Abstract:

Since the advent of Laparoscopic surgery, laparoscopic appendectomy (LA) has challenged open appendectomy (OA) as the preferred surgical treatment for acute appendicitis. As time and experience has progressed it has been used to treat even more complex cases of acute appendicitis to include perforation, abscess and gangrene. LA has demonstrated superiority over OA in many areas to include wound infection, reduced patient disability and cosmesis. The strengths of LA led have led to the application of single incision laparoscopic surgery to the treatment of acute appendicitis. Despite its promising future, SILS appendectomy (SA) cannot match the superiority of LA for treatment of acute appendicitis at this time. LA should be considered the preferred method of appendectomy.

Keywords:

Laparoscopic Appendectomy, SILS Appendectomy, Single-incision laparoscopic appendectomy (SILA), Laparoendoscopic single-site surgery appendectomy (LESS)

Methods:

A literature search was performed of the Springer Journals through the SAGES website. Keywords were chosen of “Laparoscopic Appendectomy” and “SILS Appendectomy.” Most of the articles chosen were within the past five years and compared laparoscopic versus open appendectomy and laparoscopic versus SILS appendectomy. Traditionally open appendectomy using the McBurney incision has been the gold standard of treatment for appendicitis since its description by Charles McBurney in 1889. This has been challenged by laparoscopic surgery with the first laparoscopic appendectomy performed by Kurt Semm in 1983. With the development of advanced laparoscopic equipment and improved laparoscopic skills the procedure has become more pervasive and popular. Looking for ways to take advantage of the benefits of laparoscopic surgery has led some surgeons to start performing appendectomy utilizing the SILS technique or single incision laparoscopic surgery. The progression of skin incisions has gone from a relatively large incision for the open approach to several small ones for the laparoscopic approach and lastly one small incision for the SILS approach. (Figure 1)

Laparoscopic appendectomy (LA) offers may advantages over traditional open appendectomy (OA). It been used in the past to settle any doubt as to the diagnosis particularly in women where there was some question as to the source of their symptoms. Laparoscopy offers the benefit of visualization of the entire abdomen and pelvis. According to Cox et al diagnostic laparoscopy in women provides a more accurate diagnosis, reduces the negative diagnosis rate to 6%, and avoids an unnecessary laparotomy in 35% of women presenting with presumed acute appendicitis. (1) Laparoscopic appendectomy has been shown to have fewer post op complications as noted by Geetha et al. (2) Surgical site infection (SSI) was more common in the OA group (11 patients- 9.6%) with no surgical site infection in the LA group. Ileus was another complication noted in his study groups for a total of 14 patients (OA- 10{8.8%} and LA- 4{4.7%}). Nakhamiyayev noted increased post operative complications in OA to include wound infections and abscesses, 17.4% in the OA group (19 incidents) versus 3.2% (5 incidents) in the Laparoscopic group. (3) Lin noted the complication rate of residents doing LA was 8.3% which although higher than more experienced laparoscopist was still lower than OA. (4) The complication rate went down to 2.6% with increasing experience of the laparoscopist and is comparable to that of other authors. The most common morbidity was postoperative ileus lasting more than 3 days, recorded in six patients (2.1%). The other complications included wound infection (0.7%, n = 2), intra-abdominal abscesses (0.7%, n = 2), bowel injury (0.7%, n = 2), retention of urine (0.4%, n = 1), and other medical complications (0.7%, n = 2). Multiple small incisions as compared to one larger muscle splitting incision leads to decreased post operative pain as demonstrated by Geetha. (2) Diclofenac was the analgesic used in their patients. The LA group required fewer (3.31 IV doses and 2.85 oral doses) doses compared to the OA group (7.05 IV doses and 4.53 oral doses). This was highly significant (p-0.0001). Length of stay for LA versus OA has also been examined and found to be less for LA. Geetha’s LOS was 3.13 days after LA, 4.36 days after OA, P < 0.0001; Nakhamiyayev’s median LOS in the LA group was 2days; range, 1–8 days and in the OA group was 3 days; range, 1–11 days, p\0.001; and, Cox’s LOS in the OA was 3.8 6 0.4 days and in the LA was 2.9 6 0.3 days. Cox also examined the time to return to normal activity and found it significantly longer following open appendectomy (19.7 + 2.4 days) than after laparoscopic appendectomy (10.4 + 0.9 days). Geetha’s data also supported this fact ( LA 13.86 days, OA 19.44 days).

