Comparison of Transumbilical Laparoscopy-Assisted Appendectomy with Conventional Three-Port Laparoscopic Appendectomy Performed by Pediatric Surgeons in Training for Appendicitis in Children

Introduction

In 1983, Semm first presented the three-port technique for laparoscopic appendectomy. ¹ Since then, the surgical techniques for appendectomy have been diversified to become less invasive. In contrast, acute appendicitis is one of the most common reasons for emergency operations in children, and currently conventional three-port laparoscopic appendectomy (CTPLA) has become the first-line treatment. Laparoscopic appendectomy is the first procedure performed by surgeons at the beginning of their training to master the basic techniques of laparoscopic surgery. Appendectomy is one of the most basic surgical procedures, and various techniques have been developed. Among them, transumbilical laparoscopy-assisted appendectomy (TULAA), which was described by Pelosi in 1992, is another good technique. ²

Although various techniques have been developed for the treatment of acute appendicitis, there are few reports on appropriate techniques that combine surgical training and minimally invasive techniques.

In this study, we compared surgical outcomes between pediatric patients who underwent TULAA or CTPLA for uncomplicated or complicated appendicitis. We also aimed to evaluate the feasibility of TULAA for complicated appendicitis when performed by pediatric surgeons in training (PSITs).

Materials and Methods

We conducted a retrospective study of laparoscopic appendectomies for pediatric acute appendicitis performed between April 2016 and December 2022. The patients underwent interval appendectomy, and those whose pathological findings included “catarrhalis” were excluded. All operations were performed by PSITs and the surgical technique was selected according to the preference of the supervising surgeon. CTPLA was performed between April 2016 and March 2019. TULAA was introduced on April 2019 and performed between April 2019 and December 2022

Surgical procedures

The CTPLA procedure

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

OPEN IN VIEWER

FIG. 1.

Port layout for CPTLA and TULAA. CTPLA, conventional three-port laparoscopic appendectomy; TULAA, transumbilical laparoscopically assisted appendectomy.

The TULAA procedure

A 15-mm skin incision is made at the umbilicus, so as not to exceed the umbilical ring, and laparotomy is performed. A single-port device composed of a wound protector and a cap with trocars (Arunote Lap Single^®) is applied to the incision site. The abdominal cavity is identified using a 5-mm 30° telescope (Fig. 1b). The abdomen is insufflated to 8 mmHg with an ultrasonically activated device (Harmonic ACE plus; Ethicon Endo-Surgery) for dissection. After exploration of the peritoneal cavity, the peritoneal attachments to the appendix and cecum are dissected to allow the appendix to reach the umbilicus (Fig. 1b).

The cap of the single port device is opened, and the wound protector in the single-port device is left at the transumbilical incision site. The appendix is extracted through the transumbilical incision by pulling out the grasper holding the appendix. The appendix is then resected outside the abdominal cavity.

Results

During the study period, 8 PSITs were responsible for the surgery.

Discussion

This study focused on the outcomes and retrospectively reviewed the treatment of pediatric appendicitis patients who were treated at our institution. The major findings of this study were as follows. (1) In all patients, TULAA had a shorter OT, and PT. Blood loss and length of hospital stay of the 2 groups were not significantly different. (2) The surgical site infection rate was slightly higher in the TULAA group. (3) In uncomplicated appendicitis, OT and PT in the TULAA groups were significant shorter than those in the CTPLA group. Surgical site infection in the TULAA group was significantly higher than that in the CTPLA group. (4) In complicated cases, PT in the TULAA group was significantly shorter than that in the CTPLA group. Length of hospital stay in the CTPLA group was significantly shorter than that in the TULAA group.

Single-site (incision) laparoscopic appendectomy (SLA) is an effective alternative to conventional three-port laparoscopic appendectomy (CTPLA) and is one of the techniques that is spreading to various centers because it requires only a small incision within the umbilical ring, which is barely noticeable after surgery. However, previous studies comparing SLA and CTPLA in adults have shown that SLA is associated with significantly longer operative times, and technical difficulties may be the reason for the longer operative time during internal resection of the appendix in SLA. ³

Especially in pediatric surgery, though the number is still not large, an increasing number of studies are being conducted on the removal of the appendix through a single umbilical incision and extracorporeal excision. ⁴ In contrast, TULAA combines the advantages of good intra-abdominal visibility of laparoscopy with the safety and rapidity of conventional external open appendectomy. Several recent reports using TULAA in children have shown significantly shorter operative times than CTPLA. ⁵ However, in general, there is concern that single-site (incision) surgery is more technically challenging than CTPLA, especially for surgeons in training, due to the limitations of intraperitoneal forceps manipulation and forceps–endoscope interference outside the body.

