Laparoendoscopic single-site surgery appendectomy

Transcription

1 Surg Endosc (2010) 24: DOI /s Laparoendoscopic single-site surgery appendectomy Óscar Vidal Æ Mauro Valentini Æ Cesar Ginestà Æ Josep Martí Æ Juan J. Espert Æ Guerson Benarroch Æ Juan C. García-Valdecasas Received: 31 March 2009 / Accepted: 4 July 2009 / Published online: 19 August 2009 Ó Springer Science+Business Media, LLC 2009 Abstract Background Laparoscopic appendectomy via the threetrocar technique is widely used for appendectomy. This report describes the initial experience with laparoendoscopic single-site surgery (LESS) appendectomy. Methods Between December 2008 and March 2009, patients with acute appendicitis admitted to the General Surgery and Emergency Unit of the authors institution who agreed to undergo LESS appendectomy were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of emergency surgery. The umbilicus was the sole point of entry for all patients, and the same operative technique was used in all cases. The data for patients undergoing LESS Ó. Vidal (&) M. Valentini C. Ginestà J. Martí J. J. Espert G. Benarroch J. C. García-Valdecasas General Surgery and Emergency Unit, Department of Digestive Surgery, Digestive Diseases and Metabolism Institute, Hospital Clínic i Provincial, Universitat de Barcelona, Villarroel 170, 9th Stair, 4th Floor, Barcelona, Spain ovidal@clinic.ub.es M. Valentini valentini@clinic.ub.es C. Ginestà ginesta.cir@hotmail.com J. Martí jmartis@comb.cat J. J. Espert jjespert@clinic.ub.es G. Benarroch gbena@clinic.ub.es J. C. García-Valdecasas jcvalde@clinic.ub.es appendectomy were compared with the data from an uncontrolled group of patients undergoing standard laparoscopic appendectomy during the same study period. Results The LESS and standard appendectomy groups included 15 patients each. The LESS procedure was performed successfully for all the patients, and none required conversion to an open procedure or a conventional laparoscopic appendectomy by the addition of more entry ports. The mean operating time of 51 min in the LESS group was not significantly different from the 46 min in the standard laparoscopic appendectomy group. Conclusions In this study, LESS appendectomy was technically feasible and safe, representing a reproducible alternative to standard laparoscopic appendectomy. Keywords Laparoendoscopic single-site surgery (LESS) Laparoscopic appendectomy One-trocar appendectomy Single-incision laparoscopic surgery (SILS) Transumbilical access Acute appendicitis is the most frequent surgical abdominal disease in the emergency setting [1, 2]. Laparoscopic appendectomy, a feasible and safe surgical option, has been used progressively as an emergency procedure alternative to open appendectomy. Since the initial laparoscopic appendectomy described in 1983 by Semm [3], this technique has undergone several modifications, and a number of techniques using one or more trocars have been described. Laparoscopic single-site surgery (LESS), in which only one incision is made through the umbilicus, has received increasing attention in recent years. In abdominal surgery, it is an area targeted for intensive investigation. Singleincision laparoscopic surgery (SILS), one-port umbilical

