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Single Incision Laparoscopic Appendicectomy (SILA) using standard laparoscopic instruments. A case controlled study.

Clement Tsang, MB BS, FRACS ( Correspondence Author )

Department of Upper GI surgery

St Vincent’s Hospital Sydney

390 Victoria Street Darlinghurst

NSW  Australia 2166

Keywords

Single incision, laparoscopic appendicectomy, laparoscopic appendectomy, single port, single umbilical incision

Abstract 

 Background: The use of multiple incisions for laparoscopic surgery has recently been challenged by the use single incision (SILS) in many different fields of laparoscopic surgery.

Aim: To assess if single incision appendectomy can be safely performed with the existing laparoscopic instruments while maintaining a similar operative time frame, length of stay but better cosmetic results.

Method: A prospective matched case control trial was performed in a tertiary hospital under the upper gastrointestinal team. A post operative survey on the patient’s satisfaction and pain score was also performed.

Result. There was 15 patients who had underwent this operation and 15 matched control based on age and sex. There was no significant difference in mean BMI, length of stay, total operative time between the two groups. The pain experienced was categorized as mild to moderate based on the numeric pain score. Every one was happy with their results and there was no complication on short term follow up in rooms.

Conclusion: single incision appendectomy can be safely performed with existing instruments with good cosmetic outcome and a short learning curve.

Introduction

Appendicitis is the most common acute general surgical condition that requires emergency surgery. It is also one of the conditions that has benefited from the introduction of laparoscopic surgery. When compared with open appendectomy the benefits include reduced morbidity, reduced length of stay, shorter recovery time, less pain and better cosmesis which are all advantages of laparoscopic surgery (1, 2). In performing appendectomy a three port triangulated technique is considered the standard of care. However surgeons have performed laparoscopic appendectomy through a single incision.  In 1995 Antal et al described the use of a 2 port appendectomy in a pediatric group of patients(3). Esposito was the first to published a series of 51 cases of single-trocar appendectomy through a 10mm operating laparoscope in 1998(4). Their techniques were not widely adopted due to the difficulty and lack of instrumentation for the procedures to be performed safely.

Single incision port devices have been developed for this type of surgery, however these devices add a considerable cost to the procedure and without data to support the benefits of a single incision compared to a three incision, public hospitals may be unwilling to purchase these ports on economic grounds. However, there are surgeons who think that there may be benefits to performing SILS. We present a prospective series of patients who underwent single incision laparoscopic appendectomy using existing standard equipment placed through an umbilical incision.

Patients and Method

Patients presenting with a diagnosis of acute appendicitis under the upper Gastrointestinal surgical team during the month of May and June 2009 were offered single incision laparoscopic appendectomy. Inform consent was obtained after explaining the procedure to the patient. There were 15 consecutive single incision appendectomy performed without the need for patient selection. All the operations were performed under general Anaesthetic with preoperative intravenous antibiotics and subcutaneous heparin.  Post operatively the patients were managed the same way as the standard laparoscopic appendectomy. All patients were commenced on a normal diet postoperatively, and oral analgesia in the form of oral and subcutaneous narcotic and or Anti-inflammatory medications. The details of the patient’s demographics, length of operation and duration of hospital stay, BMI and histology report were collected prospectively and analyzed. A single assessor then performed a survey on the patient relating to their post operative experience (see appendix 1). 15 patients who had previously underwent standard three ports appendectomy under the same surgeon were selected for control. They were matched by age and sex in an attempt to reduce confounders.  The data were analysed by SPSS statistical program and comparison was made based to two independent samples.

Surgical Technique

10 steps to single incision appendectomy

1.  Patient in supine position with both arms by their side. A 2cm vertical umbilical incision is made.

2.  A 2cm to 3cm diameter subcutaneous flap in pre-fascial plan is dissected out

3.  An incision is made in the umbilical cicatrix large enough for a 5mm port.

4.  An Endobag 10mm. 3inch x 6inch ( Autosuture USA) is inserted into the abdomen

5.  A 5mm x 100mm Dilating tip Endopath Xcel ( Ethicon Endo-surgery,USA ) port is now inserted and pneumoperitoneum is created. This port is transparent and allows direct vision of subsequent ports inserted.

