Single-Incision Laparoscopic Appendectomy

See Article on Page 304-308 The open appendectomy, which was described first by McBurney [1] in 1894, has been accepted as the gold standard of an appendectomy for around 100 years. Furthermore, since its introduction by Semm [2] in 1983, the laparoscopic appendectomy has been conducted more frequently than the open appendectomy due to its advantages of being minimally invasive and having a shorter length of stay, a faster return of bowel function, decreased use of narcotics and lower rates of wound complications. In addition, much attention has been paid to recent remarkable innovative developments and improvements in laparoscopic equipment, instruments and techniques. As emphasis has focused more on minimizing the surgical technique utilized to access the pathology and on the exponential development of therapeutic endoscopy, surgical procedures that enter the peritoneum through hollow visceras that can be accessed via natural body openings, precluding skin incision, have been developed. The new approaches, named natural orifice transluminal endoscopic surgery (NOTES), aim to further limit treatment morbidity, but studies addressing these approaches have yet to be initiated because the clinical techniques for these approaches are still being developed. One of the most critical issues in NOTES when it is applied to humans is whether to securely close the extraction site of an organ such as the stomach, vagina, or rectum. If the closure fails, serious morbidities such as intraperitoneal infection or fistula may arise. NOTES can be performed as a pure procedure involving one portal of entry or as a combined procedure involving use of multiple body openings. However, based predominantly on experimental results, pure NOTES should be actively pursued as a research topic until its safety has been proven. NOTES can also be performed as a hybrid procedure in conjunction with conventional transabdominal ports. Closely related to NOTES is the development of procedures performed through a solitary small transabdominal incision. These procedures have been referred to as single-port access surgery, single-port laparoscopy surgery, single-incision laparoscopy surgery (SILS), or laparoendoscopic single-site surgery; consensus on the most appropriate name for the approach has not been achieved. Since the first report of single-incision laparoscopic surgery for acute appendicitis by Rispoli et al. [3] in 2002, it has been proposed as the next evolution in minimally invasive surgery. However, evidence supporting the safety and efficacy of this innovative approach is limited. Nevertheless, the increased interest in single-incision laparoscopic appendectomy (SILA) has seemed to be primarily focused on better cosmesis (scarless abdominal surgery performed through an umbilical incision), less incisional pain, and conversion to standard multiport laparoscopic surgery if needed. SILA also has several disadvantages and limitations, such as the restricted degrees of freedom of movement, the number of ports that that can be used, and the proximity of the instruments to each other during the operation-all of which increase the complexity and the technical challenges of the operation. Many of these difficulties can be related to the technique of port placement and the utilization of instruments during single-incision laparoscopic surgery. In 2011, St Peter et al. [5] reported the results of their prospective randomized trial which compared a single-incision to a standard 3-port laparoscopic appendectomy. In that trial, the authors found that operative time, doses of narcotics, surgical difficultly and hospital charges were greater with the single-site approach. Also, the mean operative time was 5 minutes longer for the single-site group. This year, Gill et al. [6] reviewed nine studies that compared the SILA and the conventional laparoscopic appendectomy and found no significant differences in operative time, length of stay, pain scores, conversion rates, and complication rates between the SILA and the conventional laparoscopic appendectomy for acute appendicitis in adults. Currently in Korea, the single-incision laparoscopic appendectomy has been growing in popularity, and several case series have been reported. In this issue, "Comparative Study of a Single-Incision Laparoscopic and a Conventional Laparoscopic Appendectomy for the Treatment of Acute Appendicitis" is being published. Kang et al. [4] analyzed 112 SILS and 105 conventional laparoscopic appendectomies. In the study, the mean operative time in the SILS group was 65.88 ± 22.74 minutes whereas that in the LA group was 61.70 ± 22.27 minutes (P = 0.276). Although the difference was not statistically significant, the longer (about 4 minutes) operation time in the SILS group was comparable to that found in a recently reported randomized controlled trial in which the mean operation time was 5 minutes longer [5]. Also, the present study demonstrated no significant differences in mean hospital stay, use of nonsteroidal anti-inflammatory drugs, and wound infection between the two groups' the results being comparable to those of a systematic review of previously reported comparative studies [6]. The authors used a single trocar and two latex tubes, and they expected a cost savings and reduced interference by using their own system. They also advocated that the SILS appendectomy might have better cosmetic results. However, the authors could not provide any objective evidence to support their suggestions. These limitations came from the nature of retrospective nonrandomized comparative studies. Well-designed prospective trials are needed to develop more solid evidence and objective measuring tools for assessing cosmetic outcomes and patient satisfaction. Single-port surgery is gaining momentum and may represent the next frontier in minimally invasive surgery for various gastrointestinal diseases. Although many unanswered questions persist, surgeons should maintain their pioneering spirit and evaluate these new approaches carefully and scientifically.