Criticism of LA has focused on several factors to discount it as a viable option to OA. Some have focused on the learning curve necessary to enable to perform it effectively. With laparoscopic surgery being increasingly incorporated into surgical education it is becoming less of a concern. Yin has demonstrated that the complication rate is low, and that ”laparoscopic appendectomy performed by residents is safe.” (4) Another concern has been the cost of the procedure which entails special equipment and instruments above those typically required by surgery. Cox in examining this issue has shown that there is very little difference between LA and OA. The mean total cost was $5,663 for the LA group compared with $6,031 the open group. The difference of –$368 was not significant (95% CI, –$926 to $190; p = 0.19). (1) Geetha noted the cost of LA compared to OA (LA: Rs 5560.92, OA: Rs 4225.81) was significantly higher(p-0.0001) but this was factor was mitigated by a shorter LOS and faster return to normal activity. (2) Other critics have focused on the increased time to perform LA as opposed to OA. Nakhamiyayev demonstrated that when you compared experienced surgeons doing LA against experienced surgeons doing OA that the time difference is insignificant (LA mean, 55.7 ± 22.3 min; range, 20– 128 min and OA mean, 58.9 ± 23.7 min; range, 29– 135 min, 95% confidence interval [CI] –8.8–2.43; p = 0.26). (3)

Terminology of single-incision laparoscopic surgery

Single-incision laparoscopic surgery SILSTM
Embryonic NOTES E-NOTES
Transumbilical endoscopic surgery TUES
Single-port-access surgery SPA surgery
Single-access-site laparoscopic surgery SAS laparoscopic surgery
Single-site-access laparoscopic surgery SSA laparoscopic surgery
One port umbilical surgery OPUS
Natural ori fice trans-umbilical surgery NOTUS
Trans-umbilical laparoscopic assisted surgery TULA surgery
Laparo-endoscopic single-site surgery LESS (U-LESS)

Figure 2: Taken From Bruner et al (9)

In the evolution of laparoscopic surgery surgeons have tried to capitalize on the benefits of laparoscopic surgery to include better cosmesis, decreased post operative pain and decreased post operative debility and morbidity by reducing the incisions to one. This new frontier in surgery has led to the development of new instrument, camera and port technologies to promote its performance. (5) Many terms have been used to characterize single incision surgery. ( Figure 2) Single incision laparoscopic surgery reduced the traditional three-port-three-incision LA to a single skin incision with two to three ports through separate fascial incisions. Single incision surgery has further evolved to a single skin incision with a single fascial incision through which a device is inserted that can hold several ports. One such device is the SILSTM port from Covidian. (Illustration 1) Other such devices are made by Applied Medical, P Navel and Advanced Surgical Concepts.(Illustrations 2-4) While the enthusiasm to embrace this new method of surgery has increased, results from present studies fail to establish it as superior to laparoscopic appendectomy.

In SA authors have attempted to demonstrate comparability with LA or even superiority to LA with improved post operative pain, decreased wound complications and better cosmesis. Vidal et al demonstrated that the results of LA and SA were very similar. (6) The operative site was a supra-umbilical incision through which three ports were placed (two 5 mm and one 12 mm) and then closure by connecting all the incisions and closing them as one. In this study the operative times were similar mean duration of the operation was 51 ± 7 min for the LESS group and 46 ± 8 for the standard laparoscopic appendectomy group. Post operative pain was similar in the two groups. Using the VAS scale for postoperative pain intensity, the LESS appendectomy group was 2 (range, 1–3) and the standard laparoscopic group was 2 (range, 1–4). The LOS was also not significantly different between the two groups at a mean of 2.5 ± 0.6 days. There were no post operative complications in either group. While results are comparable between the two groups a number of factors should be considered. The laparoscopic skills of the authors were not addressed. There is a steeper learning curve for SA as it tends to violate typical ergonomics of laparoscopic surgery. As a result inclusion of data from less skilled laparoscopists would tend to lead to longer operative times and more conversions to LA or OA. The success of the SA approach was further enhanced by the exclusion of difficult cases of appendicitis which would include those with perforation or abscess. The authors also did not address increased cost from specialized instruments they used to overcome the ergonomic disadvantages of SA. Their method of closure led to a larger defect by connecting all of the port sites prior to closure. This would create an increased risk of incisional hernia. Only larger patient populations and longer post operative follow up will be able to settle this issue.

