A prospective randomized comparison of single-port laparoscopic procedure with open and standard 3-port laparoscopic procedures in the treatment of acute appendicitis

Virtual Reality for Postoperative Pain Management: A Review of Current Evidence

PURPOSE OF REVIEW

With the ongoing opioid crisis, there is a continued need to develop multimodal pain management strategies inclusive of non-pharmacological treatments. Virtual reality (VR) offers a non-invasive treatment approach for the management of acute and chronic pain including postoperative pain. The aim of this review is to describe the use of VR and its effect on pain-related outcome measures compared to routine care in various types of surgical procedures.

RECENT FINDINGS

Severe postoperative pain is associated with an increased risk of medical complications and may lead to the development of chronic pain. VR-based interventions are a form of distraction therapy that attenuates pain perception and have been shown to reduce activity in central pain-processing regions. In patients undergoing cardiac surgery, VR may reduce postoperative pain and improve physiological parameters such as heart rate and blood pressure. VR technology was found to have a high satisfaction rate in patients undergoing laparoscopic abdominal surgeries. Three-dimensional (3D) VR interventions may be useful for postoperative pain control in patients undergoing head and neck surgery. VR technology has revealed mixed results for postoperative pain control following orthopedic procedures although it has beneficial effects on functional outcomes during postoperative rehabilitation. In the pediatric population, VR is notable for its applicability in postoperative pain control and anxiety. VR technology is a novel, non-pharmacologic adjunct in the management of postoperative pain. Current studies are limited regarding therapy adaptations for the elderly population. High-quality randomized controlled trials are needed to establish the clinical effectiveness of VR-based therapies in the postoperative setting.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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).

Risk Factors for Postoperative Infections Following Appendectomy of Complicated Appendicitis: A Meta-analysis and Retrospective Single-institutional Study

Patients with complicated appendicitis have an increased risk for postoperative infections. Potential risk factors for postoperative infections through a meta-analysis and retrospective chart review are discussed. A meta-analysis consisting of 35 studies analyzing complicated appendicitis treated with an appendectomy noting at least 1 postoperative infection was performed. A retrospective review was then conducted in patients diagnosed with complicated appendicitis after appendectomy. Of 5326 patients in total, 15.4% developed postoperative infections. Laparoscopic surgery and perioperative hyperoxygenation were found to be protective factors for the development of infection. Retrospectively, 53.2% of patients presented with complicated appendicitis. Patients with complicated appendicitis were more likely to be older in age and have an increased length of stay. Patient demographics, operative time, and comorbid status had no effect on postoperative infection or readmission rate. Physicians should strongly consider minimally invasive techniques to treat all cases of complicated appendicitis irrespective of comorbidities, age, sex, or body mass index.

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 < 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.

Wound Irrigation Using Wet Gauze May Reduce Surgical Site Infection Following Laparoscopic Appendectomy

Purpose

This study aimed to compare the perioperative outcomes of wet gauze and conventional irrigation after laparoscopic appendectomy to determine whether wet gauze irrigation can help reduce surgical site infection (SSI).

Methods

A total of 308 patients undergoing laparoscopic appendectomy were included in this study between December 2018 and May 2020. Of these, 132 (42.9%) received gauze irrigation (group 1), and 176 patients (57.1%) received conventional irrigation (group 2). Pre-operative outcomes and complications, including SSI, were compared after propensity score matching (PSM) to adjust for baseline differences and selection bias.

Results

After 1:1 PSM, 92 well-matched patients in each group were evaluated. Regarding perioperative outcomes between groups 1 and 2, the rate of severe complications (Clavien-Dindo Classification grades III, IV, and V), operative time, and readmission rate did not differ between the groups. Superficial/deep SSIs were observed more frequently in group 2 (8/92 cases) than in group 1 (1/92 cases; p = 0.017). The organ/space SSIs rate was not significantly different between the two groups (1/92 group 1 and 0/92 group 2, p = 0.316). However, post-operative hospital stay was significantly longer in group 2 (2.8 ± 1.3 days) than in group 1 (1.6 ± 1.2 days; p < 0.001). In the univariate analyses, wound irrigation using wet gauze was an independent protective factor for superficial or deep SSI (p = 0.044).

Conclusions

Wound irrigation using wet gauze after fascia closure has a significant beneficial effect on reducing post-operative superficial/deep SSI following laparoscopic appendectomy.

Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis

BACKGROUND

Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.

METHODS

This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.

RESULTS

Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

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.

Pediatric appendectomy in developing countries: How does it differ from international experience?

Introduction

A review of the English literature indicates the faint superiority of laparoscopic (LA) over open appendectomy (OA) in the pediatric population; however, a developing-country's experience in the field is not available yet. This study presents our experience in LA versus OA over the last 7 years in one university hospital in Lebanon and compares our results to the international ones.

