Single-incision versus conventional three-incision laparoscopic appendicectomy for appendicitis: a systematic review and meta-analysis

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).

Single-Incision Laparoscopic Appendectomy Using Standard 5 mm Trocars: Single Pediatric Center Experience

Purpose: Single-incision laparoscopic appendectomy (SILA) for the treatment of appendicitis has been documented. Typically, SILA requires the use of specialized ports, instruments, and materials. The SILA technique at our institution utilizes the same instrumentation as the conventional laparoscopic approach (CLA), thus obviating the need for these specialized products. This study aims to further demonstrate the noninferiority of our SILA technique for the treatment of uncomplicated appendicitis. Materials and Methods: This is a single-institution retrospective review of patients who underwent SILA from 2011 to 2020 to treat uncomplicated appendicitis. Outcomes including demographics, operative time, length of stay (LOS), and common postsurgical complications were evaluated. These SILA cases were matched with up to 3 CLA controls based on age, gender, and weight utilizing the Greedy match method. Patients with an operative diagnosis of perforated appendicitis were excluded. Results: A total of 137 patients underwent SILA at a single institution. A total of 128 patients were in the final cohort after excluding perforated appendicitis. Mean age was 11.9 years. Case-control matching was conducted with 349 controls included. Between cases and controls, SILA had shorter operative time (27.2 minutes versus 43.7 minutes, P < .001) with no difference in mean LOS (42.4 hours versus 42.4 hours, P = .88). There was no difference in complication rate (5.4% versus 8.5%, P = .06). There was no difference in readmission rate (0.8% versus 3.4%, P = .108). Conclusion: These data suggest that for appropriately selected patients, our SILA technique is noninferior to CLA with shortened operative time.

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.

[Recommendations on treatment of acute appendicitis : Recommendations of an expert group based on the current literature]

The paradigm shift in the treatment concept for acute appendicitis is currently the subject of intensive discussions. The diagnosis and differentiation of an uncomplicated from a complicated appendicitis as well as the selection of an adequate treatment is very challenging, especially since nonoperative treatment models have been published. The laparoscopic appendectomy is still the standard for most cases. Guidelines for the treatment of acute appendicitis do not exist in Germany. Therefore, a group of experts elaborated 21 recommendations on the treatment of acute appendicitis after 3 meetings. After initial definition of population, intervention, comparison and outcome (PICO) questions, recommendations have been finalized through the Delphi voting system. The results were evaluated according to the current literature. The aim of this initiative was to define a basic support for decision making in the clinical routine for treatment of acute appendicitis.

A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery

OBJECTIVE

Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality.

BACKGROUND

Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated.

METHODS

Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality.

RESULTS

112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression.

CONCLUSIONS

There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.

Methodological overview of systematic reviews to establish the evidence base for emergency general surgery

BACKGROUND

The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions.

METHODS

Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist.

RESULTS

The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias.

CONCLUSION

This overview of reviews highlights the need for more and better research in this field.

Two-trocar appendectomy in children - description of technique and comparison with conventional laparoscopic appendectomy

Background

The aim of the study was to describe the technique of two-trocar laparoscopic appendectomy and compare the outcome between two- and three-trocar techniques in children.

Methods

All children who underwent laparoscopic surgery for suspected appendicitis from 2006 to 2014 in a center for pediatric surgery were included in the study. Converted surgeries and patients with appendiceal abscess or concomitant intestinal obstruction were excluded. A total of 259 children underwent appendectomy with either two (35 %) or three (65 %) laparoscopic trocars according to the surgeons’ preference and intraoperative judgment. Patient demographics, clinical symptoms, surgery characteristics, and complications were reviewed.

Results

The mean age of the children was 10.4 years (range, 1–14 years). The mean follow-up time was 41.2 months (SD ± 29.2). No significant differences in age, gender, weight, or signs and symptoms were found between the two- and three-trocar groups. The mean surgery time was significantly shorter in the two-trocar group (47 min) than in the three-trocar group (66 min; p < 0.001). The rates of surgical complications were 2 % vs. 4 %, (p = 0.501), and the rates of postoperative complications were 0 % vs. 5 % (p = 0.054), in the two- and three-trocar groups. The overall incidence of postoperative wound infection was low (<1 %) and did not differ between groups.