Chow et al discussed his experience with LA and SA where 33 patients underwent LA and 40 patients underwent SA. (7). Their study demonstrated a decreased operative time for SA (60.0 ± 15.5 vs. 70.2 ± 21.2 min; p = 0.02). Their LOS was also shorter for SA (LA 2.36 ± 2.62 day and SA 1.36 ± 0.95 days p = 0.07). They also examined cost of the procedure and by changing their technique reduced the additional cost of the SA from $1465 to $385 which is below the additional cost of LA at $837 to $879. Post operative complications were comparable in both groups. What was also noted in the study is that operative time may be more of a factor of the operator and not the procedure. When examining who did the procedures the predominance of SA were done by the attendings while the predominance of the LA were done by the residents (SA 34 of 40 and LA 8 of 33). When comparing the cost of each of the procedures it was not discussed whether the same cost-cutting methods could have been used on LA as well. They do acknowledge the difficult ergonomics of the procedure and have hope that future technological advancements will make the approach more feasible. While the hope was that the decrease in number of incisions would improve wound complications, each group in this study had two wound infections.

Chouillard relates their experience with 55 patients using the SA technique which they relate as a modified NOTES procedure. (8) These patients were selected from a larger population of patients using US or CT to select out the complicated cases of appendicitis. Other patients were excluded from the study for medical reasons or obesity. Of these patients 41were completed successfully using their SA procedure, while 13 were converted to LA and one to an open laparotomy. The mean operative time was 39 mins (14-111 mins) and the post operative complication rate was 5.4%; both of which are comparable to LA. Cost was not really addressed; although, the author did mention using some of the SILS articulating instruments which would add additional cost to the procedure. Another cost that was incurred was the prescreening with US or CT that could identify cases appropriate to the study. Again as in previous studies difficult cases were selected out and the procedures were done by surgeons with a great deal of experience. These surgeons are all post learning curve because of their extensive experience with NOTES procedures. These factors would tend to decrease their operative times and complications.

Brunner et all in their experience with SA echoed what other authors have stated that SA requires additional training and an increased learning curve. (9) They remark that true ambidexterity is essential in advanced surgeries utilizing single incision. They also relate that many of the suspected advantages of SA over LA such as reduced post operative pain and wound infection were not realized and so early enthusiasm for the SA was limited. Early studies demonstrated an increase rate of umbilical herniation but this was not seen in their surgeries. While they did not address the level of expertise to perform SA directly, they represented themselves as beyond the learning curve. Cost of additional instrumentation was not addressed but the need for it was mentioned.

Ahmed et al in his review of single incision surgery found a great variability in the results of SA. (9) They found that operating time ranged from 15 to 88 min and the use of additional ports ranged from 0% to 41%. The rate of conversion to open appendectomy ranged from 0% to 21% and the most common complications were wound infection (range, 0–14%) and intra-abdominal abscess (0–7%). The variability of rate of conversions, additional ports placed and complications speaks to the experience of the surgeons performing the procedures and further illustrates the learning curve necessary for surgeons to become proficient in performing the procedure. These results also demonstrate that the reduction in the number of incisions has not led to a reduction in the number of complications.

In relating their experience with SA, Kim et al published their experience with 43 patients. (11) They had a conversion rate of 4.65% where they had to add another port site. Their post operative complication rate was 11.6% and included two wound infections. They also relate the ergonomic difficulties of the single port and relate that cases of complicated appendicitis were excluded from the study. While they conclude that SA is feasible they do not demonstrate that it is superior to LA other than cosmesis.

In an interesting paper written by Muensterer et al they prospectively looked at pediatric appendectomies using a single incision technique and compared these patients against a retrospective control group of 151 patients operated on by the same surgeons using a traditional laparoscopic technique. (12) There were 75 patients included in their study who underwent appendectomy for acute appendicitis, perforated appendicitis and interval appendectomy. When compared to LA, their SA had improved operative times (37 ± 12.3 vs. 44.1 ± 20.3 min, p = 0.01, 95% CI = 32–42 min) for the acute appendicitis group. The operative time of the other two categories of SA was longer. Conversion rate to LA which meant placement of an extra port was 20%. Complication rate for the acute appendicitis was 9% using the SA technique as opposed to the LA technique where the complication rate was .5%. Included in this is the wound infection rate which was 4% for all three categories of SA and .6% for all three categories of LA. This study differs from the other studies because it includes the more difficult appendectomies and so can be more accurately compared against LA. While it does demonstrate that “the cosmetic benefit is not offset by longer operating times” there was a higher complication rate as compared to LA. LOS was similar in all categories of appendectomy in both the LA and SA groups except for the LA perforated group which tended to have an increase of 1.5 days. While the authors did address the ergonomic disadvantages of the procedure they were able to overcome them with conventional laparoscopic instrumentation. Additional costs associated with SA were not addressed by their study. Post operative pain management and return to normal activities were not examined by the study either but may be difficult to evaluate in children.

