Laparoscopic single trocar appendectomy

Laparoscopic single trocar appendectomy

MohamedA Sharaan,MD;  SamerS Bessa,MD;AhmedEI-Gendy,MD; Alaa H Abdel-Razek, MD,FRCS

Department of General  Surgery, Alexandria University, Alexandria, Egypt.

Corresponding Author:

Mohamed Abdallah   Sharaan, Department of General Surgery, Faculty  of

Medicine, Alexandria  University, Egypt.

Abstract

Background  and  objective:  Single  port  surgery  is  a new  surgical  technique  with  more promising advantages of minimal access laparoscopy. The present study was to assess the feasibility of the single trocar appendectomy, its morbidities and satisfaction for both patients and surgeons.

Methods:  Consecutive  patients presenting with acute appendicitis  were treated  by single port appendectomy. Through an umbilical incision, the single port was inserted, we used SJLS port (Covidien) in 15 cases and Xcone port (Karl Storz) in 27 cases. A 5mm 30° lens was used. The mesoappendix  was coagulated and divided by Ligasure, Harmonic scalpel or diathermy. Absorbable  endoloops  were used  to  ligate  the  base  of the  appendix. Assessment  included operative time, complications,  patient satisfaction and surgeon satisfaction.

Results: The study included 42 patients, 24 (57.1%)  females and 18 (42.9%)  males with a

mean age of27.3±5.4  years. The procedure was completed in all of the patients. Complications occurred in 4 patients (9.5%). The mean hospital stay was 1.1 days± I. The procedure achieved accepted cosmetic outcome with minimal or hidden scar. The patients were satisfied as good or very  good procedure. The surgeons found it satisfactory in 67.6% of operations as regards technical difficulties and outcome.

Conclusion: The procedure is feasible and safe. Neither mortality nor visceral injury occurred in this study. Rate of complications  was 9.5%. Accepted rate of satisfaction  was present for both patients and surgeons. It achieved accepted cosmetic results with minimal or hidden scar. Complications are expected to decrease by improvement in the learning curve.

Key words: single port; appendectomy; laparoscopy.

Introduction:

Acute appendicitis is a common intra­ abdominal  inflammatory  disease  which requires emergency surgery as the most frequent therapeutic  scenario. Since the introduction  of laparoscopic  appendectomy, it has become an alternative method of treatment to open appendectomy because of decreased postoperative pain, better cosmetic result, and rapid return to the daily activities.!

During the era of laparoscopic surgery, there has   been   a  common   trend   towards   less invasive  techniques.  A natural  extension  of this trend is to perform operations without scars. The most prominent techniques are transumbilical single-incision laparoscopic surgery  (SILS)  and  natural  orifice transluminal  endoscopic  surgery (NOTES).2

As the latter is still confronted with some technical     and    instrumental     difficulties,

SILS  seems  to  be  more   ready  for  wider use in surgical practice. There are reliable equipments available for SILS procedures. However, the operative technique, although different   from   conventional    laparoscopy, is probably  easier to be  learned   compared to NOTES technique.l,2 A number of advantages  have  been  proposed  related  to this approach including better cosmesis (abdominal  surgery performed through  a hidden umbilical incision) and the ability to convert to standard multipart laparoscopic surgery if needed without denying the disadvantage and complication related to this new  technique.3,4 SILS  appendectomy  may be even more advantageous to the patients by eliminating the scars. However, the role of the SILS appendectomy is still evolving5-7 More studies evaluating the technique in different clinical situations as well as randomized controlled trials are needed in order to assess the real benefits of the SILS appendectomy in general surgical practice.

The aim ofthe present study was to study the feasibility of the SILS appendectomy, its morbidities  and satisfaction   of both patients and surgeons.