Conclusions

Two-trocar laparoscopic appendectomy seems to be a safe and feasible technique with a low rate of postoperative wound infections. The present findings demonstrate that when the two-trocar technique could be applied, it is a good complement to the conventional three-trocar technique.

Comparison of transumbilical laparoscopic-assisted appendectomy versus single incision laparoscopic appendectomy in children: which is the better surgical option?

BACKGROUND

Transumbilical laparoscopic-assisted appendectomy (TULA) is a single incision technique that exteriorizes the appendix through the umbilicus. The aim of this study was to compare the surgical outcomes of TULA with SILA in pediatric appendicitis.

METHODS

A retrospective review of medical records between April 2011 and April 2015 identified 250 pediatric patients who underwent single incision laparoscopic appendectomy. Of these, 137 patients underwent TULA and 113 patients underwent SILA. Measured outcomes included patients' demographics, clinical characteristics, operative time, length of stay, pain, and postoperative complications.

RESULTS

TULA group had a shorter operative time than SILA group (28.93 vs. 49.19min, p<0.001). The use of rescue analgesics was more frequent in the SILA group (six cases (6.5%) vs. 19 cases (23.4%), p<0.001). There was no significant difference in cosmetic outcome between the two groups. However, TULA was associated with a lower complication rate (2/137, 1.5%) than SILA (11/113, 9.8%) (p=0.0035). In multiple logistic regression analysis, TULA was significantly associated with a lower complication rate (p=0.049).

CONCLUSIONS

TULA is preferable to SILA for treating pediatric acute appendicitis because it is technically easier, results in better surgical outcomes, and provides the same excellent cosmetic results.

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.

Systematic review and meta-analysis of single-incision versus conventional laparoscopic appendectomy in children

BACKGROUND

Increasing evidence has indicated that single-incision laparoscopic appendectomy (SILA) is a safe procedure that has a comparable clinical outcome to conventional multiport laparoscopic appendectomy (CLA) in adult patients. Nevertheless, the use of SILA in pediatric patients is still controversial, and systematic reviews that compare SILA and CLA in children are lacking in the current literature.

METHODS

A literature search in MEDLINE, EMBASE, Cochrane library, and ClinicalTrials.gov was performed to identify eligible studies that were conducted between January 1998 and September 2014. Primary outcome measures were total postoperative complications, wound infection, intra-abdominal abscess, ileus, and wound hematoma. Secondary outcome measures were operative time, length of hospital stay and the frequency of use of additional analgesics. The random effect model was used for the meta-analysis.

RESULTS

The literature search identified 2 randomized clinical trials and 12 nonrandomized clinical trials that met the inclusion criteria for the meta-analysis. These studies included a total of 2249 patients: 744 who underwent SILA and 1505 who underwent CLA. No significant differences were observed between the groups with respect to the incidence of total postoperative complications, intraabdominal abscess, ileus, wound hematoma, length of hospital stay, or the frequency of use of additional analgesics. However, SILA was associated with a higher incidence of wound infection (OR=2.25; 95%=1.21-4.17; P=0.01) compared with CLA and required a longer operative time (WMD=5.73 minutes; 95% CI=4.17-7.28; P<0.00001).

CONCLUSIONS

SILA seems to be a relatively feasible and safe procedure without any superiority to CLA. Thus, SILA may not be a better approach for pediatric patients.

Impact of experience on quality outcomes in single-incision laparoscopy for simple and complex appendicitis in children

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) is an effective treatment for appendicitis in children. We report our experience with SILA, focusing on how surgeon experience may impact quality outcomes.

METHODS

A retrospective review of patients who underwent SILA from August 2009 to November 2013 was performed. Patients were grouped by early experience, late experience without surgical trainees, and late experience with trainees and further stratified into simple and complex appendicitis.