Conclusion

LA represents a superior procedure to OA. It offers many advantages over OA to include shorter operative time, lower overall cost, less post operative pain, shorter LOS and earlier return to normal activity. It also offers the additional benefit of diagnostic laparoscopy which is done at the same time and can confirm appendicitis when there is diagnostic uncertainty. Increased cost and skill to perform the procedure are no longer a concern based on recent literature. There is no longer a concern for the learning curve in laparoscopic surgery as it is now integrated into resident training. The graduating surgeon is proficient in this procedure. Concerns over operative times are no longer valid as Surgeons gain more laparoscopic experience. SA requires additional training beyond that of laparoscopic surgery. While SA would seem to have comparable results to LA in many studies, it suffers from a patient selection bias and surgeon bias. Most of the studies did not include complicated appendicitis cases when they compared SA to LA. The comparability of SA to LA can only be established in future studies that examin both procedures in treating the full spectrum of appendicitis with larger study populations. Cost and unique instrumentation will also have to be evaluated as well as the results of long term follow up. While SA has shown itself to be cosmetically superior to LA, the reduction in incisions has not led to decreased post operative pain or complications. SA does hold promise for the future and is an exciting new frontier for laparoscopic surgery. Given the superiority of LA over OA and the incomplete data on SA, LA should be the procedure of choice in the surgical treatment of appendicitis.

References:

1. Michael R. Cox, M.S.,* John L. McCall, M.D., James Toouli, Ph.D., Robert T.A. Padbury, Ph.D., Thomas G. Wilson, M.B., B.S., David A. Wattchow, Ph.D., Mary Langcake, M.B., B.S.: Prospective Randomized Comparison of Open versus Laparoscopic Appendectomy in Men. World J. Surg. 20, 263–266, 1996

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3. Vadim Nakhamiyayev Æ Lars Galldin Æ Mario Chiarello Æ Angela Lumba Æ Piotr J. Gorecki: Laparoscopic appendectomy is the preferred approach for appendicitis: a retrospective review of two practice patterns. Surg Endosc (2010) 24:859–864

4. Yap Yan Lin Æ Asim Shabbir Æ Jimmy B. Y. So: Laparoscopic appendectomy by residents: evaluating outcomes and learning curve. Surg Endosc (2010) 24:125–130

5. John R. Romanelli Æ David B. Earle: Single-port laparoscopic surgery: an overview. Surg Endosc (2009) 23:1419–1427

6. Oscar Vidal Æ Mauro Valentini Æ Cesar Ginesta` ÆJosep Martı´ Æ Juan J. Espert Æ Guerson Benarroch Æ Juan C. Garcı´a-Valdecasas: Laparoendoscopic single-site surgery appendectomy. Surg Endosc (2010) 24:686–691

7. Andre Chow • Sanjay Purkayastha • Jean Nehme • Lord Ara Darzi • Paraskevas Paraskeva: Single incision laparoscopic surgery for appendicectomy: a retrospective comparative analysis. Surg Endosc 25 March 2010

8. Elie Chouillard • Arnaud Dache • Adriana Torcivia •Nada Helmy • Ivan Ruseykin • Andrew Gumbs: Single-incision laparoscopic appendectomy for acute appendicitis: a preliminary experience. Surg Endosc (2010) 24:1861–1865

9. W. Brunner, J. Schirnhofer, N. Waldstein-Wartenberg, R. Frass, K. Pimpl, H. Weiss: New: Single-incision transumbilical laparoscopic surgery. Eur Surg (2009) 41/3: 98–103

10. Kamran Ahmed • Tim T. Wang • Vanash M. Patel • Kamal Nagpal •James Clark • Mariam Ali • Samer Deeba • Hutan Ashrafian • Ara Darzi •Thanos Athanasiou • Paraskevas Paraskeva: The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surgical Endoscopy 10 Jul 2010

11. Hyung Jin Kim • Jae Im Lee • Yoon Suk Lee • In Kyu Lee •Jung Hyun Park • Sang Kuon Lee • Won Kyung Kang •Hyeon-Min Cho • Young Kyuong You • Seong Taek Oh: Single-port transumbilical laparoscopic appendectomy: 43 consecutive cases. Surgical Endoscopy 16 April 2010

12. Oliver J. Muensterer • Cecilia Puga Nougues •Obinna O. Adibe • Sejal R. Amin • Keith E. Georgeson •Carroll M. Harmon: Appendectomy using single-incision pediatric endosurgery for acute and perforated appendicitis. Surgical Endoscopy 19 May 2010

J. Douglas Reid III, MD, FACS
Southern Abilene Surgical Associates
1665 Antilley Rd
Suite 150
Abilene, Texas 79606