A Randomized Trial to Compare the Conventional Three-Port Laparoscopic Appendectomy Procedure to Single-Incision and One-Puncture Procedure That Was Safe and Feasible,Even for Surgeons in Training

Introduction

Laparoscopic appendectomy was reported for the first time in 1983. ¹ Since that time, this procedure has spread and has become the standard operation for appendectomy. Conventional laparoscopic appendectomy has traditionally been performed using three trocars. Recent advances in laparoscopic instruments have led to reductions in the size and number of ports. Single-incision laparoscopic surgery (SILS) has emerged because it can achieve better cosmetic results in comparison with conventional laparoscopic surgery. ² However, several studies have reported that single-incision laparoscopic appendectomy has a tendency to involve longer operative times. ³ For this reason, SILS have several difficulties in performing the operation, including interference and collision between the surgical instruments and difficulty in securing a surgical view due to the parallel placement of the scope and surgical instruments. Esposito et al. hypothesized that the difficulty was due to a lack of triangular formation with the target organ. ⁴ This would make it difficult for SILS to maintain the manipulation angle. Thus, the procedure may not be safe or feasible for inexperienced surgeons.

We believe that laparoscopic appendectomy is a crucial procedure for inexperienced surgeons, such as junior residents, as it allows them to develop their endoscopic surgical techniques. We adopted a single-incision and one-puncture laparoscopic appendectomy (SIOPLA) procedure in which two ports were introduced through an umbilical wound and one fine puncture port was introduced through the suprapubic region of the lower abdomen to maintain the manipulation angle.

The aim of this study was to compare conventional three-port laparoscopic appendectomy (CLA) to SIOPLA in terms of the clinical outcomes when performed by surgeons with equivalent levels of experience, and to evaluate the safety and feasibility of SIOPLA, when the operation is performed by inexperienced surgeons.

Materials and Methods

Surgical procedures

The CLA procedure

A 12 mm trocar was placed at the umbilicus using the open access procedure and the abdominal cavity was identified using a 5-mm 30° telescope. The abdomen is insufflated to 8 mmHg with CO₂. A 5-mm trocar was placed at the left lower abdominal quadrant, and another 5-mm port was placed at the suprapubic region as working ports (Fig. 1A). The appendix was identified and then grasped by laparoscopic grasper. The mesoappendix was dissected using an ultrasonically activated device (Harmonic ACE plus^®; Ethicon Endo-Surgery, Cincinnati, OH). Ligation was performed at the base of the appendix with an ENDOLOOP^® (Ethicon Endo-Surgery) and another ligation was performed 1 cm distal from the previous ligation and the appendix was dissected using the ultrasonically activated device.

OPEN IN VIEWER

FIG. 1.

Port layout for CLA and SIOPLA. (A) CLA. A 12 mm trocar was placed at the umbilicus. A 5 mm trocar was placed at the left lower abdominal quadrant and another 5 mm port was placed at the suprapubic region. (B) SIOPLA. A skin incision measuring 15 mm in length was made. Next, an XS sized Lap-Protector^® (Hakko, Tokyo, Japan) was inserted into the umbilical wound and then an EZ Access port^® (Hakko) was attached. Two 5 mm trocars were inserted through the EZ access port. A 2.4 mm percutaneous insertion grasper without the use of a trocar (MiniLap^®; Teleflex, Morrisville, NC) was placed at the suprapubic region. CLA, conventional three-port laparoscopic appendectomy; SIOPLA, single-incision and one-puncture laparoscopic appendectomy.

The SIOPLA procedure

A 15 mm skin incision was made at the umbilicus and laparotomy was performed; then a Lap-Protector^® (size, XS; Hakko Co., Ltd., Tokyo, Japan) was inserted into the umbilical wound and an EZ Access port^® (Hakko) was attached. Two 5 mm trocars were inserted through the EZ access port. One trocar was used for a 5-mm telescope and the other trocar was used for a working port. The 2.4 mm percutaneous insertion grasper without the use of a trocar (MiniLap^®; Teleflex, Morrisville, NC) was placed using puncture technique at the suprapubic region as a working port (Fig. 1B). Appendectomy was performed using the same procedure as described earlier.

In the case of perforated appendicitis, the abdominal cavity was irrigated using 10 L of normal saline; a drainage tube was not placed.

Results

Discussion

In our study, no significant differences were observed in any of the points of evaluation between CLA and SIOPLA when the procedures were performed by surgeons of equivalent experience.