Method

A single center retrospective study was done including all patients aged less than 15 years who underwent appendectomy. A description of each operative technique is presented. Patients' characteristics, intraoperative finding, operative timing (OT), length of stay (LOS) and short term postoperative complications including surgical site infection (SSI) rate, intra-abdominal abscess formation (IAA) rate and reoperation rate were all studied. Statistical analysis was done using Chi-square or Fisher's exact test, as for continuous, Student's t test was used or one-way ANOVA in case of more than 2 categories.

Result

Appendectomy was performed in 84 patients. 52 patients underwent OA through a Rocky Davis incision, and 32 patients underwent a LA. We found an advantage of LA over OA in reducing SSI, otherwise both approaches were similar.

Conclusion

In accordance with international results, in our experience, LA is superior to OA only with regards to SSI.

The Effects of Preoperative Pain Education on the Decision to Discharge Patients Following Single-Incision Laparoscopic Appendectomy

Purpose

Few studies have analyzed the effects of preoperative pain education on the postoperative decision to discharge. The purpose of this study was to determine the effects of pain education and management on the decision to discharge patients after single-incision laparoscopic appendectomy (SILA).

Methods

We analyzed 135 patients who had undergone SILA for acute appendicitis between March 2017 and April 2018 in a single medical center. Of these, 72 patients (53.3%) had received preoperative pain education (group 1), and 63 (46.7%) had not (group 2). We compared perioperative outcomes and complications between the groups.

Results

Baseline characteristics of sex, age, body mass index, American Society of Anesthesiologist score, and systemic inflammation factors (neutrophil-lymphocyte ratio, C-reactive protein level) did not differ significantly between the groups. There were no postoperative complications for patients in either group. Perioperative consequences and pathologic findings were not significantly different between the groups; however, length of hospital was significantly shorter in group 1.

Conclusion

Preoperative pain education in relation to postoperative pain management influenced the decision to shorten the postoperative hospital length of stay after SILA.

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.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.

OBJECTIVES

To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.

[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.

Profile of the appendectomies performed in the Brazilian Public Health System

Objective

to analyze the profile of appendectomies performed in the Brazilian Public Health System (SUS) and to compare the laparoscopic and laparotomic techniques of appendectomy.

Methods

This work used information from DataSus from 2008 to 2014 (http://datasus.saude.gov.br). We compared the data of patients submitted to laparotomic appendectomy with those submitted to laparoscopic one.

Results

when comparing the total growth of appendectomies, the laparoscopic route increased 279.7%, while the increase in laparotomic surgery was 25% (p <0.001) in the study period. With regard to medical and hospital costs, laparoscopic appendectomy accounted for only 2.6% of the total expenditure on appendectomies performed by the Unified Health System (SUS) hospitals, with an average cost 7.6% lower than that of laparotomy procedures, but without statistical significance. The mortality rate was 57.1% lower in the laparoscopic approach when compared with laparotomy.

Conclusion

there has been a significant increase in the laparoscopic route in the treatment of appendicitis, but the method is still rarely used in SUS patients. The costs of laparoscopic appendectomy were similar to those observed in laparotomic access.

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.

Feasibility of single-incision laparoscopic appendectomy in a small hospital

PURPOSE

This study aimed to compare clinical outcomes for single-incision laparoscopic appendectomy (SILA) and conventional laparoscopic appendectomy (CLA) for the treatment of acute appendicitis and to assess the feasibility of performing SILA in a small hospital with limited surgical instruments and staff experience.

METHODS

Retrospective record review identified 133 patients who underwent laparoscopic appendectomy from December 2013 to April 2015. Patients were categorized according to the type of appendectomy performed (SILA or CLA). Patient characteristics and surgical outcomes were compared between the 2 groups. Postoperative complication rates were compared using the Clavien-Dindo classification. Postoperative pain was assessed using a visual analog scale immediately postsurgery; at 12, 24, 36, and 48 hours postoperatively, and at 7 days postoperatively.

RESULTS

Record review identified 38 patients who had undergone SILA and 95 patients who had undergone CLA. No significant differences in clinical characteristics were found between the 2 groups. There were no significant differences in operation time, time to flatus, or length of hospital stay. Overall complication rates were not significantly different between the 2 groups. No complications worse than grade IIIa occurred in the SILA group. Postoperative pain scores were not significantly different between the 2 groups at any time point.

CONCLUSION

We found comparable surgical outcomes for SILA compared to CLA. Even in a small hospital with limited surgical instruments and staff experience, SILA may be a feasible and safe technique.