2 Surg Endosc (2010) 24: surgery (OPUS), and single-port access surgery (SPA) are synonymous with of LESS. Other approaches such as natural orifice translumenal endoscopic surgery (NOTES) may represent the final frontier for the minimally invasive revolution surgery without incisions. A number of advantages have been proposed for LESS including better cosmesis (scarless abdominal surgery performed through an umbilical incision), less incisional pain, and the ability to convert to standard multiport laparoscopic surgery if necessary. Different techniques for LESS cholecystectomy [4], appendectomy [5], nephrectomy [6], adrenalectomy [7], and obesity surgery [8] have been reported recently. Different methods for port access to perform LESS include multiple fascial punctures through one skin incision, the introduction of membrane-based umbilical devices, the use of additional transabdominal sutures to stabilize the target organ, and others [8, 9]. To further overcome the technical challenges of LESS, different instruments that provide angulations and small-profile trocars are being developed. We describe our initial experience with LESS appendectomy. This study aimed to assess the safety and feasibility of LESS appendectomy using a novel method of establishing single access via existing instrumentation with the addition of the SILS Procedure Kit Plus Components (Covidien, Norwalk, CT, USA) and to compare it with standard multiport appendectomy. Patients and methods Between December 2008 and March 2009, a prospective study was designed to assess the feasibility and safety of LESS appendectomy for patients of 18 years of age or older with acute uncomplicated appendicitis admitted to the General Surgery and Emergency Unit of Hospital Clínic i Provincial, in Barcelona (Spain). For comparison purposes, the same number of patients with acute uncomplicated appendicitis undergoing standard multiport appendectomy also was prospectively selected. The subjects were randomly assigned to the LESS group or the conventional laparoscopic group according to the order of arrival in the emergency department at the time of inclusion in the study. All the patients were fully informed about the characteristics of LESS and laparoscopic procedures as well as the possibility that conversion to an open procedure or standard laparoscopic appendectomy could be required at the time of operation for those assigned to the LESS group. The study was approved by the Ethics Committee of our institution. Written informed consent was obtained from all the participants. The inclusion criteria specified a clinical history suggestive of acute appendicitis, less than 48 h of evolution, typical findings of acute appendicitis at physical examination, absence of signs denoting peritoneal irritation, a left shift with or without leukocytosis, normal abdominal and chest X-rays, hemodynamic stability, and absence of medical, anesthetic, or surgical contraindications for laparoscopic surgery. Patients with complicated acute appendicitis (ruptured appendicitis and local abscess or diffuse peritonitis) and those for whom general anesthesia was contraindicated were excluded from the study. In doubtful cases of complicated appendicitis, abdominal ultrasound studies were performed to exclude the presence of a localized abscess or diffuse peritonitis. Surgical procedure All the patients followed the same preoperative protocol, with antibiotic prophylaxis before the operation and postoperative antibiotic treatment according to the macroscopic characteristics of the appendix and whether purulent free liquid into the abdominal cavity was present or not. Analgesic medication included paracetamol (1 g three times daily) and dexketoprofen trometamol (25 mg three times daily). All LESS and conventional laparoscopic operations were performed by the same experienced laparoscopic surgeons (O.V., M.V.). The LESS technique included three access ports through the same umbilical incision to obtain a good visualization of the surgical field and two working pipes which could be used with conventional laparoscopic instruments and flexible instruments from the SILS Procedure Kit Plus Components (Covidien). The operation was performed with the patient under general anesthesia and placed in the supine position with both arms abducted. The surgeon stood on the patient s left side, and the assistant stood on the right side of the surgeon, with the monitor placed on the opposite side. A paraumbilical skin incision approximately 2.5 cm long was made in the superior and left umbilical zone, and blunt dissection gave adequate access to the linea alba. The Veress needle was used to establish pneumoperitoneum. A 12-mm trocar was placed in the superior part of the incision, and another two 5-mm Dexide trocars (Covidien) were placed in an inferior position (Fig. 1). A 30 5-mm laparoscope was used for inspection of the abdominal cavity, after which the patient was placed in the Trendelenburg position with a slight left lateral decubitus to expose the cecum and the appendicular area. The instruments used included 5-mm graspers (Roticulator EndoGrasp and Roticulator Endo Dissect; Autosuture, Ascot, UK) and flexible scissors (Roticulator Endo MiniShears; Autosuture) (Fig. 2). Dissection of the mesoappendix was accomplished first, followed by its section between laparoscopic clips with

3 688 Surg Endosc (2010) 24: (phlegmonous, gangrenous), postoperative complications, postoperative pain on day 1 using a 10-cm visual analog scale (VAS) with options ranging from 0 (no pain) to 10 (worst pain imaginable), time oral diet began, and length of hospital stay. Statistical analysis The data for patients undergoing LESS and those undergoing standard multiport appendectomy were compared. The chi-square (v 2 ) test was used for analysis of categorical variables, and the Mann Whitney U test was used for continuous variables. Statistical significance was set at a p value less than Fig. 1 Positions of the trocars for laparoendoscopic single-site surgery (LESS) appendectomy Fig. 2 Special trocars and flexible material used for laparoendoscopic single-site surgery (LESS) appendectomy 10-mm Endoclip III (Covidien). Next, the section of the appendicular base was performed with a blue cartridge EndoGIA 30 (Covidien). After completion of the appendectomy, the peritoneal cavity was rinsed with sterile saline, and the appendix was removed from the abdominal cavity using the EndoCatch (Covidien) specimen bag. The three holes in the fascia were brought together and sutured with simple sutures of Polysorb 0 (Polysorb, USSC, Norwalk, USA). Then skin closure was completed with Dexon II 4-0 (Dexon, USSC, Norwalk, USA) subcuticular running suture. Assessment For all patients, the following variables were recorded: demographics (age, sex), date of admission to the hospital, clinical features, duration of the operation (min), intraoperative complications, pathologic severity of appendicitis Results The study enrolled 30 patents (19 men and 11 women) with acute appendicitis: 15 to undergo LESS appendectomy and 15 to undergo standard multiport appendectomy. The mean age of the patients was 33 ± 2.5 years. All the patients were classified as belonging to American Society of Anesthesiology (ASA) class 1. The mean duration of the operation was 51 ± 7 min for the LESS group and 46 ± 8 for the standard laparoscopic appendectomy group. The operation was successfully completed for all the patients, and neither conversion to open surgery nor the use of additional trocar was required. No intraoperative or postoperative complications occurred. The umbilical wound had a good appearance 7 days after surgery. Pathologic examination of the resected specimens confirmed the presence of acute appendicitis in all cases. Phlegmonous appendicitis was diagnosed for 18 patients and gangrenous appendicitis for the remaining 12 patients. The median (25th 75th %tile) VAS for postoperative pain intensity was 2 (range, 1 3) in the LESS appendectomy group and 2 (range, 1 4) in the standard laparoscopic group. All the patients resumed oral intake within the first 24 h after surgery. The length of hospital stay also was similar in the two study groups, at a mean of 2.5 ± 0.6 days. As shown in Table 1, no statistically significant differences between the LESS appendectomy and standard multiport laparoscopic appendectomy groups for any of the study variables were observed. Discussion The advantages of laparoscopically performed operations compared with the same procedures performed through an open approach has led to an increasing interest in

