Comparative study between single-incision and three-port laparoscopic appendectomy: a prospective randomized trial

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 versus conventional three-port laparoscopic appendectomy for acute appendicitis: A meta-analysis of randomized controlled trials

While consensus on single-incision laparoscopic appendectomy (SILA) for acute appendicitis is lacking, our meta-analysis evaluated the safety and efficacy of SILA compared to conventional three-port laparoscopic appendectomy (CTLA). A computer-based search was conducted in the China National Knowledge Infrastructure (CNKI), VIP, Wanfang, China Biological Medicine (CBM), PubMed, Embase, and Cochrane Library databases to identify randomized controlled trials (RCTs) comparing SILA with CTLA groups. Meta-analysis was performed using RevMan 5.3 software. A total of 26 RCTs were included. The meta-analysis results indicated that, compared to the CTLA group, the SILA group had a longer operation time [MD = 7.97, 95 % CI (5.84, 10.10), P < 0.00001], and a higher rate of conversion to open surgery [RR = 2.60, 95 % CI (1.27, 5.31), P = 0.009], but had a shorter time to return to normal activities [MD = -0.76, 95 % CI (-1.15, -0.37), P = 0.0001]. Additionally, the SILA group had higher satisfaction scores [SMD = 1.21, 95 % CI (0.75, 1.68), P < 0.00001] and cosmetic scores [SMD = 0.68, 95 % CI (0.45, 0.90), P < 0.00001]. There was no significant difference between the two groups in terms of pain scores at 24 h postoperatively [MD = -0.21, 95 % CI (-0.56, 0.14), P = 0.25], the incidence of wound infection [RR = 1.13, 95 % CI (0.74, 1.73), P = 0.58], or the overall complication rate [RR = 0.86, 95 % CI (0.66, 1.12), P = 0.27]. SILA is a safe and effective surgical approach that allows patients to recover to normal activities earlier, particularly for patients with a strong demand for better cosmetic outcomes. However, the quality of some RCTs in this meta-analysis is low, and further verification is needed through future high-quality RCTs.

A prospective randomized controlled study comparing patient-reported scar evaluation of single-port versus multiport laparoscopic appendectomy for acute appendicitis

Purpose

This study aimed to compare the postoperative outcomes and patient-surveyed scar assessments of single-port laparoscopic appendectomy (SPLA) with the outcomes of multiport laparoscopic appendectomy (MPLA).

Methods

Between August 2014 and November 2017, the prospective randomized study comprised 98 patients diagnosed with acute appendicitis and indicated for surgery. Fifty-one patients had MPLA and 47 patients received SPLA. The primary endpoint was the total score of Patient Scar Assessment Questionnaire (PSAQ) administered to patients 6 weeks after surgery.

Results

SPLA involved a shorter median operative time than MPLA (47.5 minutes vs. 60.0 minutes, p = 0.02). There were no apparent differences in the time before diet tolerance, length of hospital stay, and postoperative complication. SPLA patients had shorter total incision length (2.0 cm vs. 2.5 cm, p < 0.01) and required fewer analgesics on the day of surgery than MPLA patients (p = 0.011). The PSAQ favored the SPLA approach, revealing significant differences in total score (48 vs. 55, p = 0.026), appearance (15 vs. 18, p = 0.002), and consciousness (8 vs. 10, p = 0.005), while satisfaction with appearance and symptoms scale did not (p = 0.162 and p = 0.690, respectively).

Conclusion

The postoperative scar evaluated by the patient was better with SPLA than with MPLA, and patient satisfaction with the scar was comparable between the two techniques.

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.

Surgical Site Infection Following Single-Port Appendectomy: A Systematic Review of the Literature and Meta-Analysis

Introduction

Surgical site infections (SSIs) are one of the most common postoperative complications after appendectomy leading to recurrent surgery, prolonged hospital stay, and the use of antibiotics. Numerous studies and meta-analyses have been published on the effect of open versus conventional laparoscopic appendectomy (CLA) reporting faster postoperative recovery and less postoperative pain for CLA. A development from CLA has been the single-port appendectomy (SPA), associated with a better cosmesis but seemingly having a higher risk of wound infections. The aim of this systematic literature review and meta-analysis is to investigate whether reduced port or SPA alters the ratio of SSIs.

Methods

Pubmed, Embase, and Cochrane databases were screened for suitable articles. All articles published between January 1, 2002, and March 23, 2022, were included. Articles regarding children below the age of 18 were excluded as well as manuscripts that investigated solemnly open appendectomies. Articles were screened for inclusion criteria by two independent authors. Incidence of SSI was the primary outcome. Duration of operation and length of hospital stay were defined as secondary outcomes.

Results

A total of 25 studies were found through a database search describing 5484 patients. A total of 2749 patients received SPA and 2735 received CLA. There was no statistical difference in the rate of SSI (P = 0.98). A total of 22 studies including 4699 patients reported the duration of operation (2223 SPA and 2476 CLA). There was a significantly shorter operation time seen in CLA. The length of hospital stay was reported in 23 studies (4735 patients: 2235 SPA and 2500 CLA). A shorter hospital stay was seen in the SPA group (P &lt; 0.00001). Separately performed analysis of randomized controlled trials could not confirm this effect (P = 0.29).