Material and methods:

This study was approved by the Ethics Committee   in  Faculty  of  Medicine, Alexandria University. Between March 2009 and April 2011, 42 patients were subjected to Single Incision Laparoscopic Appendectomy (SILA). These patients presented with acute abdominal pain and they were all diagnosed clinically as acute appendicitis. In suspicious cases the diagnosis was confirmed by abdominal ultrasound (US) and/or computed tomography (CT). Exclusion criteria included patients with complicated appendicitis (perforated    appendix,    appendicular   mass or abscess), patients with previous lower abdominal surgery and pregnant patients. The surgical team who performed all these cases were familiar with the SILS instruments and they had performed SILS on animal models. An informedconsentwassigned bythe patients before  surgery.  All   our  patients   received intra-venous    one   gram   third    generation

Cephalosporin  and 500mg Metronidazole  at the  induction  of anesthesia.  All the  patients were placed in the supine position, the right arm was abducted 90° to the body while the left arm was alongside the body. The camera man and the surgeon were in the left side of the patient while the monitor was placed in the right side of the patient near to the right iliac fossa. Under general anesthesia, an incision was performed about 15mm inside of the umbilicus itself and not beyond the umbilical circumference, opening in layers till reaching the linea alba and the peritoneum which were opened by monopolar  diathermy. The single port device was then inserted, we used SILS port (Covidien)  in 15 cases and  Xcone port (Karl Storz)  in 27 cases.   A 5mm 300   lens was used and laparoscopic exploration was performed.  The  operating  table  was  tilted to a 30° Trendelenburg position with a left rotation to allow adequate exposure of the ceacum  and  the   ileo-ceacal   junction.   We used  conventional   straight   instruments   in

27   cases   and   articulating   instruments   in

15 cases to facilitate the procedure. The mesoappendix  was  coagulated  and  divided near  to  the  appendix  using  bipolar  cautery or LigaSure (Covidien) or Harmonic  Scalpel (Ethicon,  Johnson  & Johnson)  till  reaching the junction of the appendix with the ceacum. The base of the appendix  was ligated using

2 ligatures of absorbable suture material (Endoloop; Ethicon Endosurgery). Division was then done to the appendix sharply by scissor  soaked with betadine.  The appendix was then retrieved in a plastic sac through the single port through the umbilical scar without touching the wound.

Follow   up   was   done   for   early   and late postoperative period to assess any complications and postoperative pain. Satisfaction of patients and surgeons was assessed.   We  assessed   the   post-operative pain  by  asking  the  patients  about score  of pain from  0 to  10.   Score  from  Zero to  2 was considered minimal pain, 3 to 5 was considered mild pain, 6 to 8 was considered moderate pain, and 9 to 10 was considered severe pain. Also, patients' satisfaction in this study was assessed by asking the patients to

give a score from 0 to 10. Score from Zero to

3 was considered bad, 4 to 6 was considered good, 7 to 9 was considered very good. Surgeon satisfaction was assessed by the surgeons  comment  on technical  difficulties and morbidities.

Results:

The  study  included  42  patients,  24 (57.1%) females and 18 (42.9%) males with a mean  age  of  27.3+5.4  years  (range  14 -

46 years).  The mean  body  mass index  was

30.9 +7.3 kglm2 (ranged from 21- 46 kg/m2. We had 15 obese cases (BMI >30 kg/m2). Preoperative data are shown in Table(l).  All these  patients  had  a preoperative  diagnosis of    non-complicated     acute    appendicitis. Ten patients had collection discovered by ultrasound,  and  32  patients  had  low  grade fever preoperatively.  Two patients had para­ umbilical  hernias  which  were  operated  on

with the SILS procedure. The mean operative time was 48.2+24.5min  (range, 30-100min). No   operative   complications   (hemorrhage, bowel          perforation)      were                 reported.               The operative   difficulties   were   recorded   in  7 cases,  in  5 patients,  the  difficulty  was  due to leakage of gas from the single port, while the other 2 difficulties were due to the search of  the  appendix  which  was  hidden  due  to inflammatory               adhesions.       Postoperatively, oral  liquids  were   started   within   6  hours and a soft diet within  12 h. Only one dose of   parenteral   analgesia   was   administered followed  by oral  analgesics.  Complications occurred   in  4  patients   (9.5%).   Table(2). Post-operative  wound  infection  occurred  in

4.7% (2 out of 42 patients) they were treated

by frequent  dressing  and antibiotics.  There was  no  mortality.  The  postoperative  trocar site hernia was detected in 1 out of 42 cases (2.3%). This was operated on by hernia repair

Figure (1): Single port used (A. X cone of Karl Storz)  (B. SJLS port of Covidien).

