International Surgery Journal

Kumar R et al. Int Surg J. 2017 May;4(5):1588-1593

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DOI: http://dx.doi.org/10.18203/2349-2902.isj20171602
Original Research Article

Single incision laparoscopic appendicectomy versus conventional

laparoscopic appendicectomy- a prospective study
Rohit Kumar, Rajan Vaithianathan*, Vinoth Sundaresan

Department of Surgery, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India

Received: 11 April 2017

Accepted: 18 April 2017

*Correspondence:
Dr. Rajan Vaithianathan,
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: The advent of Single incision laparoscopic appendicectomy (SILA) has encouraged surgeons to
compare its benefits over conventional laparoscopic appendicectomy (CLA). We conducted a prospective study
comparing SILA with CLA, evaluating parameters like operative time and complications, post-operative pain,
duration of stay and the cosmetic outcome.
Methods: A prospective, comparative study of 94 consecutive patients was conducted at our institution between
December 2014 and May 2016. The data regarding the various parameters were documented in both groups of
patients.
Results: Among the 94 patients, 30 underwent SILA and 64 underwent CLA. We found statistically significant
outcomes for SILA over CLA in variables such as operative time (p=0.0018), duration of hospital stay (p≤0.0001) and
cosmetic outcome (p≤0.0001). Almost all patients in the SILA category showed no evidence of a scar after a three
month follow up.
Conclusions: SILA was found to have a better outcome than CLA with regard to operative time, hospital stay and
cosmesis. We conclude that this technique of SILA can be a better alternative to CLA.

Keywords: Appendicectomy, Laparoscopy, Single incision

INTRODUCTION Rispoli et al, it has been proposed as the next

revolutionary milestone in minimally invasive surgery.3
Appendicitis is one of the most common surgical However, at that time evidence supporting the safety and
emergency seen in young adults. Open appendicectomy efficacy of this approach was limited. The increased
was first carried out by Claudius Amyand in 1735, but practice of SILS has led surgeons to ponder whether
was described in literature only later by McBurney in SILS can soon replace conventional laparoscopic surgery.
1894.1,2 For over a century open appendicectomy was
followed as a gold standard for treatment of appendicitis. The ever-growing interest in SILA seems to be primarily
In 1983 Kurt Semm, a gynaecologist, first performed focused on cosmesis, less post op pain with early
laparoscopic appendicectomy, which led surgeons to recovery, reduction in hospital stay and expenses. SILA
strive and improve upon it by drastically reducing however has few limitations such as restricted degrees of
operative duration, hospital stay, post op complications, freedom of movement, the number of ports that can be
post op pain, cosmesis, and quick return to oral feeding used, and the proximity of the instruments to each other,
and routine work.1 Since the first report of Single incision making it technically challenging. It is to be noted that a
laparoscopic surgery (SILS) for acute appendicitis by steep learning curve exists in all newer modalities and

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 Kumar R et al. Int Surg J. 2017 May;4(5):1588-1593

can potentially serve as an area for future research. is then inserted into the cavity, using curved artery
Present study aims to assess the comparability of SILA forceps. The triple-entry port is used to create a
with CLA using conventional laparoscopic equipment, in pneumoperitoneum of 12-15 mm Hg, two 5mm trocars
various parameters such as operative duration, post op and one 10mm trocar are inserted, one of them being for
pain scores, intra operative complications, duration of the telescope.
hospital stay and the overall cosmetic outcome in both
the groups. Table 1: Wound evaluation scale.

METHODS Wound evaluation scale

Step off borders 0 for Yes, 1 for No
This was a prospective, comparative study of patients Contour irregularity
0 for Yes, 1 for No
who underwent elective appendicectomy, in Mahatma puckering
Gandhi Medical College and Research Institute, Scar width >2 mm 0 for Yes, 1 for No
Pondicherry, a tertiary care centre. This study Edge inversion- sinking,
0 for Yes, 1 for No
commenced in December 2014, after ethical approval curling
from the Human Ethics Committee of the Institute, and Inflammation – redness,
ended in May 2016. All patients falling under the 0 for Yes, 1 for No
discharge
inclusion criteria mentioned below, were included in this Overall cosmesis 0 for poor, 1 for acceptable
study after informed consent.
The patient is placed in the 30- degree Trendelenburg
Inclusion criteria position and 20-degree left lateral decubitus for adequate
intra peritoneal exposure of the right iliac fossa.
All patients above the age of 18 years, undergoing Conventional laparoscopic instruments(rigid) were used
elective appendicectomy. to perform the appendicectomy. The SILS port is
removed and the wound was closed with an absorbable
Exclusion criteria suture and inverted, aiming at a scar free surgery (Figures
1-3).
• Patients presenting with symptoms of appendicular
perforation, abscess or localised peritonitis.
• Patients with contraindications for laparoscopic
surgery.
• Patients who were contraindicated for general
anaesthesia.

