International Surgery Journal

Wani M et al. Int Surg J. 2016 Feb;3(1):177-183

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DOI: http://dx.doi.org/10.18203/2349-2902.isj20160222
Research Article

A comparative study between single incision laparoscopic

appendectomy and conventional laparoscopic appendectomy
Mumtaz-ud-Din Wani1, Shabir Ahmad Mir1*, Mohammad Yaqoob2, Yawar Watali1,
Hakim Adil Moheen3

1
Department of Surgery, Government Medical College, Srinagar, India
2
Department of Surgery, Apollo Hospital, New Delhi, India
3
BS, University of Kashmir, India

Received: 17 October 2015

Accepted: 15 December 2015

*Correspondence:
Dr. Shabir Ahmad Mir,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Until recently transumbilical single incision laparoscopic appendectomy has been less popular in
clinical practice than traditional laparoscopic appendectomy (LA). The goal of our study was to conduct a
comparative analysis of the clinical outcomes for conventional laparoscopic appendectomy (CLA) and transumbilical
single incision laparoscopic appendectomy (SILS).
Methods: This prospective study SILS versus CLA was carried out in the postgraduate department of surgery GMC
Srinagar from February 2013 to October 2014 on patients suspected of having acute appendicitis. All patients were
worked up and assessed according to a predefined protocol-detailed history, complete clinical examination, and
laboratory parameters.
Results: The mean age of the patients in the SILS group was 23.9 years (16-35 years) and that in the CLA group was
25.3 years (16-35 years) (p>0.05). The mean operating time in the SILS group was 57.66 minutes and in the CLA
group 52.83 minutes (p>0.05). The difference in the postoperative pain score of the two groups was not statistically
significant (p>0.05). In our study cosmesis was assessed by using Manchester scar scale. The mean cosmesis scores
were: 7th POD 6.0±0.587 (SILS) and 6.9±0.922 (CLA); 3 months postoperatively 5.73±0.691 (SILS) and 6.56±1.072
(CLA); 6 months postoperatively 5.33±0.606 (SILS) and 6.23±1.104 (CLA). The difference in mean cosmesis score
between SILS and CLA was statistically significant (p<0.05).
Conclusions: Our comparative study between single incision laparoscopic appendectomy and conventional
laparoscopic appendectomy shows that besides better cosmetic results in the former, there are no added advantages.
However, SILS can be a safe and feasible alternative in young females who are cosmesis-conscious.

Keywords: Single incision laparoscopic appendectomy, Conventional laparoscopic appendectomy, Acute

appendicitis

INTRODUCTION 1987.2 Since the days of Kurt Semm, much debate has
centered on which technique is the preferable mode of
The Vermiform Appendix has always been shrouded by removing the appendix. Proponents of laparoscopic
controversies. The life time risk of acute appendicitis is appendectomy, however, claim that the advantages of the
8.6% for males and 6.7% for females (male: female ratio procedure include improved cosmetic results, improved
is 1.4:1).1 The application of the laparoscopic approach wound healing, reduced postoperative pain, shorter
for acute appendicitis was first reported by Schreiber in hospital stays, and earlier return to normal activity. They

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 Wani M et al. Int Surg J. 2016 Feb;3(1):177-183

