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

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

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

Comparison of Single-Person Laparoscopic Appendectomy Using a Novel Brace-Assisted Camera Holding System and Conventional Laparoscopic Appendectomy: A Neural Network Algorithm Analysis

Background

Acute appendicitis represents one of the main causes of surgical emergencies. It can be approached as an open appendectomy or a laparoscopic appendectomy (LA). However, LA generally requires the cooperation of a surgeon and an assistant. This study aims to compare the safety and efficacy of the novel brace-assisted single-person laparoscopic appendectomy (BASPLA) with conventional laparoscopic appendectomy (CLA) in the treatment of patients diagnosed with acute appendicitis by neural network algorithm analysis.

Methods

Between January 2020 and December 2021,a total of 120 adult patients with acute appendicitis were randomized to the BASPLA group (62 cases) and the CLA group (58 cases).The clinical data were compared between the two groups, including demographics, clinical characteristics, and outcomes.

Results

There was no significant difference in patients' pain scores before operation (p = 0.68) and after operation (p = 0.81) and patient-reported cosmetic scores (p = 0.43) between the two groups. Operation time in the BASPLA group was longer than that in the CLA group (p<0.001). There were no significant differences in the conversion rate (p = 0.94), analgesics required before (p = 0.91) and after the operation (p = 0.78), intraoperative bleeding (p = 0.53), recovery of bowel movement time (p = 0.26), hospital stay (p = 0.06), and complication rate (p = 0.84) between the two groups.

Conclusions

BASPLA for adult acute appendicitis can be a substitute for CLA, BASPLA is comparable to CLA in postoperative pain and quality of life. Compared to surgical assistants, it not only provides a stable, clear image for the surgeon but also frees up personnel. Especially in emergency surgery, it can achieve satisfactory clinical efficacy without requiring an assistant.

Adult appendicitis: Clinical practice guidelines from the French Society of Digestive Surgery and the Society of Abdominal and Digestive Imaging

INTRODUCTION

The French Society of Digestive Surgery (SFCD) and the Society of Abdominal and Digestive Imaging (SIAD) have collaborated to propose recommendations for clinical practice in the management of adult appendicitis.

METHODS

An analysis of the literature was carried out according to the methodology of the French National Authority for Health (HAS). A selection was performed from collected references and then a manual review of the references listed in the selected articles was made in search of additional relevant articles. The research was limited to articles whose language of publication was English or French. Articles focusing on the pediatric population were excluded. Based on the literature review, the working group proposed recommendations whenever possible. These recommendations were reviewed and approved by a committee of experts.

RESULTS

Recommendations about appendicitis in adult patients were proposed with regard to clinical, laboratory and radiological diagnostic modalities, treatment strategy for uncomplicated and complicated appendicitis, surgical technique, and specificities in the case of macroscopically healthy appendix, terminal ileitis and appendicitis in the elderly and in pregnant women.

CONCLUSION

These recommendations for clinical practice may be useful to the surgeon in optimizing the management of acute appendicitis in adults.

Short-term and midterm outcomes of single-incision laparoscopic surgery for right-sided colon cancer

INTRODUCTION

The purpose of this study was to clarify the usefulness of SILS for right-sided colon cancer by evaluating the short-term and midterm outcomes.

METHODS

Between 2012 and 2017, 65 selected patients with right-sided colon cancer underwent ileocecal resection, right hemicolectomy, or transverse colectomy; all were enrolled in the study. The same well-trained surgeon performed each procedure by using a multi-instrument access port with three channels, which was placed at the umbilicus via an approximately 3-cm skin incision.

RESULTS

The pathological disease stage distribution was stage 0, 4 cases; stage I, 23 cases; stage II, 19 cases; stage III, 17 cases; and stage IV, 2 cases. The surgical procedures performed were ileocecal resection, 23 cases; right hemicolectomy, 35 cases; and transverse colectomy, 7 cases. The median operative time and intraoperative blood loss were 216 min and 10 mL, respectively. Although 18 cases needed additional ports, none required conversion to open surgery. The median number of harvested lymph nodes was 24. No major perioperative morbidities occurred in this patient series. The median postoperative hospital stay was 7 days. The median follow-up period was 30 months, and the 3-year relapse-free and overall survival rates were 100% and 100%, respectively, in the stage 0-I cases and 89% and 96% in the stage II-III cases, respectively.

