cecal stump in a rat model of acute appendicitis

Safety of either LigaSure or rubber band in closing inflamed appendiceal stump in acute appendicitis has been less investigated. In this study, cecal ligation followed by resecting inflamed cecum was performed to mimic appendectomy in a rat model of acute appendicitis. Rats were sacrificed immediately (Group A) and 7 days (Group B) after cecal resection, respectively. The cecal stumps were closed by silk ligature (S), 5 mm LigaSure (L), or rubber band (R). Seven days after cecal resection, the LigaSure (BL) and silk subgroups (BS) had significantly less intra-abdominal adhesion and better laparotomy wound healing than rubber band subgroup (BR). The initial bursting pressure at cecal stump was comparable among the three methods; along with tissue healing process, both BL and BS provided a higher bursting pressure than BR 7 days after appendectomy. BL subgroup had more abundant hydroxyproline deposition than BS and BR subgroup. Furthermore, serum TNF-α in BR group kept persistently increasing along with time after cecal resection. Thus, the finding that LigaSure but not rubber band is safe in sealing off the inflamed cecal stump in rat model of acute appendicitis suggests the possibility of applying LigaSure for appendectomy via single port procedure or natural orifice transluminal endoscopic surgery (NOTES).

Simple technique for gasless transumbilical single-incisional laparoscopic-assisted appendectomy

PURPOSE

Single-incision laparoscopic surgery has recently received more attention. We developed a novel simple technique of gasless transumbilical single-incisional laparoscopic-assisted appendectomy (TUSILAA) and retrospectively analyzed our initial experience.

METHODS

TUSILAA has been attempted in 50 consecutive patients with acute appendicitis. The vertical incision through the umbilicus was used for laparoscopic access and the abdominal wall was lifted by a Kent retractor set system.

RESULTS

Our technique was successful in 45 out of 50 (90 %) patients. The median operating time was 59 min (range 35-140). The median length of postoperative hospital stay was 4 days (range 2-12). None of the cases were converted to open appendectomy. There were no perioperative surgical complications.

CONCLUSIONS

Our novel technique, gasless TUSILAA, is safe and feasible with acceptable operative time and excellent cosmetic result. Furthermore, this procedure has the advantage of cost-effectiveness since any disposable instruments including trocars, staplers, or expensive devices are not required. Therefore, this could be used as the first-choice surgical procedure for selected patients with uncomplicated acute appendicitis.

Single-incision versus conventional laparoscopic appendectomy: A case-match study

Background:

Three-port laparoscopic appendectomy is considered standard in many countries for the surgical treatment of acute appendicitis. Single-incision laparoscopic technique has been recently introduced and is supposed to minimize the aggression induced by surgery. Regarding appendectomy, comparison with standard laparoscopy, benefits and drawbacks of this novel technique remain to be evaluated. The goal of this study was to assess single-incision laparoscopic appendectomy compared to conventional laparoscopic appendectomy in terms of operation time, length of hospital stay, complication rate, and postoperative antibiotherapy rate.

Methods:

From February 2011 to December 2011, single-incision laparoscopic appendectomy was proposed to patients admitted to the emergency room of the University Hospital of Lausanne (CHUV, Lausanne, Switzerland), diagnosed with uncomplicated acute appendicitis. Preoperative patients’ information, technical difficulties during the operation, and postoperative follow-ups were recorded. Every patient who underwent single-incision laparoscopic appendectomy (n = 20) was matched 1:3 conventional laparoscopic appendectomy (n = 60), controlling for age, gender, body mass index, American Society of Anesthesiologists score, and histopathological findings.

Results:

No statistically significant differences for median operation time, length of hospital stay, complication rate, and need for postoperative antibiotherapy were found. In 5 out of 20 single-incision laparoscopic appendectomy patients the Endoloop^® Ligature was judged difficult to put in place.

Conclusion:

This study suggests that single-incision laparoscopic appendectomy is a feasible and effective operative technique for uncomplicated acute appendicitis.

Single-incision laparoscopic surgery for ingested foreign body removal

This report presents a 16-year-old adolescent boy with intentional ingestion of a 6-cm-length iron nail in detention center 6 hours ago. There was no symptom and sign of acute abdominal pain. Abdominal computed tomographic scan was performed, and an iron nail was found in the left upper quadrant abdomen. Considering the size, shape, and location of the foreign body, emergency surgery was performed using single-incision laparoscopic surgery approach. Multiple trocars in umbilical incision technique and conventional instruments were used. After identification of the foreign body in jejunum by alternative clamping of small bowel, enterostomy was made, and extracorporeal suturing was performed. The operation time was 1 hour without blood loss during the surgery. The patient left the bed 6 hours after the surgery. Bowel function recovered, and the gastric tube was removed on postoperative day 2. No painkiller was used after the surgery. The patient was discharged on postoperative day 3 without any complication. To our knowledge, it is the first report on removal of ingested foreign body located in jejunum using single-incision laparoscopic surgery technique.