Discussion

SPA is an equally safe procedure considering SSI compared to CLA and does not lead to an increased risk of SSI. A longer operation time for SPA and a minor difference in the length of stay does lead to the use of SPA in selected patients only.

Single incision laparoscopic surgery (SILS) versus conventional laparoscopic technique for ileostomy: a retrospective cohort study

PURPOSE

Minimal-invasive surgery has gained wide acceptance in colorectal surgery. Single incision laparoscopic surgery (SILS) was designed to minimize surgical trauma and improve postoperative outcome. However, the role of SILS in ileostomy formation is unclear.

METHODS

In this retrospective cohort study 26 patients were included. Six patients were operated with SILS and 20 with conventional laparoscopic technique for ileostomy. We retrospectively evaluated patient charts for baseline characteristics including prior abdominal surgeries and combination of surgeries. Our primary efficacy objectives were operation time and postoperative hospitalization days. Our safety objectives included the prevalence of postoperative pain, parastomal hernia, incisional hernia, perforation, wound infection, ileus, and infections in general.

RESULTS

Baseline characteristics including previous abdominal surgery and concomitant surgeries were comparable in both groups. Total operation time using SILS (37.5 ± 6.2 min [mean ± SD]), compared to laparoscopic surgery (82.2 ± 54.8 min [mean ± SD]) was significantly shorter (p = 0.0002). In a sensitivity analysis excluding patients with combined surgery, ileostomy formation by SILS was shorter (36.5 ± 6.2 min [mean ± SD]), compared to laparoscopy (59.7 ± 28.7 min [mean ± SD]; p = 0.024). Length of postoperative stay was not statistically different between the groups (SILS: 5.5 ± 2.4 days [mean ± SD]; laparoscopic: 13.8 ± 17.3 days [mean ± SD], p = 0.193). Postoperative complication rates were low and comparable in both groups.

CONCLUSION

Placement of a loop ileostomy using SILS technique not only reduces surgical trauma but also operation time without affecting postoperative hospital stay or postoperative complication rates. Single-incision laparoscopic surgery for ileostomy is an appealing approach for ileostomy in selected patients.

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

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-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis in children: a systematic review and meta-analysis

AIM

To evaluate comparative outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis in children.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Operative time, surgical site infection, intra-abdominal collection, incisional hernia, length of hospital stay (LOS), additional port/s and conversion to open were the evaluated outcome parameters.

RESULTS

Four RCTs reporting a total number of 520 patients who underwent SPLA (n = 260) or CLA (n = 260) were included. There was no difference between SPLA and CLA group in post-operative collection (risk difference (RD) - 0.00, P = 0.94), surgical site infection (RD 0.02, P = 0.25), incisional hernia (RD 0.00 P = 1), LOS (mean difference (MD) 0.73 P = 0.93), need for additional port/s (RD 0.04, P = 0.24) and conversion to open (RD 0.00, P = 1). However, there was a significantly longer operative time in the SPLA group (MD 9.80, P = 0.00001). The certainty of the evidence was judged to be moderate for all outcomes.

CONCLUSIONS

SPLA and CLA seem to have comparable efficacy and safety in children with acute appendicitis although the former may be associated with longer procedure time. Future high-quality RCTs with adequate sample sizes are required to provide stronger evidence in favour of an intervention.

Transumbilical Single-Incision Laparoscopic-Assisted Appendectomy (TULAA) Is Useful in Adults and Young Adolescents: Comparison with Multi-Port Laparoscopic Appendectomy

Background and objectives: Single-port laparoscopic appendectomy (SLA) in most previous studies has used intracorporeal excision of the appendix and needed a longer operative time than multi-port laparoscopic appendectomy (MLA), although SLA does have the potential benefit of an almost invisible scar within the umbilicus. Some studies have reported that extracorporeal transumbilical single-incision laparoscopic-assisted appendectomy (TULAA) in children took a considerably reduced operative time compared to MLA. We adopted TULAA in adults, adding routine dissection of the peritoneal attachment of the appendix. The aim was to compare the operative outcomes between TULAA and MLA. Materials and Methods: Between March 2013 and January 2016, 770 patients with acute uncomplicated and complicated appendicitis from 15 to 75 years of age were enrolled retrospectively. The operation was performed as early (EA) and interval appendectomy (IA). Results: Operative time was shorter in the TULAA group than in the MLA group, except for IA. No open conversion occurred in the TULAA group, except one case of ileocecal resection for IA. No intra-abdominal fluid collection was found in the TULAA group. Extended resection (especially partial cecectomy) was performed less frequently in the TULAA group than in the MLA group for IA. Mean postoperative hospital stay was shorter in the TULAA group for uncomplicated appendicitis. When the data of the EA group and the IA group were compared, operative time was significantly shorter in the IA group for both MLA and TULAA. The open conversion rate and the complication rate tended to be lower in the IA group. Confined to IA, the TULAA group tended to have shorter mean initial, postoperative, and total hospital stays. Conclusions: TULAA can be a useful surgical alternative to MLA in adults and young adolescents, because it lacks open conversion and provides both a shorter operative time and a shorter postoperative hospital stay. TULAA is feasible for IA in that it showed a lower rate of extended resection and complications.