6.  Two 5mm Apple ports are placed (Apple medical corporation Massachusetts USA) at the 10 o’clock and 6 o’clock position under vision(Diagram 1).

7.  The patient is positioned head down and right side up. A standard 30º 4mm telescope is placed in between the right and left working ports. We use the laparoscopic tower by (Conmed Linvatec corporation USA).

8.  A hook diathermy is used to dissect the mesoappendix from the appendix and two 0 PDS endoloops are placed on the base of the appendix before it is amputated. This dissection may also be carried out using a curved dissector with diathermy attached.

9. The mesoappendix may be ligated with another loop PDS if desired.

10. The appendix is placed in the bag before retrieval via the umbilicus. The fascial opening and skin incision can now be closed.

Figure 1. vertical incision, subcutaneous flap and ports placements.

 

Figure 2. showing that a wider working angle can be obtained with  bulky part of the exel port further away.

Figure3. Insertion of single two 5mm ports with the assistant retracting the skin fold, the trocar can be seen through the translucent port..

 

     

Figure 4. Surgeon and assistant operating on the left hand side

The patient in reversed trendelenberg right side up.

Figure 5 working instruments parallel to the scope.

Figure 6. Umbilical wound after skin closure

Results

There were 15 consecutive single incision laparoscopic appendectomies performed without the need to add extra ports. 4 of the 15 patients in both groups had perforated appendicitis on histology. The mean age was 32.58 years for case and 31.73 years for the control group respectively. In the case group, 8 of the surgery were performed by one consultant and 7 for a Fellow. In the control group 8 were performed by the same surgeon in the control group, 4 by senior registrar and 3 by a Fellow.

The table below show some of the comparison made between the case and the control groups along with the P values. The mean operating time for the case group was 74.87 mins and 84.87 mins for the control group. This time interval is calculated from time of Anaesthetic induction to the time when the patient left the operating theatre. We timed 9 patients in the case group, the time of incision to closure of skin was 41.7 mins on average and the range was 30 to 60 mins.

Comparision between single incision and standard three incision appendectomy

 

Case n=15

Control n=15

 

P-value

95% CI Lower

 Upper

 

Mean

Range

Mean

Range

sig(2-tailed

 

 

 

 

 

 

 

 

 

Age (years)

32.53

15 to54

31.73

18 to 57

0.857

-8.2

9.2

 

 

 

 

 

 

 

 

Sex

M=10 F=5

 

M=10 F=5

 

 

 

 

Length of stay (days)

2

1 to 5

2.8

1 to 6

0.079

-1.7

0.1

Total operative time ( mins)

74.87

40 to 95

84.87

50 to 144

0.25

-27.6

7.6

Body mass index ( kg/m2)

22.10

16.7 to 29.4

24.80

18.4 to 33.2

0.12

-6.1

0.7

Table 1 Statistical analysis of two independent mean

On the post operative survey 14 out of the 15 subject preferred single incision. One subject preferred 3 ports technique because be cosmesis was not an issue for him. He was mainly concerned with safety. He had however agreed to have single incision knowing that we will add extra ports it the operation had become difficult. 13 out of 15 patients had friends or relative with appendicitis who had undergone Lanz incision. Two other patient has no knowledge as to how appendectomy was performed. This suggested that they anticipate that it will be done the same way. 14 out of 15 patient strongly agreed that single incision was a good idea, the same patient was neutral because cosmetic was not an issue for him. No patients decline to have this technique done. On a scale of 0 to 10 relating to their satisfaction with the result of the operation, the average score was 9.27 with a range of 8 to 10. All patients were happy to refer anyone to with appendicitis to have single incision performed. The table below shows the pain scores of these groups of patients. Their mean pain level is between 3 and 4 indication that their pain is mild to moderate on the numerical rating scale.

Pain score relating to posture

Position

Mean

Range

Supine

3.7

1 to 7

Standing

4

2 to 7

walking

4.1

1 to 7

Table 2.  Pain score day one post operative.                                                                                                                                                          

Discussion

Single incision laparoscopic surgery has captured the imagination and interest of surgeons worldwide. In the last twelve months there have been a number of procedures performed with the SILS technique including gastric banding, sleeve gastrectomy, splenectomy, nephrectomy, colectomy, and adrenalectomy, inguinal hernia repair and Nissen Fundoplication(5-7). The major benefit of single incision laparoscopic surgery is the better cosmetic outcome(8). Theoretically, there may be a reduction in pain, bladder injury and port site bleeding because less incision are made while achieving similar surgical outcomes. The three factors which will possibly slow the wide spread adoption of this technique is the availability of suitable and inexpensive instrumentation, the acquisition of skills (the loss of triangulation) and finally, evidence for the benefits of this technique.

