Single-Port Appendectomy

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This article describes a pure single-port appendectomy. Appendectomy is one of the most frequently performed surgical procedures in the United States. The lifetime risk of appendicitis is 8.6% for males and 6.7% for females. ^[1]

From the first laparoscopic removal of an inflamed appendix by Kurt Semm in 1980 ^[2]  to today’s standard laparoscopic technique, minimally invasive surgical approaches have been widely recognized as offering significant advantages, including reduced postoperative pain, a shorter recovery time, and better cosmesis. ^[3]

The traditional approach to laparoscopic appendectomy employs three ports. Over the past decade, successful attempts to perform the procedure with fewer ports have been reported. The medical literature has described two-port techniques, ^[4]  hybrid approaches, ^{[5, 6]}  and single-port assisted techniques. ^{[7, 8, 9]}

The two-port appendectomy technique is very similar to the standard three-port technique, except that one port provides access for a rigid endoscope with a working channel, whereas the second port provides access for a grasping instrument that is used to retract the appendix. ^[4]

In the hybrid technique, the appendix is pulled through the umbilicus, and a traditional open appendectomy is then performed extracorporeally. ^{[10, 11, 12, 13]}

The single-port assisted technique is intriguing in that a stitch is placed through the anterior abdominal wall to pull the appendix to the abdominal wall; this creates the tension necessary for performing the appendectomy intracorporeally. ^{[7, 14]}

The total single-port approach, as described in this article, employs a technique resembling that of a puppeteer. ^[15] A “pulley” is constructed in the form of a loop to the anterior abdominal wall. This loop is used as an axle over which the appendix is elevated with a string to the abdominal wall; in this way, it compensates for the absence of the additional port traditionally needed for retraction of the inflamed appendix.

Indications for single-port appendectomy include acute appendicitis, recurrent appendicitis, and chronic appendicitis. Whenever a single-port appendectomy is performed, it is important to maintain a low threshold for conversion to a standard laparoscopic or open approach. ^[12]

Absolute contraindications for single-port appendectomy include signs of perforation, pregnancy, and an American Society of Anesthesiologists (ASA) classification of 3 or 4. Patients with these contraindications are not suitable candidates for single-port appendectomy, and a standard laparoscopic appendectomy or open appendectomy should be performed instead.

Relative contraindications for single-port appendectomy include a retrocecal-lying appendix (because of the difficulty of mobilizing the appendix adequately) and adhesions from previous surgical procedures.

Anatomic considerations are of substantial clinical importance in the context of acute appendicitis; the location of the appendix often determines the symptoms and the site of pain if the appendix becomes inflamed.

The vermiform appendix is a vestigial structure that can range from less than 1 cm in length to more than 30 cm; on average, it is 6-9 cm long. Embryonically, the appendix first appears in the eighth week of life as an outgrowth of the terminal portion of the cecum. Throughout development, the cecum grows faster than the appendix does; as a result, the appendix is generally displaced more medially toward the ileocecal valve.

The three taeniae coli converge at the junction of the cecum with the appendix; this junction can and should be used as a landmark to identify the appendix. Appendiceal absence, duplication, and diverticula have all been described.

The appendiceal base is always just at the base of the cecum distal to the ileocecal valve. The tip of the appendix, however, has a more variable location and can be found in several different positions, including retrocecal, pelvic, subcecal, preileal, and right pericolic.

Studies comparing single-port and conventional laparoscopic techniques have not shown consistent findings.