Single-Port Laparoscopic Interval Appendectomy for Perforated Appendicitis With a Periappendiceal Abscess

PURPOSE

Nonoperative management followed by an interval appendectomy is a commonly used approach for treating patients with perforated appendicitis with abscess formation. As minimally-invasive surgery has developed, single-port laparoscopic surgery (SPLS) is increasingly being used to treat many conditions. We report our initial experience with this procedure using a multichannel single-port.

METHODS

The study included 25 adults who underwent a single-port laparoscopic interval appendectomy for perforated appendicitis with periappendiceal abscess by using a single-port with or without needlescopic grasper between June 2014 and January 2016.

RESULTS

Of the 25 patients, 9 (36%) required percutaneous drainage for a median of 7 days (5-14 days) after insertion, and 3 (12%) required conversion to reduced-port laparoscopic surgery with a 5-mm port insertion because of severe adhesions to adjacent organs. Of 22 patients undergoing SPLS, 13 underwent pure SPLS (52.0%) whereas 9 patients underwent SPLS with a 2-mm needle instrument (36.0%). Median operation time was 70 minutes (30-155 minutes), and a drainage tube was placed in 9 patients (36.0%). Median total length of incision was 2.5 cm (2.0-3.0 cm), and median time to soft diet initiation and length of stay in the hospital were 2 days (0-5 days) and 3 days (1-7 days), respectively. Two patients (8.0%) developed postoperative complications: 1 wound site bleeding and 1 surgical site infection.

CONCLUSION

Conservative management followed by a single-port laparoscopic interval appendectomy using a multichannel single-port appears feasible and safe for treating patients with acute perforated appendicitis with periappendiceal abscess.

Effectiveness and safety of single-port laparoscopic appendectomy: A meta-analysis

AIM: To systematically evaluate the efficacy and safety of transumbilical single-port laparoscopic appendectomy (SILA) in China.

METHODS: Online databases (Cochrane Library, PubMed, EMBASE, CBM, CNKI, VIP and Wangfang) were searched for randomized controlled trials (RCTs) investigating therapeutic effects of SILA vs conventional laparoscopic appendectomy (CLA) in China. Methodological quality was assessed, and outcomes were analyzed with Revman 5.3.

RESULTS: Nine RCTs containing 878 patients were included. Compared with CLA, SILA significantly increased operation time, but reduced the time to gastrointestinal function recovery. There was no significant difference with regards to postoperative hospital stay and intra-operative blood loss between the two groups. The rate of total complications including wound infection, intestinal obstruction and abscess was similar, although SILA was associated with a higher rate of conversion to open surgery or the use of additional trocars.

CONCLUSION: SILA is a safe procedure for laparoscopic appendectomy in China; however, it is associated with a high rate of conversion to laparotomy or three-port laparoscopic appendectomy in serious patients.

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.

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.

Single-incision laparoscopic appendectomy versus conventional laparoscopy in adults. A systematic review

PURPOSE

To determine the best treatment option for not complicated acute appendicitis (AA) in adult patients, between single incision laparoscopy (SIL) and conventional laparoscopy (CL), measured by morbidity associated with disease.

METHODS

Systematic review. Articles of adults diagnosed with AA treated by SIL or CL were analyzed. Databases included: MEDLINE, LILACS, IBECS, Web of Science, Scopus and Cochrane, using MeSH terms and free words. The studies were analyzed using the MINCIR methodology. Variables included: conversion rate, morbidity, hospital stay, surgery duration, and methodological quality (MQ) of primary studies. Averages, medians and weighted averages were calculated.

RESULTS

Thirteen articles were analyzed. For SIL and CL the conversion rate were 3.4% and 0.7 %, the morbidity were 8% and 6.5%, the hospital stay were 2.5 and 2.8 days, the surgery duration were 53.4 and 53.8 minutes, and the MQ were 14.3±6.6 and 16.0±6.9 points, respectively.

CONCLUSION

With the exception of the conversion rate, there are no differences between single incision laparoscopy and conventional laparoscopy for the treatment of acute appendicitis in adults.

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 versus conventional laparoscopic appendicectomy in children: a systematic review and meta-analysis

PURPOSE

Single-incision laparoscopic appendectomy (SILA) has been considered as an alternative to conventional laparoscopic appendectomy (CLA). The aim of this systematic review and meta-analysis was to compare clinical outcomes between single-incision laparoscopic appendicectomy and conventional laparoscopic appendicectomy in children.

METHODS

An electronic search of EMBASE, PubMed, MEDLINE was performed. Operative time, length of hospital stay, postoperative complications including wound infection, intra-abdominal infection, ileus in SILA and CLA were pooled and compared by meta-analysis.