Is single-incision laparoscopic appendectomy suitable for complicated appendicitis? A comparative analysis with standard multiport laparoscopic appendectomy

BACKGROUND

Despite emerging evidences on the feasibility and efficacy of single-incision laparoscopic appendectomy (SILA) for managing simple appendicitis, advancing its use for treating complicated appendicitis remains unwarranted. This study aimed to evaluate the surgical outcome of SILA compared with that of standard multiport laparoscopic appendectomy (MPLA) in the management of complicated appendicitis.

METHODS

Between July 2013 and September 2017, 40 patients who underwent SILA and 150 patients who underwent MPLA for the treatment of complicated appendicitis, defined as AAST grades II-V, were recruited for this study. The demographic characteristics, intraoperative and recovery parameters were retrospectively recorded. No routine drainage was placed in the SILA group.

RESULTS

SILA was smoothly performed without requiring conversion to MPLA. No significant difference was observed between the 2 groups in demography and preoperative severity. The operation duration was approximately 8 min shorter in the SILA group than in the MPLA group, without a statistical difference (60.03 ± 21.01 vs. 68.04 ± 32.03 min, p = 0.222). The recovery parameters, including soft diet intake and postoperative hospitalization, were more favorable in the SILA group (p < 0.001). Despite the absence of routine drainage in the SILA group, only 1 patient developed an intra-abdominal hematoma necessitating further computed tomography-guided drainage.

CONCLUSION

SILA is safe and feasible for the management of complicated appendicitis. SILA had non-inferior results to MPLA in terms of time to resume oral intake and postoperative hospital stay. Furthermore, this study posted a question on the concept of routine postoperative drainage in complicated appendicitis.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

BACKGROUND

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

METHODS

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

RESULTS

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

CONCLUSIONS

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

[Appendectomy: open versus laparoscopic versus single port : Evidence for choice of surgical procedure]

The treatment of choice in acute appendicitis is still the surgical removal of an inflamed vermiform appendix. There is still some disagreement regarding the optimal access route, i.e. conventional open or minimally invasive. The best available evidence is used to answer the question of the current optimal choice of procedure. For laparoscopic appendectomy there are evidence-based benefits in terms of access trauma, postoperative pain, wound infection rates and convalescence. For the alternative minimally invasive procedure single port appendectomy, mini-laparoscopic appendectomy or NOTES appendectomy, there is still a lack of scientific evidence to advocate the broad clinical use of these procedures. It is recommended that whenever the infrastructure permits, laparoscopic appendectomy should be the treatment of choice.

Single-port laparoscopic surgery in uncomplicated acute appendicitis: a randomized controlled trial

BACKGROUND

Single-port laparoscopic surgery (SPLS) is an alternative, minimally invasive surgical approach for managing appendicitis. The aim of this randomized trial was to evaluate the safety and efficacy of SPLS in uncomplicated appendicitis.

METHODS

Between December 2009 and November 2010, 194 patients with radiologically diagnosed acute appendicitis were randomly allocated to undergo either SPLS or multiport laparoscopic surgery (MPLS). Patients with intraoperative findings of perforated appendicitis were excluded from the analysis. The primary endpoint was perioperative morbidity. All data were analyzed according to the intention-to-treat principle.

RESULTS

Fourteen cases were excluded from the analysis. Of the remaining 180 patients, 90 were assigned to the SPLS group, and 90 to the MPLS group. Baseline characteristics were well balanced between the groups. In the SPLS group, the rate of conversion to MPLS was 11.1%. The operation time was 14.5 min longer for SPLS than for MPLS (p < 0.01), but there was no between-group difference in the rate of intraoperative complications (SPLS, 4.4%; MPLS, 0%; p = 0.12) or postoperative complications (SPLS, 4.4%; MPLS, 2.2%; p = 0.68). Compared to the MPLS group, the SPLS group had higher cumulative dose of analgesics (tramadol; 73.9 vs. 51.7 mg, p = 0.04), longer postoperative time to first passage of flatus (27.7 vs. 20.1 h, p < 0.01), longer postoperative hospitalization (2.5 vs. 2.1 days, p < 0.05), and higher total cost (1826.9 vs. 1662.4 USD, p < 0.01).

CONCLUSIONS

This randomized trial indicates that, compared to MPLS, SPLS does not increase the rate of perioperative or postoperative complications in uncomplicated appendicitis, but may have disadvantages such as increased operation time, later postoperative functional recovery, longer hospital stay, and higher costs, although the difference is minimal (ClinicalTrials.gov Identifier: NCT01007318).

Single-port Laparoscopic Appendectomy: Beyond the Learning Curve: A Retrospective Comparison With Multi-port Laparoscopic Appendectomy

OBJECTIVES

Previous comparisons between single-port laparoscopic appendectomy (SPLA) and multi-port laparoscopic appendectomy have been conflicting and limited. We compare our single-surgeon, SPLA experience with multi-port cases performed during the same time.