Liang et al concluded that single-incision laparoscopic appendectomy resulted in rapid recovery, no increase in pain or complications, and a better cosmetic outcome. ^[16]  Choi et al found that postoperative pain outcomes between single-incision laparoscopic appendectomy yielded reduced pain as compared with conventional laparoscopic appendectomy. ^[17]  Qiu et al concluded that single-port laparoscopic appendectomy had no benefits over conventional laparoscopic appendectomy. ^[18]  Antoniou et al concluded that the two methods showed similar postoperative morbidity and wound infection. ^[19]

With regard to the use of single-port appendectomy in pediatric populations, Zhang et al found that in children, single-port appendectomy, though safe and feasible, appeared to offer no significant advantages. ^[20]  A transumbilical approach has also been found to be beneficial. ^{[21, 12, 13]}

In a study of conventional single-port appendectomy in children with complicated appendicitis, Karakus et al found the procedure to be associated with a reasonable operating time, a shorter hospitalization period, reduced rates of postoperative wound infection and adhesive intestinal obstruction, and equivalent operative costs as compared with open and multiport laparoscopic appendectomy. ^[22]

Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990 Nov. 132(5):910-25. [Medline].

Semm K. Endoscopic appendectomy. Endoscopy. 1983 Mar. 15(2):59-64. [Medline].

Kang BM, Hwang JW, Ryu BY. Single-port laparoscopic surgery in acute appendicitis: retrospective comparative analysis for 618 patients. Surg Endosc. 2016 Nov. 30 (11):4968-4975. [Medline].

Schier F. Laparoscopic appendectomy with 1.7-mm instruments. Pediatr Surg Int. 1998 Nov. 14(1-2):142-3. [Medline].

Fazili FM, Al-Bouq Y, El-Hassan OM, Gaffar HF. Laparoscope-assisted appendectomy in adults: the two-trocar technique. Ann Saudi Med. 2006 Mar-Apr. 26(2):100-4. [Medline].

Meyer A, Preuss M, Roesler S, Lainka M, Omlor G. [Transumbilical laparoscopic-assisted “one-trocar” appendectomy — TULAA — as an alternative operation method in the treatment of appendicitis]. Zentralbl Chir. 2004 Oct. 129(5):391-5. [Medline].

Ates O, Hakgüder G, Olguner M, Akgür FM. Single-port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture. J Pediatr Surg. 2007 Jun. 42(6):1071-4. [Medline].

Baik SM, Hong KS, Kim YI. A comparison of transumbilical single-port laparoscopic appendectomy and conventional three-port laparoscopic appendectomy: from the diagnosis to the hospital cost. J Korean Surg Soc. 2013 Aug. 85(2):68-74. [Medline]. [Full Text].

Park J, Kwak H, Kim SG, Lee S. Single-port laparoscopic appendectomy: comparison with conventional laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A. 2012 Mar. 22(2):142-5. [Medline].

Valla J, Ordorica-Flores RM, Steyaert H, Merrot T, Bartels A, Breaud J. Umbilical one-puncture laparoscopic-assisted appendectomy in children. Surg Endosc. 1999 Jan. 13(1):83-5. [Medline].

D’Alessio A, Piro E, Tadini B, Beretta F. One-trocar transumbilical laparoscopic-assisted appendectomy in children: our experience. Eur J Pediatr Surg. 2002 Feb. 12(1):24-7. [Medline].

Mohan A, Guerron AD, Karam PA, Worley S, Seifarth FG. Laparoscopic Extracorporeal Appendectomy in Overweight and Obese Children. JSLS. 2016 Apr-Jun. 20 (2):[Medline]. [Full Text].

Mohan A, Karam PA, Buta MR, Worley S, Seifarth FG. Transumbilical laparoscopically assisted extracorporeal appendectomy in children and young adults: A retrospective cohort study. Int J Surg. 2016 Dec. 36 (Pt A):261-264. [Medline].

Carus T. Current advances in single-port laparoscopic surgery. Langenbecks Arch Surg. 2013 Oct. 398 (7):925-9. [Medline].

Roberts KE. True single-port appendectomy: first experience with the “puppeteer technique”. Surg Endosc. 2009 Aug. 23 (8):1825-30. [Medline].

Liang HH, Hung CS, Wang W, Tam KW, Chang CC, Liu HH, et al. Single-incision versus conventional laparoscopic appendectomy in 688 patients: a retrospective comparative analysis. Can J Surg. 2014 Jun. 57(3):E89-97. [Medline]. [Full Text].