We decided to assess this technique for acute appendicitis as it is a relatively common condition and the steps in performing the procedure relatively straightforward. The procedure was offered to all patients with a presentation of acute appendicitis and one whom there was no contraindication to laparoscopy. We felt this was important as most papers emphasize the need for careful patient selection but if this technique is to be adopted widely then any patient who would normally be considered for a laparoscopic appendectomy should be eligible.

The technique that we describe here differs from those published previously.(4, 9, 10). Reports have described the use of an endoscope with a working channel, specialized (NOTES) instruments, roticulated gaspers or larger ports. Although technically challenging because the working instruments are parallel to each other rather than triangulated. The learning curve is short as we have included all patients in this report. Some of the issues that we faced are: 1) how to maintain a small incision 2) overcoming poor image quality 3) lost of depth perception 4) instrument collision 5) light lead collision 6) lost of triangulation 7) inexperience assistant.

A small umbilical incision was maintained by using a 5mm xcel port and two 5mm low profile Apple ports. The low profile nature of the ports also allows more maneuverability of the instruments. Moreover the Apple ports are reusable.

A high definition digital system is required when a 5mm scope is used in order for the image quality to be adequate. We use the laparoscopic tower by (Conmed Linvatec corporation USA). It provides a camera that allow for optical zoom which ease the difficult of the operation. The picture quality provided by the digital HD laparoscopy also has superior objective performance characteristics compared with standard laparoscopes(11). The dark grainy pictures using an analogue system would make this operation hazardous to perform. The Linvatec system allows for the use of a 30º 4mm scope. The field of view is narrower compared to the standard 30º 10mm scope. The image and contrast is not as bright, but it was adequate to complete all the operation safely.

When operating in a parallel fashion with restricted movement of the instruments, the depth of perception and field of view can be diminished. Some cues such as pass pointing, heptic feedback, tissue shading can improve the depth perception. This is obtained by having the assistant constantly moving the scope while the surgeon is manipulate the appendix to give the best view.

One of the major technical difficulties with this operation was the collision of instruments as they are all very close together. This can occur at the tip of the instruments or at the handles.  A few methods can reduce this clashing. Firstly the ability to zoom would allow the camera head to sit further away from the patients. Secondly, when the Xcel port is placed as far out as possible. Thirdly, the use of a longer scope. Currently on the market, there is a bariatric 5mm 30 degree scope available that is 45cm long. This allows the bulky camera head to sit further back from the patient and more importantly the scope does not limit the operating field. Finally the use of roticulated  instruments.                                                                                                                                                                                                 

Current design of the light lead that attaches perpendicularly to the scope also causes clashing of instruments during single incision laparoscopic surgery. Doing this operation we constantly have to move the light lead to improve the range of movements for the surgeon. However we found that having the 30º scope looking upward results in the least collision. There is now an attachment available for certain scopes that makes a 90 degree bend and allows the light lead to sit parallel to the scope. This allows rotation of the scope and maximise the advantage of using 30 degree scope without the light lead clashing with the other instruments.

A fundamental shortcoming of single incision laparoscopic surgery is the loss of triangulation. The technique is quite awkward initially as the movement of graspers is very different to standard laparoscopic surgery. However, the technique is quickly learned and the surgeons got used to the new movements very quickly. The loss of triangulation can be partly overcome with the new roticulating laparoscopic instruments which have been introduced recently. These new instruments improves triangulation and allow better range of movement but the skills required to maneuver these instruments are different to standard laparoscopy, hence a learning curve would still apply. The use of these instruments would mean a significant increase in cost of the operation as the instruments are all disposable and more expensive than existing instruments. The technique we describe uses existing equipments without additional cost. However it is not a contraindication to use these instruments if it is available. To date, we have not yet required to use one.