also support the idea of laproscopically evaluating the A total of 60 patients of acute appendicitis were included
peritoneal cavity prior to committing to appendectomy, in this prospective study and were randomly distributed
particularly in difficult cases.3-6 into two groups viz. SILS and CLA. An informed written
consent was taken after explaining the procedure in
With the advent of minimal invasive surgery, the number detail.
of ports has been reduced to further improve cosmetic
outcome.7-9 Single port laparoscopic appendectomy that RESULTS
requires only a single incision is becoming more popular.
This surgical approach provides a number of advantages, The mean age of the patients in the SILS group was 23.9
including improved aesthetics (a single umbilical years (16-35 years) and that in the CLA group was 25.3
incision), lower risk of injury to abdominal muscle years (16-35 years) (p>0.05). Out of total of 21 males, 7
vessels, less postoperative pain and the possibility of (33.33%) underwent SILS and out of 39 females, 23
converting to the conventional laparoscopic procedure (58.97%) underwent SILS. This difference however was
(combined trocars) if necessary.10,11 Various methods not statistically significant (p>0.05). Out of 28 patients
have been reported, from a single incision at the right coming from rural background, 10 (55.55%) underwent
iliac fossa12 to use of a single suprapubic incision that can SILS and out of 32 patients from urban areas, 20 (62.5%)
be concealed in the pubic hair.13 Among these methods, a underwent SILS. This difference however was not
single incision at the umbilicus is virtually scarless. Since statistically significant (p>0.05). The difference in height
1992, after the initial performance of a single-trocar and weight of patients in both the groups was not
appendectomy by Pelosi various studies evaluating statistically different (p>0.05).
transumbilical single incision laparoscopic
appendectomies have been conducted.14-18 However, Table 1: Comparison of the mean operative time of
until recently transumbilical single incision laparoscopic the two groups.
appendectomy has been less popular in clinical practice
than traditional laparoscopic appendectomy (LA). The Operative time (in mins.) Mean SD P- value*
goal of our study was to conduct a comparative analysis SILS 57.66 7.62
of the clinical outcomes for conventional laparoscopic 0.4243
CLA 52.83 7.27
appendectomy (CLA) and transumbilical single incision SD= standard deviation, * Fishers exact test
laparoscopic appendectomy (SILS).
The mean operating time in the SILS group was 57.66
METHODS min (45-70) and in the CLA group 52.83 min (40-65).
This difference was not statistically significant (p>0.05).
This prospective study SILS versus CLA was carried out
in the postgraduate department of surgery GMC Srinagar, Table 2: Comparison of the postoperative pain scores
India, from February 2013 to October 2014 on patients in the two groups.
suspected of having acute appendicitis.
Visual analogue
All patients were worked up and assessed according to a SILS CLA p-
score (time in
(Mean±SD) (Mean±SD) value*
predefined protocol-detailed history, complete clinical hours)
examination, laboratory parameters (CBC, KFT, LFT, At 1 hour 2.7±0.749 2.5±0.727 0.7402
CRP),urine examination, ECG, chest x-ray, USG At 12 hour 3.4±0.498 3.2±0.430 0.2668
abdomen and CT scan (if needed). At 24 hour 1.9±0.999 2.0±0.980 0.8812
*Fishers exact test
Inclusion criteria
The difference in the postoperative pain score of the two
Patients with Alvarado score of ≥7; patients with
groups was not statistically significant (p>0.05). Mean
Alvarado score of 4-6 with evidence of appendicitis on
number of intravenous doses of analgesic required was
high resolution USG; patient age ≥16 years and stable
1.4 in the SILS group and 1.2 in the CLA group. This
hemodynamic state.
difference was not statistically significant (p>0.05).
Exclusion criteria
The difference in duration of ileus in the two groups was
not statistically significant (Table 3).
Patients suspected of complicated appendicitis; patients
with history of cirrhosis or coagulation disorder; shock on
The difference between hospital stay and return to work
admission; patients with previous open abdominal
in the two groups was not statistically significant
surgery; a large ventral hernia; severe cardiac or
pulmonary disease; mental disability; pregnancy and (p>0.05) (Table 4).
patients refused to consent.