Choi GJ, Kang H, Kim BG, Choi YS, Kim JY, Lee S. Pain after single-incision versus conventional laparoscopic appendectomy: a propensity-matched analysis. J Surg Res. 2017 May 15. 212:122-129. [Medline].

Qiu J, Yuan H, Chen S, He Z, Wu H. Single-port laparoscopic appendectomy versus conventional laparoscopic appendectomy: evidence from randomized controlled trials and nonrandomized comparative studies. Surg Laparosc Endosc Percutan Tech. 2014 Feb. 24(1):12-21. [Medline].

Antoniou SA, Koch OO, Antoniou GA, Lasithiotakis K, Chalkiadakis GE, Pointner R, et al. Meta-analysis of randomized trials on single-incision laparoscopic versus conventional laparoscopic appendectomy. Am J Surg. 2014 Apr. 207(4):613-22. [Medline].

Zhang Z, Wang Y, Liu R, Zhao L, Liu H, Zhang J, et al. Systematic review and meta-analysis of single-incision versus conventional laparoscopic appendectomy in children. J Pediatr Surg. 2015 Sep. 50 (9):1600-9. [Medline].

Boo YJ, Lee Y, Lee JS. Comparison of transumbilical laparoscopic-assisted appendectomy versus single incision laparoscopic appendectomy in children: which is the better surgical option?. J Pediatr Surg. 2016 Aug. 51 (8):1288-91. [Medline].

Karakuş OZ, Ulusoy O, Ateş O, Hakgüder G, Olguner M, Akgür FM. Conventional single-port laparoscopic appendectomy for complicated appendicitis in children: Efficient and cost-effective. J Minim Access Surg. 2016 Jan-Mar. 12 (1):16-21. [Medline].

Yu J, Wang YN, Hu YF, Cheng X, Zhen L, Li GX. Single-incision laparoscopic appendectomy performed above the pubic symphysis – a new scarless approach. Minim Invasive Ther Allied Technol. 2011 Jan. 20(1):18-21. [Medline].

Zhang Z, Wang Y, Liu R, Zhao L, Liu H, Zhang J, et al. Suprapubic single-incision versus conventional laparoscopic appendectomy. J Surg Res. 2016 Jan. 200 (1):131-8. [Medline].

Hong TH, Kim HL, Lee YS, Kim JJ, Lee KH, You YK, et al. Transumbilical single-port laparoscopic appendectomy (TUSPLA): scarless intracorporeal appendectomy. J Laparoendosc Adv Surg Tech A. 2009 Feb. 19(1):75-8. [Medline].

Varshney S, Sewkani A, Vyas S, Sharma S, Kapoor S, Naik S. Single-port transumbilical laparoscopic-assisted appendectomy. Indian J Gastroenterol. 2007 Jul-Aug. 26(4):192. [Medline].

Rehman H, Rao AM, Ahmed I. Single incision versus conventional multi-incision appendicectomy for suspected appendicitis. Cochrane Database Syst Rev. 2011 Jul 6. CD009022. [Medline].

Raakow R, Jacob DA. Initial experience in laparoscopic single-port appendectomy: a pilot study. Dig Surg. 2011. 28 (1):74-9. [Medline].

Teoh AY, Chiu PW, Wong TC, Wong SK, Lai PB, Ng EK. A case-controlled comparison of single-site access versus conventional three-port laparoscopic appendectomy. Surg Endosc. 2011 May. 25(5):1415-9. [Medline].

Carter JT, Kaplan JA, Nguyen JN, Lin MY, Rogers SJ, Harris HW. A prospective, randomized controlled trial of single-incision laparoscopic vs conventional 3-port laparoscopic appendectomy for treatment of acute appendicitis. J Am Coll Surg. 2014 May. 218 (5):950-9. [Medline].

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

The author thanks his wife, Annette, for her support in writing this article.

Single-Port Appendectomy

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