METHODS

A retrospective chart review of 128 single-surgeon single-port and 941 multi-port laparoscopic appendectomy cases from April 2009 to December 2014 was conducted.

RESULTS

Patient demographics and preoperative laboratory values were comparable. SPLA was associated with shorter operative time (P=0.0001). There was no statistically significant difference in length of hospitalization, postoperative pain medication use, cost, postoperative complication rates (ileus, urinary retention, deep space infection), or readmission between the 2 groups. There were no postoperative incisional hernias in the single-port group. The single-port group had more postoperative oxycodone use (P=0.0110).

CONCLUSIONS

Our study supports recently published metaanalyses that fail to support older studies demonstrating longer operative times, and higher hernia rates with SPLA.

Bayesian network meta-analysis of the effects of single-incision laparoscopic surgery, conventional laparoscopic appendectomy and open appendectomy for the treatment of acute appendicitis

The present study aimed to systematically evaluate the effectiveness of single-incision laparoscopic surgery (SILS), conventional laparoscopic appendectomy (CLA) and open appendectomy (OA) for the treatment of acute appendicitis. PubMed and Embase databases were systematically searched to identify relevant studies comparing the effectiveness of different appendectomy methods for treating acute appendicitis published prior to April 2016. ADDIS 1.16.5 software was used for data analysis. Heterogeneity was assessed using I² statistic. Odds ratios or standardized mean differences and 95% confidence intervals were calculated and pooled accordingly. Consistency was assessed using node-splitting analysis and inconsistency standard deviation. Convergence was assessed with the Brooks-Gelman-Rubin method using Potential Scale Reduction Factor (PSRF). Surgical procedure duration, duration of hospital stay, wound infection and incidence of abscesses were compared. A total of 24 eligible studies were included in this meta-analysis. A consistency model was used to pool data regarding the four outcomes. The PSRFs in each item were all <1.03. Pooled results showed that, compared with OA, SILS and CLA were associated with significantly shorter durations of hospital stay (all P<0.01) and lower risk of wound infection (SILS vs. OA P=0.02 and CLA vs. OA P<0.01, respectively), but no significant differences were identified between SILS and CLA. However, compared with OA, SILS exhibited a significantly longer surgical procedure duration (P=0.01) and lower incidence of abscesses (P=0.04), while no significant difference was observed between OA and CLA. This comprehensive network meta-analysis indicated that laparoscopic appendectomy, including SILS and CLA, may have more advantages for acute appendicitis compared with OA. Furthermore, SILS procedures require improvement and simplification to reduce the surgical procedure duration.

Optimal stump management in laparoscopic appendectomy: A network meta-analysis by the Minimally Invasive Surgery Synthesis of Interventions and Outcomes Network

BACKGROUND

Laparoscopic appendectomy is the predominant method of treatment of acute appendicitis. There is insufficient evidence on the most effective management of the appendix stump. The aim of this study was to investigate the relative effectiveness and provide a treatment ranking of different options for securing the appendix stump.

METHODS

Electronic databases were searched to identify randomized controlled trials comparing ligation methods of the appendix. The primary outcomes were organ/space infection and superficial operative site infection. We performed a network meta-analysis and estimated the pairwise relative treatment effects of the competing interventions using the odds ratio and its 95% confidence interval. We obtained a hierarchy of the competing interventions using rankograms and the surface under the cumulative ranking curve.

RESULTS

Forty-three randomized controlled trials were eligible and provided data for >5,000 patients. Suture ligation seemed to be the most effective treatment strategy, in terms of both organ/space infection and superficial operative site infection. Statistical significance was reached for the comparisons of clip versus endoloop (odds ratio 0.56, 95% confidence interval, 0.32-0.96) for organ/space infection; and suture versus clip (odds ratio 0.20, 95% confidence interval 0.08-0.55) and clip versus endoloop (odds ratio 2.22, 95% confidence interval 1.56-3.13) for superficial operative site infection. The network was informed primarily by indirect treatment comparisons.

CONCLUSION

The use of suture ligation of the appendix in laparoscopic appendectomy seems to be superior to other methods for the composite parameters of organ/space and superficial operative site infection.

Single-incision versus conventional three-incision laparoscopic appendectomy: A meta-analysis of randomized controlled trials

BACKGROUND

Conventional three-incision laparoscopic appendectomy (CTLA) is considered the new golden standard for the treatment of acute appendicitis. However, single-incision laparoscopic appendectomy (SILA) can further reduce the number of abdominal incisions and visible scars.

METHODS

Major databases were researched for randomized clinical trials (RCTs) comparing SILA and CTLA for acute appendicitis from January 1983 and to March 2015. The technical feasibility, effectiveness, and safety between SILA and CTLA were compared. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects models.

RESULTS

In total, 11 RCTs with 1489 patients were analyzed. The patients in the SILA group had a significantly shorter hospital duration (WMD: -0.63; 95% CI: -1.04, -0.21; P = 0.003) and return to activity (WMD: -2.91; 95% CI: -5.45, -0.37; P = 0.02) but experienced a longer operating time (WMD: 6.56; 95% CI: 3.55, 9.58; P < 0.0001) and higher rate of conversion (OR: 6.82; 95% CI: 3.14, 14.79; P < 0.00001). There were no differences between the two groups in visual analog pain scores, doses of analgesics, overall complication rates, wound infection, or cosmesis (all P > 0.05).