In the case of TULAA, many studies have reported a completion rate of ∼80% in adults and children without conversion to laparotomy or additional port. ⁶ In our cases, the percentage of cases in whom the appendix was resected internally because it could not be pulled out of the umbilicus was only 4.6%. No cases were treated with an additional port and no cases were converted to laparotomy. The OT for these patients was 67.0 ± 28.4 minutes for TULAA and 78.3 ± 21.7 minutes for CTPLA. This difference was statistically significant, which suggests that TULAA is a shorter and better tolerated technique.

This may be because the distance between the umbilicus and the ileocecal area is shorter, especially in children, and the ileocecal area is loosely fixed, facilitating withdrawal to the umbilicus. As for wound infections, all did not require antibiotics and those improved with home cleaning alone. Although CTPLA and TULLA showed no difference in postoperative wound infection rates, the present results show that surgical time is comparable and PSIT is as acceptable for performing TULLA as it is for CTPLA

Especially in the cases of uncomplicated appendicitis, there were no significant differences in patient background, and the OT, PT, and the length of hospital stay in the TULAA group were significantly shorter than in the CTPLA group. The reason for the shorter OT in the TULAA group may be related to the fact that the resection of the appendix and the mesoappendix is easier than in CTPLA because appendectomy is performed by pulling the appendix out of the wound, and the PSITs are working with the supervising surgeon, making the procedure similar to open surgery. Unfortunately, wound infections were somewhat more common in uncomplicated appendicitis.

The fact that there was no overall difference and only minor infections suggests that measures such as additional intraoperative wound cleansing and covering should be considered. These results were in line with the relevant literature, and TULAA is considered feasible, especially for uncomplicated appendicitis.

In several studies of complicated appendicitis, SLA including TULAA was reported to be associated with a longer OT in comparison with CTPLA,^4,7,8 and many other operative outcomes were reported to be comparable between the two groups. ⁹ However, the results of this study differed from some previous reports: the OT remained the same and there were no significant differences in surgical outcomes, such as the complication rate. This difference may be due to two factors: the surgeons who performed the surgeries were PSITs (either near to or after the end of their surgical training) and they may have been more familiar with laparoscopic appendectomy than expected. In fact, some of the trainees had never performed open appendectomy.

They performed laparoscopic dissection of adhesion and, in some cases, dissected the ileocecal site and pulled the appendix out of the wound, even in cases in whom the appendix could not be easily pulled out from the wound due to difficulty in detaching adhesions due to abscess formation, physiological adhesions, and other reasons. Although potentially more invasive, the technique of detaching adhesion from the retroperitoneum can be applied to other procedures, such as ileal resection, with no difference in blood loss or complications and would be a very good method for surgeons in their later training and for surgeons with a high degree of specialization. ¹⁰

Also, unlike in the past, the training environment for laparoscopic surgery has improved considerably, and one factor may be that trainees can use a dry box to familiarize themselves with the operation of equipment used in SLA and other procedures. In fact, TULAA was associated with a very high completion rate (96.5%), and the rate of achievement was higher than that described in the relevant literature.

Basically, the complications of TULAA are the same as those of CTPLA. However, studies have reported that TULAA is associated with a higher incidence of wound infection in comparison with conventional CTPLA. ⁶ This is presumably because the appendix is pulled directly into the wound, making it easier for the appendix to come into contact with the wound and cause infection. In our institution, the rate of surgical site infection was high in simple appendicitis. It is thought that devices such as the wrap protector used in our institution, which prevents contamination of the wound, can improve the incidence of wound infection. According to the results of this study for simple appendicitis, this issue should be further investigated with the accumulation of more cases in the future.

Many studies have reported that TULAA is superior to CTPLA from a cosmetic standpoint. Although objective evaluation is difficult, in many cases who were managed in our institution, the scars were not noticeable and the surgery was well received by the patients' families. In addition, similarly to other reports, TULAA was considered a useful technique from the medical economic viewpoint, as it reduced the number of supplies used in comparison with CTPLA.

Conclusion

We compared the TULAA and CTPLA techniques, which combine the advantages of SLA and open surgery, when performed by a pediatric surgeon in training. TULAA had a shorter OT and PT than CTPLA. TULAA for PSITs shows similar safety and feasibility to CTPLA. The results showed that TULAA was considered an acceptable technique even for complicated appendicitis, even performed by trainee surgeons. According to our results, TULAA can be performed for appendicitis with adhesions and abscesses and can be flexibly modified to a multi-port approach in difficult cases, while CPTLA can be performed for appendicitis with adhesions and abscesses. TULAA can be used for appendicitis and the results were comparable with the conventional principle. TULAA can also be cosmetically and economically superior to CPTLA. Further improvement of surgical techniques and instruments is needed to improve the infection rate in TULAA.