Laboratory investigations

Routine tests included complete hemogram, urine

analysis and microscopy, serum electrolytes, renal
function tests and ultrasonography of the abdomen to
confirm the diagnosis of appendicitis.

The patients were divided into two groups,

Figure 1: Triple entry single incision
• Group A- 30 patients who underwent SILA port with obturators.
• Group B- 64 patients who underwent CLA

Parameters such as operative duration, intra operative

complications, post-operative pain score, duration of
hospital stay and cosmetic outcome after 3 months’ post
op were documented. Pain was scored using Visual
analog pain scale along with Wong-Baker Faces pain
rating scale, and a simple bedside, 6-point wound
evaluation scale was used to assess the cosmetic outcome
(Table 1). A wound with a score of 6/6 was considered as
having an optimal scar.4,5

In the SILA group, a 2-cm vertical transumbilical

incision is made under direct vision down to the
peritoneum. The single-incision laparoscopic surgery Port Figure 2: Port in position with conventional rigid
laparoscopic instruments.

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 Kumar R et al. Int Surg J. 2017 May;4(5):1588-1593

RESULTS

The data collected was then incorporated into an Excel

Data Sheet. This data was further analyzed using the
Statistical Package for the Social Sciences v20.0 software
(SPSS). The comparative evaluation of operative
duration, post op pain scores, duration of hospital stay,
intra operative complications and cosmesis in both SILA
and CLA groups were calculated using ‘chi square’ test
and ‘t’ test.

Distribution by age

The following table shows the distribution of patients

Figure 3: SILA patient at 3 month follow up. according to their age. It showed that the majority of
patients were between 30-40 years of age (36.7%) in
In the CLA group, the procedure was done according to SILA group and 20-30 years of age (38.3%) in CLA
the established standard 3 port technique for removal of group. There were 33.3% patients between 20-30 years of
the appendix. The three port sites were closed with age in the SILA group and 26.6% patients between 30-40
sutures. All patients in both groups received the same years of age in CLA group (Table 2).
regimen for post -op analgesia.

Table 2: Demographic data.

Age in Years SILA CLA Total

Number Percentage Number Percentage Number Percentage
<20 Years 4 13.3% 12 18.8% 16 17%
20-30 Years 10 33.3% 26 40.6% 36 38.3%
30-40 Years 11 36.7% 14 21.9% 25 26.6%
>40 Years 5 16.7% 12 18.8% 17 18.1%

Comparison of clinical parameters significant difference between the groups in terms of pain
score (Table 3). Intra operative and immediate post-
The groups were compared by ‘t’ test and the results of, operative complications. There was only one patient who
duration of surgery (t=2.98, p=0.0018), duration of was converted to open appendicectomy from SILA, due
hospital stays (t=9.389, p<0.0001) and cosmetic outcome to extensive adhesions rendering dissection of the
(t=44.954, p<0.0001) were significant. The result of pain appendix difficult. Among the CLA group there were no
score (t=1.065, p=0.144) shows that there is no intra operative or immediate post-operative complications
in any patient.

Table 3: Comparison by clinical parameters.

Clinical Parameters SILA CLA ‘t’ Value ‘p’ Value

Mean SD Mean SD
Duration of surgery 37.133 15.19 48.703 15.528 2.98 0.0018 (S)
Pain Score 1.7 0.5959 1.8593 0.709 1.065 0.144 (NS)
Cosmetic 1.2 0.5508 2.703 0.7904 9.389 <0.0001 (S)
Outcome 0.133 0.7302 5.7968 0.477 44.954 <0.0001 (S)
(S – Significant, NS – Not Significant)

DISCUSSION delay, can lead to increased morbidity and mortality.

Since the advent of laparoscopic surgery, surgeons
Acute appendicitis is a common condition prevalent in throughout the world have constantly worked towards
adolescent patients but at times also presents in adults. improving the surgical methods to treat this condition.
Early diagnosis and choice of treatment is pivotal as a The aim was to make the treatment, as patient friendly