CONCLUSIONS

SILA is a safer and more effective than CTLA in both pediatric and adult patients.

Interventions to optimize recovery after laparoscopic appendectomy: a scoping review

BACKGROUND

No enhanced recovery after surgery protocol has been published for laparoscopic appendectomy. This was a review of evidence-based interventions that could optimize recovery after appendectomy.

METHODS

Interventions for the review Clinical pathway, fast-track or enhanced recovery protocols; needlescopic approach; single incision laparoscopic (SIL) approach; natural orifice transluminal endoscopic surgery (NOTES); regional nerve blocks; intraperitoneal local anaesthetic (IPLA); drains. Data sources MEDLINE, EMBASE, the Cochrane Library, and the Web of Science Core Collection. Study eligibility criteria Randomized controlled trial (RCT); prospective evaluation with historical controls for studies assessing clinical pathways/protocols. Participants People undergoing laparoscopic appendectomy for acute appendicitis. Study appraisal and synthesis methods Meta-analysis, random effects model.

RESULTS

Clinical pathways for laparoscopic appendectomy were safe in selected patients, but may be associated with a higher readmission rate. Needlescopic surgery offered no recovery advantage over traditional laparoscopic appendectomy. SIL afforded no recovery advantage over conventional laparoscopic surgery, but may increase operative time in children. The search found no RCT on NOTES appendectomy. Transversus abdominis plane blocks did not significantly reduce pain after laparoscopic appendectomy. IPLA should be considered in laparoscopic appendectomy; studies in paediatric surgery are needed. The search found no RCT on the use of drains in appendectomy.

CONCLUSIONS

This review identified gaps in the literature on optimizing recovery after laparoscopic appendectomy and found the need for more randomized controlled trials on regional anaesthesia and intraperitoneal local anaesthesia in children.

The use of expanding ports in laparo-endoscopic single-site surgery may cause more pain: a meta-analysis of randomized clinical trials

BACKGROUND

Previous meta-analyses on the clinical outcome after laparo-endoscopic single-site surgery (LESS) versus conventional laparoscopic surgery (CLS) have not revealed any major differences in postoperative pain between the two procedures. This meta-analysis aims to evaluate the difference in postoperative pain between the two procedures, focusing on whether LESS was conducted with a non-expanding port (LESSnonex) or a port expanding (LESSex) within the incision.

METHOD

EMBASE, Medline, PubMed, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials were searched for randomized clinical trials (RCTs) on LESS versus CLS for general abdominal procedures. Weighted mean difference (WMD) and Odds ratios (OR) were calculated with 95% confidence intervals (CI).

RESULTS

A total of 29 RCTs with 2999 procedures were included. Pain (VAS 0-10) 6 h after surgery was significantly lower in the group where LESS was conducted with LESSnonex compared to CLS, WMD=-0.72 (- 1.10 to - 0.33). Pain 18-24 h was significantly higher in the group where LESS was conducted with LESSex compared to CLS, WMD = 0.38 (0.01-0.75). Wound-related complications were significantly more frequent in LESSex procedures compared to CLS, OR = 1.94 (1.03-3.63).

CONCLUSION

The present meta-analysis indirectly indicates that the type of access device that is used for an abdominal LESS procedure may contribute to the development of early postoperative pain as the use of a non-expanding model was associated with a more advantageous outcome. Direct randomized comparison of LESSnonex and LESSex is warranted to confirm if the use of expanding access devices generates more pain and wound complications.

Single incision laparoscopic appendicectomy versus conventional three-port laparoscopic appendicectomy: A systematic review and meta-analysis

BACKGROUND

Appendicectomy is a well-established surgical procedure used in the management of acute appendicitis. The operation can be performed with minimally invasive surgery or as an open procedure. A further development in the minimally invasive appendicectomy technique has been the introduction of single incision laparoscopic surgery (SILA).

AIM

To ascertain any differences in outcomes from available trials comparing SILA with conventional multi-incision laparoscopic appendicectomy (CLA).

METHODS

A literature search of MEDLINE/PubMed, EMBASE/Ovid and CENTRAL for articles from Jan1990 to June 2015 with key words: 'appendectomy', 'appendicetomy'; 'appendicitis'; 'laparoscopy'; 'keyhole'; 'single port'; 'single incision'; 'single site'; 'one port'; 'incisionless'; 'scarless'. Randomised control trials of patients with signs and symptoms of appendicitis undergoing laparoscopic appendicectomy, with one arm being SILA were included. Statistical analysis was performed through Mantle-Haenszel and inverse variance methods.

RESULTS

A total of 8 RCTs published between 2012 and 2014 with a total of 995 patients were included. Meta-analysis showed no significant differences between SILA and CLA for complication rates, post-operative ileus, length of hospital stay, return to work or post-operative pain. CLA was significantly superior to SILA with reduced operating time (mean difference 5.81 [2.01, 9.62] P = 0.003) and conversion rates (OR 4.14 [1.93, 8.91] P = 0.0003). SILA surgery had better wound cosmesis (mean difference 0.55 [0.33, 0.77] P = 0.00001).

