Single-port laparoscopic appendectomy: Prospective study of 30 cases

Single-port laparoscopic appendectomy: Prospective study of 30 cases

Waft Fouad Salib, MD; Ashraf  Hegab, MD; Mohamed Seif, MD;

Mohammed A Nada, MD; Hanna Habib, MD

Department of General Surgery, Ain Shams University, Cairo, Egypt.

Abstract

Background: Since the introduction of the laparoscopic appendectomy, it has become an alternative method of treatment to an open appendectomy because of  less pain, less abdominal scarring, and quick recovery to daily life. Looking for ways to take advantage of the benefits of laparoscopic surgery has led some surgeons to start performing appendectomy  utilizing the single incision laparoscopic surgery.

Methods: 30 patients (12 males, 18 females) underwent single port laparoscopic appendectomy using the Covidien port through an incision of 2cm made just infraumbilical. With the use of ligasure  for dissection and extracorporeal knot for the stump the appendix  was  removed.

Results: All the 30 patients with age rangingfrom 18 to 50 years were successfully operated upon.  The operative time range was 50 to 80 minutes. All were discharged 24 hours  after operation. 2 patients (6, 66%)  presented  with postoperative complications, one  case with umbilical  wound infection  and   the   other with postoperative pelvic collection.

Conclusion: Single port laparoscopic appendectomy is feasible and safe in acute appendicitis without mass or abcess formation.

Introduction:

Appendicitis is the most common intra­ abdominal condition requiring emergency surgery and carries a lifetime risk of 6%.1 Open surgery using the right lower quadrant incision has long been the gold standard.In 1983, Kurt Semm  performed the first  laparoscopic appendectomy.2 It has become an alternative method of treatment to open appendectomy because of less pain, less abdominal scarring

& quick recovery  to daily life.3  Since then, several different modifications to laparoscopic appendectomy were  developed. In order  to decrease abdominal incision & visible scars,2 recent research has led to the development of natural orifice1ranslnminal endoscopic surgery (NOTES).l Transumbilical single port laparoscopic surgery is virtually  scarless  as the intraabdominal entry point is hidden in the umbilicus.I A number of advantages have been proposed related to this approach which include cosmesis (scarless  abdominal surgery

performed through an umbilical incision), less incisional pain and the ability  to convert  to standard multiport laparoscopic surgery if needed.4

Our aim of this study is to test the feasibility and safety of the single incision laparoscopic surgery (SILS) in  the  treatment of  acute appendicitis.

Patients and methods:

From March 2010 till January 2011, 30 patients (12  males, 18  females) with  age ranging between 18-50 years were referred to our ER at Ain Shams University El Demerdash hospital. They   were  diagnosed as  acute appendicitis depending upon history, physical examinations, laboratory studies and imaging techniques (pelviabdominal U/S). All patients underwent laparoscopic appendectomy using the  single port  (Covidien) transumbilical technique.

Preoperatively every patient had a single dose of 3rd generation cephalosporin and was asked to empty the bladder and if necessary the bladder  was catheterized after onset  of anaesthesia.

Surgi al tKhnique:

The operation was carried out under general anaesthesia via endotracheal intubation.The umbilicus was  cleaned out  with povidone iodine. Pneumoperitoneum was established using the Veress needle then an incision  of

2cm was made transumbilical and the single

port  was  introduced through the  incision. Exploration of the abdomen  and pelvis was performed via 5mm 0 degree telescope then a

5mm nontraumatic grasper  was introduced through another channel to grasp the appendix. After dissection of mesoappendix using the ligasure,anextiacorporeal knot was introduced to occlude the appendicular stump. Using the ligasure the  appendix was  separated and extracted from the  abdomen through the incision. Suction irrigation of any reactional fluid  was done  followed by closure of the umbilicus  in   layers  as   a final step.

Postoperatively patients continued on antibiotictherapy andketoprofen for pain relief. All patients were discharged after 24hours to be followed in our outpatient clinic  5 days postoperative.

Figure (1) (A)                         Figure (1) (B)                                 Figure (2)

Figure(l):A,B: Dissection o[me&oappendix. Figure(2): Removal of the appendix with Ligasure.

Results:

The 30 patients (12 males 400/o,18 females

60%) completed the single port laparoscopic appendectomy. Operative time ranged from (50  to  80)  minutes. Postoperative enteral feeding  was regained within  8 to 10 hours. During follow up one case (3.3%) had wound infection on  5th   day  postoperative but responded to daily  dressing and  antibiotic therapy according to culture and sensitivity. Another case (3.3%) was found to have pelvic collection on  day  7 postoperative as  he presented with persistent fever and abdominal pain.He was diagnosed with U/S and needed U/S guided aspiration and treatment with 3rd generation cephalosporins and metronidazole

Dis ussion:

Open appendectomy was the gold standard treatment for appendicitis as described by Me Burney in1894.A promising alternative was started by  Semm in  1983 during the laparosoopic era.2Laparoscopic appendectomy offers  many  advantages, exploration of the abdominal cavity especially the internalgenital organs infemales.Also reduced postoperative pain, shorter hospital stay and earlier return to work.5 With  the development of advanced laparoscopic equipment and  improved laparoscopic skills the procedure has become more popular. Looking for ways to take the advantages of the laparoscopic appendectomy, many surgeons start to perform single incision and single port laparoscopic appendectomy.

In 2007,  Zhu from  China reported  his first experience using the umbilicus to access the peritoneal cavity.6 Single incision laparoscopic surgery reduced the traditional three incisions with three ports to single skin incision  with two or three ports through separate fascial incisions. Single incision has been evolved to single skin incision with single fascial incision through  which  a device  is inserted  or even glove that can hold several ports.7 In our series the operative time was 50 to 80 minutes, slightly longer than that found by Chow et al.8 The operative time in his study (60 minutes) was found to be less than in traditionallaparoscopic appendectomy. Also Vidal et al9 demonstrated in his results that the time (46 minutes) was similar between the single port and the three ports  technique. We  referred the  longer operative time to the fact of the learning curve due to the restricted degree of freedom of the movement through the single port (crowding of the instruments).In spite that port site hernia is rare complication following  laparoscopic surgery,  Tonouchi et ailO reported  that the incidence of port site hernia was 0.65%-2.8% and the risk is higher  in single  port  due to larger  incision  length  and stretching of the fasia with the bigger umbilical port. Fortunately we did not have such a complication. In his study of 43 patients, Kim et alll reported three cases of umbilical  wound infection  and one case needed aspiration of fluid collection. Park et ail  revealed one case of wound  infection and one case of intrabdominal abscess that was in conjunction with our study.  We had one case of wound infection  which presented on the 5th day postoperative and one case of intra

abdominal fluid collection on the 7thday. Better

cosmetic results were similar to the other series as the visible scar can be avoided through the umbilical incision. Finally there is limitation in our study concerning type of pathology as the  complicated appendicitis is  excluded (appendicular mass, appendicular abscess). We hope  in  other  work  to include all  the appendix pathology.

Conclusion:

From the obtained results we found that single port laparoscopic appendectomy is feasible and  safe  in cases of non  complicated appendicitis. Further  studies  are needed for

complicated appendicitis.

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