RESULTS

SILA was performed on 703 patients with a mean age of 11.8±3.9years. Four hundred eleven (58.5%) patients were diagnosed with simple and 292 (41.5%) with complex appendicitis. There was a significant decrease in operative time between early and late groups for both simple and complex appendicitis. Following the introduction of surgical trainees, there was a significant increase in operative time compared to the late group for simple appendicitis. There were no significant differences in complication rates between any of the groups.

CONCLUSION

The adoption of SILA requires a significant learning curve even for the experienced laparoscopist with the potential for decreased operative times with experience. While there may be an increase in operative time with the introduction of trainees, this does not impact quality outcomes.

Single-port versus conventional laparoscopic total extra-peritoneal inguinal hernia repair: a prospective, randomized, controlled clinical trial

BACKGROUND

The advantage of single-port total extra-peritoneal (TEP) inguinal hernia repair over the conventional technique is still debatable. Our objective was to compare the outcomes of TEP inguinal hernia repair using either a single-port or conventional surgical technique, in two blind randomized groups of patients.

METHODS

In this prospective, randomized, double-blind, controlled clinical trial, 100 patients undergoing surgery for unilateral inguinal hernia were randomized into two groups: One group underwent conventional laparoscopic TEP inguinal hernia repair, while the other was selected for single-port TEP repair. Primary endpoint is postoperative pain (VAS), while secondary endpoints are recurrence, chronic pain and complications.

RESULTS

From 100 patients, 49 underwent single-port hernia TEP repair, 50 had conventional three-port TEP hernia repair, and one patient declined to participate after randomization. The two groups were comparable in terms of patient demographics and operative findings. Mean operative time was 49.1(±13.8) min in the conventional group and 54.1(±14.4) min in the single-port group (p = 0.08). Mean hospital stay was 19.7(±5.8) h in the conventional group and 20.5(±6.4) h in the single-port group (p = 0.489). No major complications and no recurrence reported at 11-month follow-up. No statistically significant difference noted in postoperative pain between the two groups at regular intervals.

CONCLUSIONS

The outcomes after laparoscopic TEP inguinal hernia repair with a single-port device are similar but not superior to the conventional technique.

Suprapubic single incision laparoscopic appendectomy

BACKGROUND

The single incision method through the umbilicus is commonly used for laparoscopic appendectomy. To obtain a better cosmetic outcome and less surgical complexity, we have designed a new single-incision laparoscopic appendectomy technique performed above the pubic symphysis.

METHODS

Between January 2011 and January 2012, patients with uncomplicated acute or chronic appendicitis, excluding those with abscess, perforation, peritonitis, and previous pelvic surgery, underwent this innovative laparoscopic appendectomy. During each operation, a multichannel trocar composed of a small wound protector and a size 6 sterile glove was deployed after a 2 cm transverse incision was made 1-2 cm above the pubic hair area.

RESULTS

Of the 42 patients, 24 were male and 18 were female. Their mean age was 30 ± 11 y. The mean operative time was 58 ± 11 min, mean time to first flatus postoperatively was 17 ± 8 h, and mean postoperative length of hospital stay was 3 ± 1 d. No complications occurred during surgery. No patient required conversion to either multiport or open appendectomy. Postoperative wound inflammation was observed in one case (2.3%).

CONCLUSIONS

Our results suggested that suprapubic single-incision laparoscopic appendectomy seems to be safe and feasible for selected patients, in consideration of cosmetic outcomes.

Routine utilization of single-incision pediatric endosurgery (SIPES): a 5-year institutional experience

BACKGROUND

Single-incision pediatric endosurgery (SIPES) allows operation through one access site, eliminating the multiple sites traditionally used. There are few large series evaluating the versatility of SIPES. The purpose of this study is to review a 5-year single-institution experience with routine SIPES use.

PATIENTS AND METHODS

This is an Institutional Review Board-approved retrospective analysis of prospectively collected data. All SIPES cases from March 2009 to December 2013 were included. Our database contains demographics, procedure type, operative duration, estimated blood loss, instance of added ports or conversion to open, complications, and follow-up duration.