CONCLUSION

SILA is comparable to CLA in terms of complications, post-operative pain and recovery. Therefore, SILA could be a viable option in the hands of an experienced surgeons and for patients' groups who place great value on the final cosmetic outcome.

Systematic review and meta-analysis of randomized controlled trials comparing single incision versus conventional laparoscopic appendectomy

BACKGROUND

Single incision laparoscopic appendectomy (SILA) has been proposed as an alternative to conventional laparoscopic appendectomy (CLA).

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of SILA when compared with CLA through a systematic review.

METHODS

We performed an electronic search of EMBASE, PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) that compared SILA with CLA were included.

RESULTS

Six RCTs met eligibility criteria, which included a total of 800 patients, 401 in the SILA group and 399 in the CLA group. There were no significant differences in terms of overall complications (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.59-1.47; p = 0.77). SILA had a higher technical failure rate (OR 3.30; 95% CI 1.26-8.65; p = 0.01) and required a longer operative time (mean difference [MD] 4.67; 95% CI 1.76-7.57; p = 0.002). SILA was associated with better cosmetic results (standardized MD -0.4; 95% CI -0.64 to -0.16; p = 0.001) and earlier return to normal activity (MD -0.64; 95% CI -1.09 to -0.20; p = 0.005), although these advantages should be taken with caution due to the small number of studies reporting these two items and the short follow-up in the evaluation of cosmetic results. There were no significant differences in terms of postoperative pain or length of hospital stay between groups.

CONCLUSIONS

SILA is comparable to CLA in selected patients, although it is associated with a higher technical failure rate and longer operative time. Further randomized trials are needed to determine if SILA really offers benefits over CLA.

Gasless transumbilical laparoscopic-assisted appendectomy as a safe and cost-effective alternative surgical procedure for mild acute appendicitis

PURPOSE

Several reports have demonstrated the effectiveness and feasibility of single incisional transumbilical laparoscopic-assisted appendectomy (TULAA). We developed a modified TULAA technique, gasless-TULAA, which involves lifting the abdominal wall with a retractor, without pneumoperitoneum or another incision.

METHODS

We assessed the surgical outcomes of 257 patients treated for appendicitis in our hospital between 2005 and 2013. In a preoperative comprehensive evaluation, appendicitis without abscess was defined as mild appendicitis (mild appendicitis group: MAG), and appendicitis with abscess was defined as severe appendicitis (severe appendicitis group: SAG). The clinical outcomes were compared with those in other published reports. The cost-effectiveness of gasless-TULAA was compared with that of conventional multiport laparoscopic appendectomy (CMLA) in our hospital.

RESULTS

In MAG (n = 228), the operation time and postoperative hospital stay were 46.9 ± 22.7 min and 2.6 ± 1.2 days, respectively. The gasless-TULAA was completed without trocars in 91.2 % of patients. The surgical outcomes of SAG were significantly worse than those of MAG (p < 0.001). The surgical cost of gasless-TULAA was significantly lower than that of CMLA (p < 0.001).

CONCLUSION

Gasless-TULAA is a cost-effective, safe, and readily available surgical technique for mild appendicitis, which can obviate the need for specialized equipment.

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.

Single-incision laparoscopic appendectomy versus conventional 3-port laparoscopic appendectomy for appendicitis: an updated meta-analysis of randomized controlled trials

PURPOSE

To compare the efficacy and safety of single-incision laparoscopic appendectomy (SILA) and conventional 3-port laparoscopic appendectomy (3-port LA) for appendectomy.

METHODS

We searched the PubMed, Embase, Springer link, and the Cochrane library databases up to April, 2014, for relevant randomized controlled trials (RCTs). Data were pooled by weighted mean differences (WMDs) or odds ratios (ORs) with their 95% confidence intervals (CIs).

RESULTS

We found 11 RCTs, with a collective total of 731 patients treated with SILA and 725 patients treated with 3-point LA. Results indicated no significant differences between SILA and 3-port LA in primary outcomes, including wound infection, intra-abdominal abscess, postoperative ileus, and total postoperative complications, and some secondary outcomes, including postoperative pain scores and length of hospital stay. However, SILA was associated with significantly longer operative times (WMD = 6.78, 95% CI = 3.78-9.79, P < 0.00001) and higher doses of analgesia (WMD = 0.96, 95% CI = 0.45-1.47, P = 0.0002) than the 3-port LA.

CONCLUSION

Although there was no significant difference in the safety of SILA vs. that of 3-port LA, our findings do not support the application of SILA because of its significantly longer operative times and the higher doses of analgesia required compared with those for 3-point LA.

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

BACKGROUND

The efficacy of single incision laparoscopic appendectomy (SILA) in comparison with conventional multiport laparoscopic appendectomy (CMLA) has not been conclusively determined.

METHODS

A systematic literature review (Medline, EMBASE, Science Citation Index, and Cochrane Central Register of Controlled Trials) was performed. Meta-analyses of randomized controlled trials (RCTs) comparing SILA with CMLA were carried out by RevMan 5.0 software.