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 Wani M et al. Int Surg J. 2016 Feb;3(1):177-183

Table 3: Comparison of the duration of ileus in the DISCUSSION

two groups.
Operative time
Return of Mean P-
SD
bowel sounds (time in hours ) value* The entire operative time from the skin incision to the last
SILS 18.76 0.751 stitch was measured in the minutes. The mean operating
0.7306
CLA 19.05 0.758 time in the SILS group was relatively more- 57.66
*Fishers exact test minutes (45-70) in SILS group; 52.83 minutes (40-65) in
CLA group, though this difference was not statistically
significant (p>0.05).
Table 4: Comparison of the hospital stay and return
to work in the two groups.
6.9
SILS CLA 6.5
7 6 6.2
5.7
Parameter (mean± (mean± P- value* 6 5.3
SD) SD)
5
Hospital stay 3.43 ± 3.53 ±
0.4536 4
(days) 0.404 0.507
Return to work 3.53 ± 3.63 ± 3
0.600
(days) 0.507 0.490 2
*Fishers exact test 1
0
Table 5: Comparison of postoperative complications 7th pod 3 months 6 months
in the two groups. SILS CLA

Parameter SILS CLA p- value*

Intra-abdominal Figure 1: Comparison of cosmetic results in the two
0 0 groups.
abscess 1.000
Port site Infection 1 1
*Fishers exact test The relatively increased operative time in SILS can be
accounted for by the initial learning curve due to
crowding of instruments and chopstick effect i.e. criss-
Port site infection was noted in 3.33% of patients in each crossing of instruments while operating via the single
group whereas none of our patients developed intra- transumbilical wound. However, we noted with time,
abdominal collection. The difference was not statistically when we were accustomed to the configuration and
significant (p>0.05). orientation of instruments, the operative time in SILS
reduced substantially.
In our study cosmesis was assessed by using Manchester
Scar Scale on 7th POD, 3 months postoperatively and 6 Similar reports were published by Lee JS et al19 with
months postoperatively. SILS requiring 58.9±18.7 minutes and CLA requiring
52.3±22.0.
Table 6: Comparison of cosmetic results in the two
groups. Additional findings

SILS CLA p- Laparoscopy has the inherent advantage of inspecting

Category
Mean±SD Mean±SD value* whole of the abdominal cavity and thus looks for any
7th POD 6 ± 0.587 6.9 ± 0.922 0.00512 concomitant or alternate pathology. Additional findings
3 months 5.7 ± 0.691 6.5 ± 1.072 0.00569 (concomitant or alternate pathology) were observed in
6 months 5.3 ± 0.606 6.2 ± 1.043 0.00568 23.33% of patients undergoing SILS procedure and in
*Chi-square test 20% of patients undergoing CLA. This difference was
not statistically significant (p>0.05).
The difference between cosmetic results of the two
groups was statistically significant (p<0.05) (Figure 1). The concomitant/alternate pathologies observed were
managed accordingly.
Figures 2 to 6 reveals various aspects of SILS from
diagnosis to postoperative assessment. Postoperative pain and analgesic requirement

Postoperative pain was assessed by 1 to 10 visual

analogue scales. The pain scores were calculated at 1, 12
and 24 hours after surgery. The cumulative mean visual

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 Wani M et al. Int Surg J. 2016 Feb;3(1):177-183

analogue score at 1 hour was 2.7 in SILS group and 2.5 in

CLA group; at 12 hour 3.4 in the SILS group and 3.2 in
the CLA group; and at 24 hour 1.9 in the SILS group and
2.0 in the CLA group.

Figure 4: A photographic view of SILS using

conventional laparoscopic instruments.

Figure 2: HR USG documenting acute appendicitis.

The pain scores in the SILS group at 1 and 12 hours after

surgery was higher, probably because of vigorous
manipulation while using wound retractor in umbilical
wound so as to create adequate fasciotomies for trocar
insertion. The difference in the postoperative pain score
of the two groups was not statistically significant
(p>0.05).

Figure 5: Intraoperative photograph showing division

of mesoappendix using harmonic scalpel.

Duration of ileus

Postoperatively the patient’s abdomen was auscultated

for bowel sounds and mean duration of ileus was
calculated as the time taken for return of normal bowel
sounds. Mean duration of ileus was 18.76 hours in SILS
group and 19.05 hours in CLA group; the difference was
not statistically significant (p>0.05).

