Page 28 - Laparoscopic Journal - WJOLS

Khaled Al-yaqout et al
and showed five reports proposing umbilical herniation factor is that the surgeons are familiar with SSILA, a third
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as secondary to infection at this site. In the other hand, possibility is that many of these studies has excluded
7
varying depth the umbilicus is thought to result in a complicated cases, except for Ze Zhange et al, but he also
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higher local wound complication rate. A descriptive achieved equal results even after including the compli-
study published in 2013, it included 570 patients. They cated cases. Drain placement is subjected to the surgeons
analyzed port-site complications, and concluded that preference, and, the intra­abdominal findings. The high
the umbilical port is the most common site (47% of port- percentage of drains used is due to a liberal use of drains
site complications). The complications ranged from PSI, by Alvarez in his study. A total of 13 drains were placed
bleeding, herniation, omental entrapment and port-site in 15 individuals in his study. We could not conclude if
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metastasis. S Ghata et al in a prospective study on 100 pain in SSILA is better than an umbilical approach, this
patients assessing wound complication, they have found is mainly due to the lack of evidence on this topic. Only
that most PSI is at the umbilicus, along with subcutane- one author used VAS and the sample was too small to
6
ous emphysema and port-site hernia. One hundred and come up with a conclusion. Authors claim that cosmetic
fifty patients were studied in an randomized clinical outcome is better. Hypothetically, we can assume that the
trial conducted by P Bucher et al, it showed similar rates presence of the incision in the pubic area will be invisible,
of seroma and hematoma in both umbilical and other even if complications, such as infection arises in such an
ports (3%), in conventional laparoscopic cholecystectomy, area, the concern regarding it final outcome will not be
he has also shown a 0% hernial rate, yet his study lacks as if it was at the umbilicus, but as from the evidence
long-term follow-up in regards to hernia, showed no available, one author has presented an objective cosmetic
7
blinding or concealment and suffers selection bias in our assessment. Hence, we can only base our conclusion
opinion. Although no infection was reported one can hypothetically supported by the subjective opinion of
predict that hematoma/seroma can predispose to wound the SSILA authors that we can achieve a better cosmetic
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infection. No level one evidence is present to support outcome with such an approach. The follow-up duration
a suprapubic SILS. This paper aims not to establish SILS was too short in some studies to evaluate complications,
as a gold standard management of AA, but to describe such as herniation, we are hoping that the upcoming
an alternative to the commonly used access site, in order RCTs will give a better answer, yet assuming that the
to decrease the complication rate associated with it as infection rate is lower we can hypothesis that we will
described previously, and hence to get more acceptance, have a lower rate of hernia formation.
to motivate the conduction of RCTs regarding this topic.
Suprapubic single-incision laparoscopic appendectomy ConCLuSion
(SSILA) is relatively new, it was first proposed in 2005. Finding a different access site in AA might decrease the
Hence, we would have come to a better conclusion if rate of port-site complications, and hence the morbidity
sufficient sample sizes were available to achieve power.
Another issue is the lack of RCTs, but we are looking for- associated with it, the suprapubic incision is an appea-
ward to see the results of Ze Zhang et al upcoming RCT, ling alternative, with lack of strong evidence to support
which will aid in determining the fate of SSILA. With the it. The available evidence supports its use, but more RCTs
have to be conducted to give a better decision on such
available evidence we can conclude that, using the com-
mercially available SILS ports, the operative time may be an approach.
shorter. The mean operative time presented in our paper
reflects mostly the work presented by one institute, 7,11 ReFeRenCeS
they used a self made port that might have resulted in 1. Vettoretto N, Cirocchi R, Randolph J, Morino M. Acute appen-
longer operative time, not only this but also the use of dicitis can be treated with single-incision laparoscopy: a
conventional instruments in their approach would alter systematic review of randomized controlled trials colorectal
the ergonomics and triangulation in the field and hence disease. Wiley-Blackwell 2015;17(4);281-289.
result in operative delay. The safety of SSILA might be 2. Xu AM, Huang L, Li TJ. Single-incision versus three-port
laparoscopic appendectomy for acute appendicitis: syste-
questioned by some, but the 0% rate of intraoperative matic review and meta-analysis of randomized controlled
complications proves no such claim to date. Cosmesis is trials. Surgical Endoscopy. Springer Science + Business
not compromised by the use of extra-ports or conversion Media, 2014;29(4):822-843.
to conventional nor open. All four authors claimed no 3. Antoniou SA, Koch OO, Antoniou GA, Lasithiotakis K,
use of extra-ports, this can be due to many factors. One Chalkiadakis GE, Pointner R, Granderath FA. Meta-analysis
of randomized trials on single-incision laparoscopic versus
is that the viewing angle in such an approach can ease conventional laparoscopic appendectomy. Am J Surg Elsevier
the dissection and retrieval of the appendix, another BV 2014;207(4):613-622.
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