In the first report of laparoscopic appendectomy described by Semm, the operation was performed using three trocars (one telescope and two surgical instruments). ¹ Recent advances in laparoscopic instrument technology and surgical techniques have led to the performance of SILS, which is associated with reduced wound pain and superior cosmetic results. However, several studies have reported that SILS is associated with a longer operation time in comparison with multiport surgery. ⁴ SILS is associated with problems such as interference and collision between surgical instruments due to the parallel placement of the scope and the surgical instruments; thus, several studies have suggested that SILS may be difficult for inexperienced surgeons to perform. In our study, however, the operation time of CLA and SIOPLA did not differ to a significant extent when the procedures were performed by surgeons of equivalent experience. One remarkable finding was that there was no significant difference in the operation time of CLA and SIOPLA performed by SITs. In the SIOPLA procedure that we adopted, it is possible to maintain the manipulation angle toward the organ (appendix), and procedure provides a reasonably wide field of view and allows for the use of both hands. Some authors have stated that the preservation of the manipulation angle is of great importance in laparoscopic surgery. ⁵ The addition of suprapubic port also leads to increased maneuverability of the instruments and better retraction of the appendix. ⁶

The frequency of analgesic use could be correlated with postoperative pain. Donmez et al. presented that the frequency of analgesic use would be associated with the number and size of the incisions for trocars in laparoscopic surgery. ⁷ Although the number of trocars was decreased from three to two and the incision size was decreased from 5 to 2 mm in the SIOPLA operation that we adopted, the frequency of analgesic use did not differ to a statistically significant extent between SIOPLA and CLA. Kang et al. showed that SILS did not reduce the frequency of analgesic use due to the increased length of the umbilical incision. ⁸ Referring to Kang's study, in our study, the frequency of analgesic use when CLA was converted to SIOPLA was not increased.

In this study, the intraoperative blood loss did not differ to a statistically significant extent between CLA and SIOPLA. As the intraoperative blood loss was recognized when the mesoappendix was dissected, the procedure applied in the dissection of the mesoappendix and the devices that are used would be very important. In all of the cases in which SIOPLA was performed in this study, the operators were able to dissect the entire mesoappendix using an ultrasonically activated device (the same as CLA); thus, we did not observe any cases of serious intraoperative blood loss.

With regard to postoperative complications, intraperitoneal abscess and wound infection are the complications that most commonly affect the duration of postoperative hospital stay. In some reports, laparoscopic appendectomy clearly reduced the incidence of wound infection and intraperitoneal abscess in comparison with open appendectomy.^9,10 This reduction of infectious complications was definitely observed in cases involving the gangrenous and perforated appendectomy. ¹¹ Referring to these results, the irrigation of the abdominal cavity after the resection of appendix is of great importance. The SIOPLA operation that we adopted could achieve local and wide views with a favorable manipulation angle for surgical instruments the same as CLA. Thus, purulent ascites located in the bilateral hypodiaphragmatic space could be thoroughly irrigated. Since the operation time of SIOPLA for gangrenous appendicitis performed by SITs did not differ to a statistically significant extent from CLA performed by SITs, SIOPLA is considered to be an optimal procedure for severe cases, such as gangrenous or perforated appendicitis.

The hospital stay would be associated with postoperative complications and pain. In this study, there were no significant differences in the incidence of postoperative complications, the frequency of analgesic use, or the length of hospital stay between SIOPLA and CLA. Based on these results, we considered that SIOPLA and CLA achieved the same outcomes.

The incidence of postoperative complications, the frequency of analgesic use, and the length of hospital stay after operations performed did not differ to a statistically significant extent. In this study, experienced expert surgeons were always on hand to supervise CLA and SIOPLA operations performed by SITs. Thus, inexperienced operators, such as SITs, could perform laparoscopic appendectomy safely and satisfactory postoperative outcomes could be obtained. We, therefore, believe that SIOPLA has become an optimal surgical procedure, even for young SITs.

Our study is associated with several limitations. This study was performed in a single institution. The comparisons between SITs and APSs were based only on their experience as pediatric surgeons and not on their previous experience in performing CLA before performing SIOPLA.

Conclusions

In conclusion, SIOPLA was associated with satisfactory postoperative outcomes in comparison with CLA. SIOPLA obtained good postoperative outcomes and was a safe and feasible surgical procedure, even for young SITs.