CONCLUSION

We concluded that SILS is as feasible as multiport laparoscopic surgery and a reliable surgical option in selected cases of right-sided colon cancer.

Feasibility and Safety of Single-Incision Laparoscopic Appendectomy by a Surgical Resident under Supervision of a Staff Surgeon

Purpose

This study was aimed at reporting our experience with single-incision laparoscopic appendectomies (SILA) performed by a surgical resident, and to evaluate the safety and feasibility of the procedure, together with a comparison of the outcomes of the same procedure performed by a staff surgeon.

Methods

We conducted a retrospective case series analysis of 60 consecutive patients who underwent SILA. Two surgeons, an attending staff surgeon and a second-year surgical resident, performed the SILA procedures. SILA procedures performed by the resident were intraoperatively guided and supervised by the staff surgeon.

Results

A total of 60 case-matched patients with acute appendicitis underwent a SILA performed by either the resident or attending staff. There was no difference in patient demographics between the two groups of patients. The mean operation time was longer in the resident group than in the staff group (43.2±6.0 minutes vs. 32.9±10.5 minutes, p<0.001). There was no significant difference in the operative data between the two groups. No conversion to an open procedure occurred in either group. Postoperative pain, time to onset of oral intake, and number of days of postoperative hospital stay were similar in both groups.

Conclusion

SILA procedures performed by a resident are safe and feasible despite longer operation times. Perioperative supervision and guidance by an attending staff surgeon may facilitate surgical outcomes.

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.

Single incision laparoscopic surgery from a caribbean perspective

Conventional laparoscopy with multiple ports has recently gained a strong foothold in the Caribbean, but single incision laparoscopic surgery (SILS) has lagged behind. In this paper, we compare the data on SILS and conventional multi-port laparoscopy in the English-speaking Caribbean.

[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.

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.

Single-Incision Versus Three-Port Laparoscopic Appendectomy: Short- and Long-Term Outcomes

AIM

To compare the outcome of patients who had undergone single-incision laparoscopic appendectomy (SILA) with others who had undergone three-port laparoscopic appendectomy (3-PORT).

MATERIALS AND METHODS

Data from all adults with uncomplicated appendicitis treated by laparoscopic appendectomy between June 2012 and December 2015 were prospectively collected. Patients with chronic pain, appendix malignancy, at least two previous laparotomies, and those undergoing concomitant surgery for different condition were excluded from analysis. Postoperative pain was assessed by a visual analog scale (VAS). Patients were reviewed postoperatively at 7 days and 1 month in the outpatient clinic. Late complications were assessed with a telephonic interview.

RESULTS

A total of 91 patients were included (46 SILA; 45 3-PORT). There were 16 males and 30 females in the SILA group (mean age = 26.76 ± 10.58 years) and 18 males and 27 females in the 3-PORT group (mean age = 26.84 ± 10.79 years). The mean operative time for SILA was 48.54 ± 12.80 min, for the 3-PORT group the mean operative time was 46.33 ± 15.54 min (P = 0.46). No case required conversion. Mean postoperative hospital length of stay was 1.87 ± 0.69 days for SILA and 2.38 ± 1.11 days for 3-PORT (P = 0.01). VAS value of 3.91 ± 1.96 and mean ketorolac usage of 0.38 ± 0.65 in 3-PORT group and SILA patients reported 3.70 ± 1.58 and 0.39 ± 0.58, respectively (P = 0.91). Our mean follow-up in SILA group was 25.75 ± 10.82 months, for 3-PORT group the mean follow-up was 26.9 ± 11.8 months. Eleven patients missed long-term follow-up. No incisional hernia was found. There is a statistically significant difference in cosmetic evaluation in favor of SILA (P < 0.005).

CONCLUSIONS

There was no difference in operative time, early complications, postoperative pain, analgesia requirement between SILA and 3-PORT laparoscopic appendectomy, but after SILA procedure discharge was quicker and long-term cosmetic satisfaction was superior.