Park JH et al reported the mean duration of ileus to be

Figure 3: A transumblical SILS incision marked 19.2 hours in SILS group and 20.8 hours in CLA group.
before surgery. The results published were reflected by our study. 20

Similar data were published by Lee JS et al19 who

A B C
reported the mean pain scoring 24±3 hours after surgery
as 2.63±1.3 in SILS group and 2.59±1.0 in CLA group
(p>0.05).

Mean number of intravenous doses required was 1.4 in

the SILS group and 1.2 in the CLA group and this
difference in the analgesic requirement of the two groups
was not statistically significant (p>0.05). Data published
by Park JH et al20 was in concordance with our study. In Figure 6: (A) Intraoperative picture of SILS; (B) &
this study SILS group required 1.6 mean IV doses while (C): Immediate postoperative pictures of SILS.
CLA required 1.4 IV doses.

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 Wani M et al. Int Surg J. 2016 Feb;3(1):177-183

Kang DB et al published data similar to our study and

none of their patients developed intra-abdominal
collection. Postoperative port site infection developed in
6.6% of patients in SILS group and 4.0 % of patients in
CLA group.21
A
Hospital stay

Patients in the SILS group had mean operative stay of 3.4

days while it was 3.5 days in CLA group. The difference
B was not statistically significant (p>0.05).

Park JH et al published data similar to our study wherein

they reported a mean hospital stay of 3.6 days in SILS
Figure 7: SILS pictures at 3 and 6 months follow up group and 3.9 days in CLA group.20
(A) and (B).
Return to work

It was calculated in number of days, after discharge from

hospital, when patient started mild to moderate activity.
The mean duration of return to work was 3.5 days in
SILS group and 3.6 days in CLA group; the difference
was not statistically significant (p>0.05).

Similar results were also published by Demibras S et al in

which mean time for return to work (from the day of
surgery) was 8.14±2.5 days.22

Cosmetic results and patient satisfaction

Figure 8: Another patient SILS picture at 6 months Scarring affects patients following trauma, burns, and
follow up. surgical procedures. Several modalities have been
devised to quantify scars for the purposes of determining
response to treatment and for evaluating outcomes. Scar
assessments can be objective or subjective. Objective
assessments provide a quantitative measurement of the
scar, whereas subjective assessments are observer
dependent. Quantitative assessment of scars requires
devices to measure their physical attributes. Subjective
methods to assess scar provide a qualitative measurement
of scar by a patient or clinician. Semi-quantitative
methods to assess scars have been Scar scales devised to
quantify scar appearance in response to treatment. There
are currently at least 5 scar scales that were originally
designed to assess subjective parameters in an objective
way: The Vancouver Scar Scale (VSS), Manchester Scar
Figure 9: Postoperative photograph of conventional Scale (MSS), Patient and Observer Scar Assessment
laparoscopic appendectomy showing scars of 3 ports. Scale (POSAS), visual analog scale (VAS), and stony
brook scar evaluation scale (SBSES). These observer-
Intra-abdominal abscess and port site infection dependent scales consider factors such as scar height or
thickness, pliability, surface area, texture, pigmentation,
None of our patients developed intra-abdominal and vascularity. The measurements range across a
collection. Port site infection was noted in 3.33% of continuum of values. Thus, the scales are best used to
patients in each group. The difference was not determine change within an individual rather than
statistically significant (p>0.05). Port site infection was between individuals developed by using scales to make
managed by oral antibiotics and daily antiseptic subjective methods more objective. The manchester scar
dressings. Recovery from port site infection was scale, proposed by Beausang et al, includes an overall
uneventful. VAS (0-10 points) that is added to the individual attribute
scores.23 It assesses and rates 5 scar parameters: scar
color (perfect, slight, obvious, or gross mismatch to

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 Wani M et al. Int Surg J. 2016 Feb;3(1):177-183

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Cite this article as: Wani M, Mir SA, Yaqoob M,

Watali Y, Moheen HA. A comparative study between
single incision laparoscopic appendectomy and
conventional laparoscopic appendectomy. Int Surg J
2016;3:177-83.

International Surgery Journal | January-March 2016 | Vol 3 | Issue 1 Page 183