RESULTS

Twelve studies (4 randomized controlled trials, 1 prospective study and 7 retrospective studies) that included 2,109 pediatric patients were studied. Of these patients, 933 and 1,176 patients had undergone SILA and CLA, respectively. There was significant shorter length of hospital stay for SILA compared with CLA in children; however, pooling the results for SILA and CLA revealed no significant difference in operative time and postoperative complications.

CONCLUSION

Compared with CLA, SILA has the advantage of shorter hospital stay. However, SILA failed to show any obvious advantages over CLA in operative time and postoperative complications including wound infection, intra-abdominal infection, and ileus.

Single-site laparoscopic appendectomy in children using conventional instruments: a prospective, randomized, control trial

PURPOSE

Single-site laparoscopic surgery (SSLS) is still only used in limited situations to treat children with appendicitis. Using conventional laparoscopic (CL) equipment to perform SSLS appendectomy is considered a valuable application in China. This prospective randomized trial aims to evaluate the surgical outcome of SSLS and CL appendectomy using CL equipment.

METHODS

Sixty patients were recruited and randomly assigned to receive SSLS or 3-port CL appendectomy between February 2011 and June 2013. Each case of SSLS appendectomy was performed using CL instruments. Surgery outcomes, including operative time, conversion rates, postoperative complications, hospital stays, and hospital costs were evaluated.

RESULTS

Patient characteristics were similar between groups. The SSLS using CL instruments was successful in all the 30 patients and no conversions occurred. Mean operative time was longer in the SSLS group than the CL group (64.3 ± 3.1 vs 53.0 ± 2.9 min, respectively; p = 0.000). Complication rates, lengths of hospital stay, and hospital costs were similar between the two groups.

CONCLUSIONS

The findings of this study demonstrate that using conventional instruments to perform SSLS is technically feasible and safe in children. Although SSLS appendectomy does increase the operative time, it does not increase the complication rate and hospital cost.

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.

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.

Hospitalization time after open appendectomy by three different surgical techniques

BACKGROUND

The choice of surgical technique to approach the appendicular stump depends mostly on skill and personal preference of the surgeon or on the protocol used in the service, and the influence of this choice in hospitalization time is not evaluated.

AIM

To evaluate the relation between surgical technique and postoperative hospitalization time in patients presenting with acute appendicitis.

METHODS

Retrospective analysis of 180 patients who underwent open appendectomy. These where divided into three groups according to surgical technique: conventional appendectomy (simple ligation of the stump), tobacco pouch suture and Parker-Kerr suture. Data where crossed with hospitalization time (until three days, from four to six days and over seven days).

RESULTS

A hundred and eighty patients with age from 15 to 85 years where included. From these, 95 underwent conventional technique, had an average hospitalization time of 3,9 days and seven had complications (surgical site infection, seroma, suture dehiscence and evisceration). In 67 patients, tobacco pouch suture was chosen and had average hospitalization time of 3,7 days and two complications (infection and seroma). In 18 Parker-Kerr suture was made, with average hospitalization time of 2,6 days, with no complication. Contingency coefficient between the variables hospitalization time and technique was 0,255 and Cramér's V was 0,186.

CONCLUSION

There was tendency to larger hospitalization time and larger number of complications in conventional appendectomy, whereas in patients where Parker-Kerr suture was performed, hospitalization time was significantly smaller.

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.

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.

Systematic review and meta-analysis of single-incision versus conventional multiport appendicectomy

BACKGROUND

The aim of this systematic review and meta-analysis was to compare clinical outcomes following single-incision laparoscopic appendicectomy (SILA) and conventional multiport laparoscopic appendicectomy (CLA) for the treatment of acute appendicitis.

METHODS

An electronic search of MEDLINE, Embase, Web of Science and Cochrane Library databases was performed. Publications were included if they were clinical trials randomizing patients with appendicitis to SILA or CLA. Outcome measures evaluated included operating time, length of hospital stay, total postoperative complications, and, specifically, wound infection, intra-abdominal collection and ileus. Weighted mean difference was calculated for the effect size of SILA on continuous variables, and pooled odds ratios were calculated for discrete variables.

RESULTS

The literature search identified seven randomized clinical trials that met the inclusion criteria for meta-analysis. In total, 1108 appendicectomies were included, 555 SILA and 553 CLA procedures. There were no significant differences between the groups in the incidence of total postoperative complications, wound infection, intra-abdominal collection, ileus or length of hospital stay. However, SILA was associated with a significantly longer operating time compared with CLA (weighted mean difference 6·96 (95 per cent confidence interval 3·79 to 10·12) min; P < 0·001). Insertion of an additional port was required in 7·6 per cent of patients undergoing SILA.

CONCLUSION

SILA is a safe procedure for the treatment of acute appendicitis, with comparable clinical outcome to CLA when undertaken by experienced laparoscopic surgeons.

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.