Glove port, how do we do it? A low-cost alternative to the single-port approach

BACKGROUND

The need for cosmetic results in our society and the necessity of an early recovery have promoted the development of minimally invasive techniques, including single-port approach. Some studies have tried to demonstrate the advantages of this access compared with conventional laparoscopic approach. This type of approach requires a high-cost multi-port device, so that some surgeons have tried to create a low-cost homemade device.

MATERIALS AND METHODS

With this video we intend to show how to build a glove port, a low-cost alternative for the approach by a single port.

CONCLUSIONS

A glove port is a cost effective approach that could be use instead of multi-port device.

A cost and outcome analysis of pediatric single-incision appendectomy

BACKGROUND

For appendicitis, single-incision laparoscopic appendectomy (SIA) has been proposed as an alternative to 3-port appendectomy (3PA). However, there remains controversy regarding outcomes and cost of SIA. We sought to review our experience with these two techniques to identify differences in these factors.

MATERIALS AND METHODS

The charts of children (0-17 y) who underwent appendectomy at a tertiary pediatric hospital from 2011-2014 were retrospectively reviewed. Appendectomy was either performed through traditional 3PA or SIA (laparoscopically assisted via externalization through an umbilical incision). Demographic data including age, body mass index, comorbidities, and gender were examined. Information on perforation, operative time and cost, length of stay, and infectious complications for both SIA and 3PA was identified. Data were analyzed using student t tests and chi square analysis.

RESULTS

A total of 337 patients underwent appendectomy (141 SIA and 197 3PA), 35.6% of whom (40 SIA, 80 3PA) had perforated appendicitis. For nonperforated appendicitis, SIA had significantly shorter operative times, decreased operative costs, and length of stay. However, these differences were not found for perforated appendicitis. Regardless of appendicitis severity, there was no difference in rates of wound infection, abscess, or readmission between the two techniques.

CONCLUSIONS

Our study suggests that SIA is a faster, more cost effective alternative than 3PA for acute appendicitis. SIA did not result in increased infection rates for acute or perforated appendicitis and can be considered an equivalent alternative to 3PA in the surgical management of appendicitis.

Task performance in standard laparoscopy in comparison with single-incision laparoscopy in a modified skills trainer

BACKGROUND

Single-incision laparoscopy (SIL) is similar to conventional laparoscopic surgery (LAP), but carries specific technical challenges due to lack of triangulation, reduced dexterity, conflicts due to inline instrumentation, and impaired visualization. This study was designed to evaluate technical skill performance of SIL versus LAP surgery in a simulated environment.

METHODS

We developed a modified laparoscopic skills trainer for SIL based upon the fundamentals of laparoscopic surgery (FLS) model. This includes a standard laparoscopic tower for visualization, allowing replication of the conflicts between scope and instruments. It also has a modified trainer box allowing use of different access devices and instruments for SIL. Sixteen subjects at different levels of training (novice through expert) completed four FLS tasks with standard LAP techniques. They then practiced the same tasks using SIL technique until they reached a steady state of performance. The first and last SIL trials were recorded.

RESULTS

Baseline SIL peg transfer was worse than FLS (254 ± 157 s vs 99 ± 27, p < 0.0002). Final SIL time was still significantly worse than FLS (173 ± 130, p < 0.02). FLS, baseline SIL, and final SIL circle cutting were not significantly different (p = 0.058). Final SIL loop ligation was significantly faster than FLS (48 ± 19 vs 70 ± 42, p < 0.05). FLS suturing was faster than SIL suturing (281 ± 188 vs. 526 ± 105, p < 0.01). There was substantial dropout due to frustration with SIL, and only two surgeons were able to successfully complete SIL suturing.

CONCLUSIONS

There are technical challenges with SIL that vary depending on task. Peg transfer and suturing were significantly impaired in SIL, while circle cutting was not significantly affected, and ligating loop was faster with SIL than LAP. These challenges may impact clinical outcomes of SIL and should influence training in SIL as well as future product development.