Reduced port surgery for appendectomy: Early experience and surgical technique

AIM: To evaluate our experience and surgical technique of laparoscopic appendectomy via reduced port surgery (LARPS).

METHODS: Sixteen patients (8 men and 8 women; median age: 31.0 years) who underwent LARPS between November 2009 and May 2012 were included in the present study. We performed LARPS, in which access devices were inserted through an umbilical skin incision with 1 additional skin incision in the left lower abdomen. After setting access devices, pneumoperitoneum was maintained at 10 mmHg using CO₂ and a 3 mm trocar was positioned (or direct puncture was performed by the Endo Relief system) under laparoscopic guidance. The mesoappendix was dissected using an ultrasonically activated device. After mesoappendix dissection, ligation was performed near the appendix base and the appendix was dissected using an ultrasonically activated device. The appendix was then removed. At the end of surgery, we administered local anesthesia with ropivacaine 1% (10 mL) for the skin incisions. The outcomes were evaluated in terms of operation time, intraoperative blood loss, length of postoperative hospital stay and surgical complications.

RESULTS: Our surgical procedure allowed operators to use instruments as in conventional laparoscopic appendectomy. The basic principle of triangulation of instrumentation was maintained to some degree. LARPS was performed in 9 patients with catarrhal appendicitis, 5 with phlegmonous appendicitis, and 2 with gangrenous appendicitis. The median surgery time was 60 min and the median intraoperative blood loss was 1.2 mL. The median length of postoperative hospitalization was 4 d. There were no conversions to open surgery, no operation-related complications or mortality.

CONCLUSION: Our experience and surgical technique suggest that LARPS is a safe and feasible procedure for patients with appendicitis.

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

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

Single-port laparoscopic appendectomy 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).

The evolution of the appendectomy: from open to laparoscopic to single incision

Beginning with its initial description by Fitz in the 19th century, acute appendicitis has been a significant long-standing medical challenge; today it remains the most common gastrointestinal emergency in adults. Already in 1894, McBurney advocated for the surgical removal of the inflamed appendix and is credited with the initial description of an Open Appendectomy (OA). With the introduction of minimally invasive surgery, this classic approach evolved into a procedure with multiple, smaller incisions; a technique termed Laparoscopic Appendectomy (LA). There is much literature describing the advantages of this newer approach. To name a few, patients have significantly less wound infections, reduced pain, and a reduction in ileus compared with the OA. In the past few years, Single Incision Laparoscopic Appendectomy (SILA) has gained popularity as the next major evolutionary advancement in the removal of the appendix. Described as a pioneer in the era of "scarless surgery," it involves only one transumbilical incision. Patients are postulated to have reduced post-operative complications such as infection, hernias, and hematomas, as well as a quicker recovery time and less post-operative pain scores, in comparison to its predecessors. In this review, we explore the advancement of the appendectomy from open to laparoscopic to single incision.

Single-incision Laparoscopic Surgery for Appendiceal Mucoceles: Safety and Feasibility in a Series of 16 Consecutive Cases

Purpose

The aim of this study was to evaluate the technical feasibility, safety, and oncological outcomes of transumbilical single-incision laparoscopic surgery in patients with an uncomplicated appendiceal mucocele.

Methods

A review of a prospectively collected database at the Kyungpook National University Hospital from January 2006 to September 2010 revealed that a series of 16 consecutive patients underwent single-incision laparoscopic surgery (SILS) for an appendiceal mucocele. Data regarding patient demographics, operating time, conversion, surgical morbidity, lateral lymph node status, and mid-term oncologic result were analyzed.

Results

The reported series consisted of 7 women (50%) and 9 men with a mean age of 61.6 years (range, 41 to 88 years). The mean operative time was 66.8 minutes (range, 33 to 150 minutes). Perioperative mortality and morbidity were 0% and 6.2%, respectively. Recovery after the procedure was rapid, and the mean hospital stay was 6.8 days (range, 3 to 22 days). Pathology revealed 12 lesions compatible with a mucinous cystadenoma and four others compatible with benign cystic tumors. All surgical margins were clear. In one case, an extra port had to be placed, and another case required conversion from SILS to a standard open laparotomy immediately after identification of the tumor because of a micro-perforation with focal mucin collection. With a median follow-up of 28.7 months, no re-admission or tumor recurrence, such as pseudomyxoma peritonei, was noted in 14 patients.

Conclusion

A single-port laparoscopic mucocelectomy should be safe and feasible and has the advantage of being a minimally invasive approach. Prospective controlled studies comparing SILS and conventional open surgery, with long-term follow-up evaluation, are needed to confirm the author's initial experience.

Laparoscopic appendectomy: new concepts

Over the last three decades more surgeons have used laparoscopic appendectomy as their surgical approach of choice in the management of patients with appendicitis. This includes special groups of patients, namely, pediatric, pregnant, and obese patients. Laparoscopy has the benefit of lower morbidity, decreased rate of wound complications, faster recovery, shorter length of hospital stay, and faster return to work over open appendectomy.

Single port laparoscopic appendectomy: are we pursuing real advantages?

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