RESULTS

Eleven RCTs comparing SILA and CMLA were included. Overall, 1,216 patients were operated on: 611 cases by SILA versus 605 cases by CMLA. Compared with CMLA, SILA was associated with increased procedural difficulty, prolonged procedural duration, shorter length of hospital stay, earlier return to normal activity and better cosmesis. There were no significant differences in postoperative pain scores and complication rates between SILA and CMLA.

CONCLUSION

The current best evidence shows SILA holds the promise of improving postoperative recovery and cosmetic result with equal efficacy and safety, whereas it is associated with higher surgical difficulty with longer surgical time when compared with CMLA.

Single port laparoscopy in gastroenterology and hepatology: A fine step forward

Single incision laparoscopy (SIL) has become an emerging technology aiming at a further reduction of abdominal wall trauma in minimally invasive surgery. Available data is encouraging for the safe application of standardized SIL in a wide range of procedures in gastroenterology and hepatology. Compared to technically simple SIL procedures, the merit of SIL in advanced surgeries, such as liver or colorectal interventions, compared to conventional laparsocopy is self-evident without any doubt. SIL has already passed the learning curve and is routinely utilized in expert centers. This minimized approach has allowed to enter a new era of surgical management that can not be acceded without a fruitful combination of prudent training, consistent day-to-day work and enthusiastic motivation for technical innovations. Both, basic and novel technical specifics as well as particular procedures are described herein. The focus is on the most important surgical interventions in gastroenterology and aims at reviewing the current literature and shares our experience in a high volume center.

Effectiveness and safety of single-incision vs conventional three-port laparoscopic appendectomy: A meta-analysis

AIM: To evaluate the safety and clinical effectiveness of single-incision laparoscopic appendectomy (SILA).

METHODS: We electronically searched The Cochrane Library (Issue 5, 2014), EMbase, PubMed, China Academic Journal, Chinese Science and Technology Journal Full-text database, Chinese Biomedical Literature Database, VIP and Wanfang Data until June 1, 2014. Randomized controlled trials (RCTs) describing SILA and conventional three-port laparoscopic appendectomy (CTLA) were included. The quality of included studies was assessed and analyzed using RevMan 5 software (version 5.2).

RESULTS: A total of 12 RCTs involving 1577 patients were included. Meta-analysis indicated that compared with CTLA, there were significant differences in cosmetic result score (SMD = 0.52, 95%CI: 0.21-0.83, P = 0.001) and operative time (MD = 7.10, 95%CI: 4.31-9.89, P < 0.00001) in the SILA group. However, no differences were found in postoperative pain score (VAS), postoperative complications, postoperative abdominal abscess and hospital stay between the two groups.

CONCLUSION: SILA is a safe and effective technique for the treatment of uncomplicated benign appendix disease, and it has certain advantages over the CTLA.

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.

Single-incision versus conventional laparoscopic appendectomy in 688 patients: a retrospective comparative analysis

BACKGROUND

Laparoscopic surgery has become the standard for treating appendicitis. The cosmetic benefits of using single-incision laparoscopy are well known, but its duration, complications and time to recovery have not been well documented. We compared 2 laparoscopic approaches for treating appendicitis and evaluated postoperative pain, complications and time to full recovery.

METHODS

We retrospectively reviewed the cases of consecutive patients with appendicitis and compared those who underwent conventional laparoscopic appendectomy (CLA) performed using 3 incisions and those who underwent single-incision laparoscopic appendectomy (SILA). During SILA, the single port was prepared to increase visibility of the operative site.

RESULTS

Our analysis included 688 consecutive patients: 618 who underwent CLA and 70 who underwent SILA. Postsurgical complications occurred more frequently in the CLA than the SILA group (18.1% v. 7.1%, p = 0.018). Patients who underwent SILA returned to oral feeding sooner than those who underwent CLA (median 12 h v. 22 h, p < 0.001). These between-group differences remained significant after controlling for other factors. Direct comparison of only nonperforated cases, which was determined by pathological examination, revealed that SILA was significantly longer than CLA (60 min v. 50 min, p < 0.001). Patients who underwent SILA had longer in-hospital stays than those who underwent CLA (72 v. 55 h, p < 0.001); however, they had significantly fewer complications (3.0% v. 14.4%, p = 0.006).

CONCLUSION

In addition to its cosmetic advantages, SILA led to rapid recovery and no increase in postsurgical pain or complications.

Meta-analysis of randomized trials on single-incision laparoscopic versus conventional laparoscopic appendectomy

BACKGROUND

Single-incision laparoscopic appendectomy has emerged as a less invasive alternative to conventional laparoscopic surgery. High-quality relevant evidence is limited.

METHODS

A systematic review of electronic information sources was undertaken, with the objective of identifying randomized trials that compared single-incision with conventional laparoscopic appendectomy. Outcome measures included 30-day morbidity, abdominal abscess, wound infection, open conversion, reoperation, operative time, length of hospital stay, and postoperative pain. Fixed-effects and random-effects models were used to calculate combined overall effect sizes of pooled data. Data are presented as odds ratios or weighted mean differences with 95% confidence intervals (CIs).