Figure (3): Instruments application to single port.

Figure (4): Umbilical scar left at the end of the operation.

Table (1): Preoperative data of the patients.

Table (2): Operative and postoperative data.

and prolene mesh application. The mean hospital stay ofthis study was 1.1 days; only

4 cases (9.5%)  had hospital  stay  of 2 days

because of post-operative ileus that delayed their discharge. No cases of post-operative fistula  or  post-operative   abscess  were reported.  In this  study, patients'  satisfaction was  assessed.  The  results  of  postoperative pain  score,  patients'  satisfaction  and  other data are shown in Table(2).  We also assessed satisfaction  of the surgeons  who performed the operations.  We reported that in 11 cases (26.1%)  this  procedure  was  technically difficult due to narrow operative field and collision of instruments with adherent hidden severely inflamed appendix, and in 31 cases (73.8%) this procedure was relatively easier. There was no conversion to open or standard laparoscopy in all of the cases of this study.

Discussion:

Appendectomy  is the most common abdominal operation in the western world. Laparoscopic  appendectomies are currently preferred due to the fact that it offers advantages to patients in terms of more accurate diagnosis, diminished wound infections,  and more rapid recovery.8 SILS appendectomy may result surely in better cosmesis  but  probable  additional   benefits, in  terms  of  more  rapid  recovery  and  less post-operative  pain, these have not been proven scientifically. However, randomized controlled clinical trials are urgently needed to define the role of SILS appendectomy  in the modem surgical armamentarium. Always when a new technique is introduced, the focus should be concentrated on the feasibility, safety, and clinical advantage of the method. Moreover, safety of the procedure is highly dependent on how easily the new technique can be learned by average surgeons. It is expected  from  a  new  technique  that  it can be associated with an increased risk of complications   emphasizing  the  importance of thorough training and education by the interested  surgeons.  The SILS technique differs from the standard laparoscopic technique   remarkably   by  the   use   of  the single  port, specially  designed grasping and

dissecting instruments, also the access and the application of the single port in the umbilicus. These differences make the procedure more challenging and initiating new learning curve for surgeon.

Standard      laparoscopic      appendectomy

is  usually   done  by   using   2   instruments and a lOmm camera, the same in SILS appendectomy procedure but through a single port, also the use of articulating instruments in SILS procedure  can facilitate  the technique. Furthermore SILS appendectomy is relatively easy operation that can be performed properly by one straight instrument and one curved instrument.

When performing appendectomy, one must

be prepared for different abdominal findings, like     thickened         appendix,            gangrenous, perforated with peritonitis, or even with pelvic abscess. In these situations the technique  of appendectomy   should  be  selected.   In  this study  we  had  easy  and  difficult  cases,  all our  42 patients  were operated  on  by  SILS technique   without   conversions   or   adding ports. All of the patients in this study had an uneventful  recovery.            Moreover,  the  mean operating time  was 48±24.5  minutes  (range

30-100min)  comparing well to the operating time  in other  studies  (mean  40min  , range

35-102minutes)8 and that ofthe conventional

laparoscopic  appendectomy  in  our  hospital

(mean 43 minutes, range 18-103).8

From our experience  in SILS procedure, we  believe  that  it  is  feasible  for  different kinds  of  appendicitis,  with  the  possibility of conversion to conventional laparoscopic appendectomy. Also it can be useful in case of double pathology, like appendicitis and cholecystitis,  appendicitis  and ovarian  cyst, also in wrong diagnosis for exploratory laparoscopy. In this study we found that access into the peritoneal cavity and insertion of the single port is more difficult in obese patients, compared  to non-obese  patients.  According to literature especially  obese patients benefit from  laparoscopic  appendectomy  compared to open one and laparoscopy should be the preferred technique  for these  patients.8-10 It is, thus, important that new mini-invasive operative  techniques like  SILS  are suitable

for this patient population too.

