A Randomised Controlled Trial on LESS Versus Conventional Laparoscopic Appendicectomy.

Study Overview
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Brief Summary
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LESS laparoscopic appendectomy is associated with less pain than conventional 3-port laparoscopic appendectomy.

Detailed Description
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Since the original description in the 1970's, the laparoscopic approach to management of surgical diseases has gained widespread acceptance. It has been shown to be associated with decreased wound pain, analgesic requirements, hospital stay and allows improved cosmesis and quality of life without significantly increasing the risks of morbidities and mortalities. With continued improvements in technology, however, efforts to reduce the number of abdomen wounds in an attempt to further decrease pain, improve cosmesis and outcomes are underway. Natural Orifices Transluminal Endoscopic Surgery (NOTES) has received widespread attention in both the medical field as well as the general public. However, there are still a multitude of problems that needs to be solved before the technique can be broadly applied to human subjects [7]. On the other hand, a renewed interest in single incision laparoscopic surgeries is emerging. The approach has been shown to be safe and feasible in our experience as well as the others. It also has the potential to further decrease the surgical trauma induced to the patient and to improve cosmesis. Since laparoscopic appendicectomy is one of the most basic procedures in laparoscopic surgery, it is an appropriate model for initial evaluation of single incision laparoscopic surgery. Our unit has already performed 20 cases of single site access laparoscopic appendicectomy (SSALA) and so far, the results have been encouraging (data pending publication). All the patients in the series had their procedures completed with a single incision. None of the patients suffered from adverse events and all had resumption of oral diet by day 1 and were discharged on day 2 post-operatively. However, whether the approach is more beneficial as compared to conventional three-port laparoscopic appendicectomy is still uncertain. Hence, the aim of the current study is to compare the approach of SSALA to conventional three-port laparoscopic appendicectomy in reducing surgical trauma and improving cosmesis to the patient.

Official Title
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A Double-blinded Randomised Controlled Trial of Laparoendoscopic Single-site Access (LESS) Versus Conventional Three-port Appendicectomy.

Conditions
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Appendicitis

Intervention / Treatment
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* Procedure: LESS appendectomy
* Procedure: Conventional 3-port laparoscopic appendectomy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: History of right lower quadrant pain or periumbilical pain migrating to the right lower quadrant Fever ≥ 38°C and/or WCC > 10 X 103 cells per mL, Right lower quadrant guarding, and tenderness on physical examination. All patients included were 18-75 years old. Exclusion Criteria: Patients are excluded if the diagnosis of appendicitis is not clinically established (symptoms attributable to urinary or gynaecological problems). History of symptoms > 5 days and/or a palpable mass in the right lower quadrant, suggesting an appendiceal abscess treated with antibiotics and possible percutaneous drainage. Patients with the following conditions are also excluded: history of cirrhosis and coagulation disorders, generalized peritonitis, shock on admission, previous abdominal surgery, ascites, suspected or proven malignancy, contraindication to general anesthesia (severe cardiac and/or pulmonary disease), inability to give informed consent due to mental disability, and pregnancy.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Conventional 3-port laparoscopic appendectomy<br>Laparoscopic appendectomy will be performed with the standard 3-port technique. The laparoscope is introduced via a 10mm subumbilical port. Dissection will be performed with a 5mm LLQ port and a 5mm RLQ port. Exploratory laparoscopy was first carried out to locate the appendix and to rule out other pathologies. The mesoappendix will be divided with the ultrasonic dissector (Sonosurg, Olympus surgical, Tokyo, Japan). The appendix will be ligated between two polydioxanone suture loops. The specimen will be delivered within a plastic bag via the subumbilical port. Purulent fluid will be irrigated and suctioned from the subhepatic space, right lower quadrant and the pelvis if present. Fascial defects will be closed with 2-O polydioxanone sutures and skin closed with 4-O absorbable subcuticular sutures. A pelvic drain (12Fr) will be inserted in cases of abscesses or gangrene. | Procedure: Conventional 3-port laparoscopic appendectomy<br>* See under arms description<br>|
| Active Comparator: LESS appendectomy<br>Two 5 mm ports and a 10mm port will be inserted through a 13mm transumbilical incision. Exploratory laparoscopy was first carried out to locate the appendix and to rule out other pathologies. Retraction of the appendix would be performed with a flexible curved forceps. The mesoappendix will be divided with the ultrasonic dissector (Sonosurg, Olympus surgical, Tokyo, Japan). The appendix will be ligated between two polydioxanone suture loops. The specimen will be delivered within a plastic bag via the subumbilical port. Purulent fluid will be irrigated and suctioned from the subhepatic space, right lower quadrant and the pelvis if present. Fascial defects will be closed with 2-O polydioxanone sutures and skin closed with 4-O absorbable subcuticular sutures. A pelvic drain (12Fr) will be inserted in cases of abscesses or gangrene. | Procedure: LESS appendectomy<br>* See under arms description<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall pain score experienced by the patient within the last 24 hrs using the visual analogue scale | The main outcome is the overall pain score (measured as the most severe pain experienced within the last 24 hrs using the visual analogue scale) experienced by the patient after the operation | 1st post-operative day | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Conversion | defined by the use of incisions and/or trocars in addition to the ones described in the Methods section, or the need to perform an open procedure | 24 hours | 
| Operative time | defined as the amount of time to perform the operation from skin-incision to application of the dressing. | 24 hours | 
| Wound infection | defined as presence of skin erythema, discharge and a positive culture | 14 days | 
| Deep space infection | defined as the need for reoperation, readmission, or percutaneous drainage of a deep (organ space) infection within 30 days of surgery. | 30 days | 
| activity score | defined by a composite score including 4 items using a five point scale: lying in bed, getting out of chair or bed, walking on level ground and climbing stairs [1. no difficulty; 2. a little difficult; 3. some difficulty; 4. a lot of difficulty; 5. not able to perform.] | 14 days | 
| Satisfaction score | Overall satisfaction of the procedure by the patient measured with the visual analogue scale | 14 days | 
| Cosmesis score | defined as the score given by the patient on the overall cosmesis of the wound measured by the visual analogue scale | 14 days | 
| quality of life | measured by the gastrointestinal quality of life index (GIQLI) and SF-36 at 2-weeks follow-up | 14 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Single incision laparoscopic surgery, Single site access laparoscopic surgery, SILS, Single-port access, Laparoendoscopic single site surgery, Appendectomy