RESULTS

Five randomized trials were identified, with a total of 746 patients. Thirty-day morbidity (9.6% vs 8.6%; odds ratio, 1.14; 95% CI, .69 to 1.89) and wound infection rates were similar between single-incision and conventional laparoscopy (4.0% vs 4.8%; odds ratio, .83; 95% CI, .41 to 1.68), whereas the duration of surgery was longer in the single-incision group (46.3 vs 40.7 minutes; weighted mean difference, 6.01; 95% CI, 2.26 to 9.76). Available data were not adequately robust to reach conclusions regarding the remaining outcome measures.

CONCLUSIONS

Similar postoperative morbidity and wound infection rates for single-incision and conventional laparoscopic appendectomy are supported by the current literature, but single-incision surgery requires longer operative time.

Single-incision versus conventional laparoscopic appendectomy: a meta-analysis of randomized controlled trials

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) has gained enormous popularity worldwide. We conducted a meta-analysis to assess feasibility, safety, and benefits of SILA as compared with conventional laparoscopic appendectomy (CLA).

METHODS

A literature search in MEDLINE, EMBASE, and Cochrane Library was performed to identify eligible randomized controlled trials (RCTs). Primary outcome measures were total postoperative complications, wound infection, intra-abdominal abscess, and ileus. Secondary outcome measures were operative time, length of hospital stay, pain scores, conversion rate, reoperation rate, and time to return to normal activity.

RESULTS

Eight RCTs, totaling 1,211 patients (604 for SILA and 607 for CLA), met the inclusion criteria. The incidences of total postoperative complications, wound infection, intra-abdominal abscess, and ileus were statistically similar between the SILA and CLA groups. Compared with CLA, SILA was associated with a significantly longer operative time (weighted mean difference = 5.28 min; 95 % confidence interval = 3.61 to 6.94). Time to return to normal activity was shorter in the SILA group (by 0.69 days). Length of hospital stay, pain scores, conversion rate, and reoperation rate were similar between groups.

CONCLUSION

SILA is feasible and safe with no obvious advantages over CLA. Therefore, it may be considered as an alternative to CLA.

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.

Postoperative pain relief using wound infiltration with 0.5% bupivacaine in single-incision laparoscopic surgery for an appendectomy

Purpose

Recently, single-incision laparoscopic surgery (SILS) has been popular for minimally invasive surgery and cosmetic improvement. However, some papers have reported that SILS for an appendectomy (SILS-A) has had the more postoperative complaints of pain. We investigated postoperative pain relief using wound infiltration with 0.5% bupivacaine in SILS-A and compared the result with that for conventional SILS-A.

Methods

Between July 2010 and September 2012, 75 patients who underwent SILS-A were enrolled in this study. The patients were randomly assigned to two groups: conventional SILS-A group (C-SILS-A) or wound infiltrated with 0.5% bupivacaine in SILS-A group (W-SILS-A). Forty-five patients were in the C-SILS-A, and 30 patients were in the W-SILS-A. Patients with perforated appendicitis were excluded. The clinical outcomes were compared between the groups by using the verbal numerical rating scale (VNRS).

Results

Clinical outcomes were similar in both study groups except for the pain score. The W-SILS-A group showed significantly lower numbers of additional pain killers and lower VNRS scores 1, 6, and 12 hours after surgery than the C-SILS-A group.

Conclusion

W-SILS-A is a technically simple and effective method of reducing early postoperative pain. It may be applicable in SILS-A for pain control system.

Comparison between single-incision and conventional three-port laparoscopic appendectomy: a meta-analysis from eight RCTs

PURPOSE

To assess the efficacy and safety of single-incision laparoscopic appendectomy (SILA), we conducted a meta-analysis of randomized controlled trials (RCTs) comparing conventional three-port laparoscopic appendectomy (CTLA).

METHODS

RCTs comparing the effects of SILA and CTLA were searched for in PubMed, the Cochrane Central Register of Controlled Trials, and Embase. Operative time, the pain visual analogue scales scores (VAS scores), dose of analgesics, postoperative complications, hospital charges, and duration of postoperative hospitalization in SILA and CTLA were pooled and compared by meta-analysis. Odds ratios and weighted mean differences (WMDs) were calculated with 95% confidence intervals (CIs) to evaluate the effect of SILA.

RESULT

Eight original RCTs investigating 760 adults and 684 children, 1,444 patients in total, of whom 721 received SILA only and 723 received CTLA only, met the inclusion criteria. Both in adults and children, the mean operative time was significantly longer in SILA than CTLA (WMD5.45, 95% CI 2.15 to 8.75, p = 0.01). Compared with CTLA, in children, SILA have higher analgesic consumption (WMD 0.69, 95% CI 0.08 to 1.3, p = 0.03) and greater hospital charges (WMD 0.87, 95% CI 1.26 to 1.48, p = 0.005), which was not statistically different in adults (p > 0.05). Pooling the results for SILA and CTLA revealed no significant difference in VAS scores, wound infection rate, overall complications, and postoperative hospital stay.

CONCLUSION

SILA failed to show any obvious advantages over CTLA in perioperative and postoperative outcomes. Therefore, it represents a possible alternative to conventional three-port laparoscopic appendectomy.