Wong et al,11 reported  in a recent prospective case control study, a decrease post­ operative pain after single port laparoscopic cholecystectomy as compared to conventional laparoscopic    cholecystectomy.    Bucher   et al, 12 also reported recent randomized clinical trial,  resulting  in  a  reduced  post-operative pain in SILS cholecystectomy compared to conventional  laparoscopic  cholecystectomy. In  our  study  the  post-operative   pain  was in 57.2% mild and in 42.8% minimal, a prospective randomized trial of SILS versus laparoscopic  appendectomy  is needed to clarify   post-operative   pain   difference.   In SILA we  used an umbilical  incision  of 15- mm, leaving virtually no scar. Using a single port for laparoscopic appendectomy  in this study was not a real problem except for a minority of patients in whom we used flexible and rotating instruments (i.e., scissors, graspers,     dissectors).     Moreover,    tilting the operating table enabled us to achieve adequate exposure and dissection. Appendix extraction was through the umbilical incision with protection (plastic sac, the single port itself). In our study, the incidence of port-site infection was 4.7% (2 out of 42 patients), not greater than in other series of LA. We reported in this study an incidence  port site hernia of about 2.3%, this may be due to the fact that we did a big incision in the umbilical scar to adapt the single port size, and the difficulty of perfect closure  of the rectus sheath because of the depth of the incision and obesity. Tonouchi  et  ai13 reported  in  their  review article  about  trocar   site  hernia,  that   risk factors  for  occurrence  of trocar site  hernias are, the large trocar size, non-closure  or bad closure of the fascial defect, the location if umibilical   or  paraumbilical,  the  stretching of the port site for retrieval, obesity, poor nutrition  and  wound  infection.    Fransen  et ai14 reported that in SILS the risk of hernia is increased because of the widening of the incision, in addition to the application of the single  port which  exerts more  pressure    on the tissue, causing more damage and leading to possible more herniation at the entry site. Our trocar site hernia case was our first case,

and it might be related to more widening of the umbilical incision and retraction in the beginning ofthe study.

The      SILS      appendectomy     approach,

is    considered     as     "Embryonic   NOTES" appendectomy  using an embryologic  natural orifice  (the  umbilicus)   as  a  sole  site  of abdominal access and is a sure and feasible approach  for  selected   patients  with  acute appendicitis.  Its main aim is to improve the post-operative    outcomes   (shorter   hospital stay, faster return to activity, better cosmesis) by reducing the size and number ofincisions.l5

Although SILS technique looks promising and offers some potential benefits for patients compared to conventional laparoscopy, two possible disadvantages should be considered. SILS technique may be associated with increased risk of hernias. The technique necessitates fascial incision through the abdominal midline that has been considered to  be  prone  to  hernia  formation.   Further, the  fascial  incision  is  more  traumatic compared to 5 or 12mm trocar wounds made with dilating trocars. The second possible disadvantage   is   the   presumed   additional costs caused  by the  procedure-specific  port and   instruments.    These    extra   operative costs  should  be  taken  into  account  in  the current trend towards cost-effectiveness in HealthCare. After introduction of re-usable (autoclavable)   instruments   for   SILS  port and instruments, the cost problem could be dealt with. Unfortunately, we did not assess cost effect in this study, it should be assessed in a comparison with standard laparoscopic appendectomy in future studies.

Conclusion:

SILS  technique   is  technically   feasible and safe for the appendectomy  procedure. It offers accepted rate of satisfaction for both patients  and  surgeons.  The  technique  may offer evident cosmetic benefit; it is feasible in obese patients but with more difficult access to the peritoneal cavity. SILA have some complications related to SILS technique, like hernia  and wound  infection. Appendectomy is a suitable procedure for the training ofSILS technique;   laparoscopic   surgeons   starting