It was noted during our experience that this technique requires a good surgical assistant that is familiar with the fundamentals of laparoscopic surgery. Performing this operation with junior staff without appreciation of laparoscopic surgery and maneuvering of the 30º scope greatly increase the difficulty of the operation and possible complications. We suggest when performing the first few of this operation, an assistant with sound laparoscopic skills should be used.

In this small case control study, the patient’s sex, age and BMI were well matched with no significant difference between the two groups. It was surprising to find that the length of stay and operative time was shorter in the case group compared to the control group. This was not statistically significant. Their mean pain level was between 3 and 4 indication that their pain is mild to moderate on the numerical rating scale. The results of our small survey showed that patient still anticipate that appendectomy is performed by a Lanz incision. When offered single incision laparoscopic appendectomy 14/15 strongly agreed that was a good idea. All the patients were more than happy with their results and wound recommend any one with acute appendicitis to have it done this way. There was no short term complication on post operative follow up in the consulting room.

We believe that the technique we have described is a safe procedure that obtains the same surgical outcome as standard laparoscopic appendectomy but with a single scar.  This technique has the advantage over other form of single incision laparoscopic surgery requiring the SILS ports. This is because it uses existing laparoscopic instruments already available in most operating theatres without additional cost. Although awkward initially, the learning curve is short in surgeons with existing laparoscopic skills. Once the surgeon is comfortable with this new technique then a progression to more complex single incision laparoscopic operation such as cholecystectomy can be followed.

Appendix

Survey

  1. What is your referred mode of surgery 1) Lanz incision 2) standard 3 incision laparoscopic appendectomy 3) single incision
  2. Do you know of anyone who had appendectomy done, what scar do they have? 1) midline 2) Lanz 3) 3 small incision 4) single umbilical incision
  3. Is single incision appendectomy is a good idea?

1) Strongly agree 2) agree 3) neutral 4) disagree 5) strongly disagree.

  1. Would you object to have it done?

1) Strongly object 2) object 3) neutral 4)  no objection5) strongly no objection

  1. Are you happy with the results? Yes or No. If yes, on a scale of 1 to 10 how would you rate it?
  2. How much pain do you expect to have? Scale 1 to 10
  3. What the pain level that you have experienced? 1) Laying 2) standing 3) walking. Scale 1 to 10.
  4. Would you recommend it to another person who you know have appendicitis and need surgery? Yes  No

References

1.         Frazee RC, Roberts JW, Symmonds RE, Snyder SK, Hendricks JC, Smith RW, et al. A prospective randomized trial comparing open versus laparoscopic appendectomy. Ann Surg. 1994 Jun;219(6):725-8; discussion 8-31.

2.         Chung RS, Rowland DY, Li P, Diaz J. A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg. 1999 Mar;177(3):250-6.

3.         Antal A, Ezer P, Hideg G. Laparoscopic appendectomy (LA) with a new technique. Acta Chir Hung. 1995;35(3-4):225-8.

4.         Esposito C. One-trocar appendectomy in pediatric surgery. Surg Endosc. 1998 Feb;12(2):177-8.

5.         Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech A. 1999 Aug;9(4):361-4.

6.         Reavis KM, Hinojosa MW, Smith BR, Nguyen NT. Single-laparoscopic incision transabdominal surgery sleeve gastrectomy. Obes Surg. 2008 Nov;18(11):1492-4.

7.         Remzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port laparoscopy in colorectal surgery. Colorectal Dis. 2008 Oct;10(8):823-6.

8.         Podolsky ER, Rottman SJ, Poblete H, King SA, Curcillo PG. Single port access (SPA) cholecystectomy: a completely transumbilical approach. J Laparoendosc Adv Surg Tech A. 2009 Apr;19(2):219-22.

9.         Nguyen NT, Reavis KM, Hinojosa MW, Smith BR, Stamos MJ. A single-port technique for laparoscopic extended stapled appendectomy. Surg Innov. 2009 Mar;16(1):78-81.

10.       Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Praveenraj P. Transumbilical endoscopic appendectomy in humans: on the road to NOTES: a prospective study. J Laparoendosc Adv Surg Tech A. 2008 Aug;18(4):579-82.

11.       Pierre SA, Ferrandino MN, Simmons WN, Fernandez C, Zhong P, Albala DM, et al. High definition laparoscopy: objective assessment of performance characteristics and comparison with standard laparoscopy. J Endourol. 2009 Mar;23(3):523-8.

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