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 Kumar R et al. Int Surg J. 2017 May;4(5):1588-1593

and surgeon friendly as possible. Single incision that employed the glove port technique for SILA with the
laparoscopic appendicectomy, first published by Rispoli results of our study, we found that in the first study by
et al revolutionised minimal invasive surgery with regard Kang et al, they found that post op pain was less in the
to appendicectomies.3 In this age of minimal access SILA category and also in view of cosmesis the result
surgery, there has been a continuous debate among was similar(p=0.043) to present study where the three
surgeons, on whether Single incision laparoscopic was better cosmetic outcome in SILA than in CLA
appendicectomy(SILA) is the treatment of choice for this (p≤0.0001).8
condition. With more patients requesting for affordable
day care surgery and better cosmesis in recent times, Lee et al, in their study, found similar results to our study
research work to evaluate the benefits of SILA over the (p≤0.0001) with regards to duration of hospital stay
conventional laparoscopic appendicectomy (CLA) has where patients operated with CLA required a longer
become the need of the hour. period of admission (p=0.018). They also found that 27%
of SILA patients required an additional port insertion for
The principle aim of the study was to assess the benefits better dissection, which is contradicting to our results
of single incision laparoscopic appendicectomy over where we had to convert only one patient to open
conventional laparoscopic appendicectomy while appendicectomy from SILA.9
employing standard SILA technique but with rigid
laparoscopic instruments instead of the routinely used Another study by Lee et al, stated that there was no
expensive roticulating laparoscopic instruments. Hence significant difference between the two groups in
various parameters such as operative duration, operative time, duration of hospital stay and pain scores.
complications during surgery, post op pain, duration of Although our findings are similar to theirs with regards to
hospital stay and cosmetic outcome were evaluated in pain scores in both groups, we found contradicting results
both groups for the same. with the remaining parameters as patients who underwent
SILA had considerably less operative time and
The collected data of the aforementioned parameters in hospitalization.10
both groups were evaluated using simple ‘chi square test’
for direct comparison and ‘t test’ for comparing the Baik et al showed that in their study, there was increased
average of the outcomes in the clinical parameters in both post op pain on POD#1 (p=0.048) in the SILA category,
groups. The results of a direct comparison showed but this finding is not common between our study and
statistically significant outcomes for SILA in duration of theirs. Although the remaining variables were
hospital stay (p≤0.0001) and in the cosmetic outcome comparable in both groups which was similar to our
(p≤0.0001). But there was no significant result with study.11 Kang et al in another study concluded that other
regard to operative duration (p=0.06) and post op pain on than a marginal increase in operative time in SILA
POD#1 (p=0.306). (0.276) all the other variables were quite comparable.12

However, comparing the average of the outcomes in the The glove port technique although cost effective could
same parameters showed statistically significant results considerably increase operative time as it has a steep
for SILA in operative duration (p=0.0018), duration of learning curve, and surgeons require high technical skills
hospital stay (p≤0.0001) and cosmetic outcome to perform it. And some studies showed post op pain to
(p≤0.0001). The post op pain score was found to be be increased in SILA.12 Hence our technique could be a
comparable in both groups (p=0.144). Kim et al, and Wu simple alternative to the glove port technique with better
et al compared the post op pain scores in patients who results in operative time, pain scores, hospital stay and
underwent SILA using a SILS port and conventional cosmesis.
laparoscopic instruments and patients who underwent
CLA. While the former suggested that in SILA patients Commercially available roticulating instruments have
there was an increase in use of analgesics in the post op allowed surgeons to achieve triangulation and manoeuvre
period (p=0.009), the latter suggested results that were freely with the working instruments, but they have a steep
similar to our study (p=0.132), where the pain scores learning curve and are not cost effective for the patient.
were comparable between the two groups with no St peter et al conducted a study to compare SILA and
significant p value (p=0.144).6,7 CLA employing this surgical technique for the former.
They found that the operative duration, post op pain and
Wu et al, also found that operative time for SILA was cost of surgery were all considerably increased with the
more compared to the CLA group (p=0.000), whereas in SILA patients which were contrary to our findings. They
our study we found SILA performed with less time when concluded that hospitalization was for a similar period in
compared to CLA (p=0.0018). We believe this could be both groups, whereas in our study SILA patients required
due to the result of one surgical team operating for SILA lesser hospitalization than CLA patients.13
and the others operating for CLA in our study. The
results of the remaining parameters such as duration of Teoh et al concluded that all variables were comparable
hospital stay and complications during surgery were in both groups, but found that SILA patients complained
similar to our results.6 Comparing the results of studies of pain on stress eg. Coughing (p=0.001). They also

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 Kumar R et al. Int Surg J. 2017 May;4(5):1588-1593

found that the cosmetic outcome in the SILA category Funding: No funding sources
was satisfactory compared to CLA (p=0.002) which is Conflict of interest: None declared
concurrent with our finding.14 And three separate studies Ethical approval: The study was approved by the
employing this technique showed that SILA had a institutional ethics committee
minimally increased pain score when compared to
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