RESULTS

Of 1322 SIPES operations performed, most (82.1%) were appendectomies and cholecystectomies. Of 871 (66%) patients seen in follow-up, with a median duration of 26 days, 53 (6.1%) experienced postoperative complications. Forty-two cases (4.8%) were surgical-site infections, of which 4 required drainage. Less frequent complications that required operative intervention include recurrent inguinal hernia (n=4), umbilical hernia (n=3), intraabdominal abscess (n=1), bleeding (n=1), abdominal compartment syndrome (n=1), bowel obstruction (n=1), stitch granuloma (n=1), and persistent postoperative pain (n=1).

CONCLUSIONS

Operative times and complication rates are comparable to those in prior reported multiport laparoscopic series, allowing safe integration of SIPES into the routine of a surgical practice for most common procedures.

Minimal access laparoscopic surgery for treatment of ulcerative colitis and familial adenomatous polyposis coli in children and adolescents

BACKGROUND

Laparoscopic restorative proctocolectomy is standard surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis coli (FAP). Scar burden can be minimized by reducing the number of laparoscopic ports. The aim of this study is to review the authors' experience with reduced-port laparoscopy in this setting and to compare it with conventional laparoscopy using multiple ports.

MATERIALS AND METHODS

Charts of pediatric patients undergoing colectomy for UC or FAP between 2009 and 2012 were retrospectively reviewed. Patients who had the operation performed through one or two multichannel ports were assigned to the minimal access (MA) study group. Patients who had four or five single-channel ports with or without an additional small laparotomy were assigned to the LAP group.

RESULTS

Twenty-two patients were identified. Ages at first operation were 2-18 years (median, 13.5 years). There were no conversions to laparotomy and no mortality. Mean operative times for the MA and LAP groups, respectively, were 250 and 284 minutes for abdominal colectomy with end ileostomy (P=.15), 198 and 301 minutes for completion proctectomy with diverting loop ileostomy (DLI) (P=.26), and 455 and 414 minutes for proctocolectomy with ileal pouch-anal anastomosis and DLI (P=.72). A major complication requiring laparotomy occurred in 1 patient (9%) in the MA group and in 2 patients (18%) in the LAP group.

CONCLUSIONS

Minimal access laparoscopic surgery for UC and FAP is safe and feasible. A slightly larger incision at the ostomy site facilitates extraction of the specimen and extracorporeal construction of a J-pouch. Operative times and hospital stay are comparable to those with multiport laparoscopy.

Single-incision versus three-port laparoscopic appendectomy for acute appendicitis: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Three-port laparoscopic appendectomy (TPLA) has been shown superior to open appendectomy for acute appendicitis (AA); alternatively, single-incision laparoscopic appendectomy (SILA) is gaining popularity. The choice between SILA and traditional TPLA remains controversial. This meta-analysis of high-quality randomized controlled trials (RCTs) aims to compare efficacy and safety of SILA with TPLA for AA.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library for RCTs comparing SILA with TPLA. Reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases were also searched. Primary outcomes were operative time, postoperative complications, hospital duration, and days back to normal activities. Meta-analysis was conducted where possible comparing items using weighted mean differences (WMDs) and relative risks (RRs) according to type of data. Methodological quality was evaluated to assess bias risk.

RESULTS

A total of 8 distinct RCTs comparing SILA (n = 616) with TPLA (n = 618) published from 2010 to 2013 were identified in our analysis. SILA took longer to conduct than TPLA (43 vs 38, WMD: 5.96, 95 % CI 2.54-9.38, P = 0.0006). Patients undergoing SILA needed more extra trocars addressed during operation (7 % vs 0 %, RR: 12.36, 95 % CI 3.83-39.90, P < 0.0001), but could return to full activities earlier (6 vs 7, WMD: -0.68, 95 % CI -1.10 to -0.26, P = 0.001). However, these differences were not clinically significant. All other parameters were comparable.

CONCLUSIONS

These results provide level 1a support for the clinical similarity that SILA is basically as feasible, effective and safe as TPLA when dealing with AA, although statistically, SILA takes longer to perform, requires more extra trocars, and benefits patients with faster recovery compared with TPLA. Further RCTs are needed to update our finding with advancement of surgical techniques and skills.