4 Surg Endosc (2010) 24: Table 1 Comparison of demographic and surgery-related variables between the laparoendoscopic single-site surgery (LESS) and the standard multiport laparoscopic appendectomy groups Data Surgical procedure p Value LESS appendectomy Multiport laparoscopic Appendectomy Patients Men/women 10/5 9/ Mean age (years) 30 ± 3 36 ± Duration of operation (min) 51 ± 7 46 ± Intraoperative complications None None Appendicitis severity: n (%) Phlegmonous 10 (66.7) 8 (53.3) Gangrenous 5 (33.3) 7 (46.7) Postoperative complications None None Postoperative pain (VAS): median (25th 75th % tile) 2 (1 3) 2 (1 4) Time of starting oral intake after surgery: n (%) B24 h 15 (100) 15 (100) [24 h 0 0 Mean hospital stay (days) 2.4 ± ± developing lesser invasive procedures [10 12] and reducing the size of laparoscopic instruments for an evolving field in which suitable instruments have been lacking. Unlike NOTES, which faces obvious hurdles in safety [13] and reproducibility, single-incision transumbilical laparoscopy is ready for widespread implementation. At this writing, LESS appendectomy can be implemented. The LESS approach involves no scar surgery and may not be associated with any significant learning curve beyond standard laparoscopic surgery. Our group developed a laparoscopic technique for acute appendicitis through a single skin umbilical incision. The procedure is based on the simultaneous use of three trocars through the same skin incision. With this technique, all instruments (including the laparoscope) must be parallel and closely introduced through one small hole. This fact reduces motion possibilities, and the surgeon must be adapted to an eventual crossing of instrument shafts at the point of entry into the abdominal cavity. This crossing increases the difficulty of surgical dissection compared with conventional laparoscopic surgery. A perfect coordination between the surgeon and the camera assistant, with frequent corrections of instrument and laparoscope positions between the three ports, is essential to obtain an optimal vision and to avoid crossing instruments with the laparoscope. If necessary, the surgeon can convert LESS into a conventional laparoscopic procedure by adding another trocar while preserving safety for the patient. For the aforementioned reasons, the introduction of this new technique without adding complications requires good experience with laparoscopic surgery. Although special ports [14], trocars, and flexible laparoscopes [9, 15] have been used in other studies, we use conventional 5-mm trocars and a laparoscope. Only the instruments (Roticulator EndoGrasp, Roticulator Endo Dissect, and Roticulator Endo MiniShears) are flexible. For LESS or SILS, different authors have suggested that the ideal access should be through the umbilicus [9, 15], and we also restricted the incision to this area. This incision permits three operative pipes to be used simultaneously, which enables the entirely intracorporeal appendectomy. Positioning of the incision at the umbilicus offers better cosmetic results. In reducing the number of skin incisions from three to a single one, it is possible to reduce postoperative pain by eliminating muscular penetration by the ports, and this also can avoid injury to muscular or epigastric vessels [15]. The umbilicus is located in the thinner area of the abdominal wall, and this condition makes the port introduction easier as well as motion of the instrument in all directions. Another advantage of this approach comes from closure of the fascial holes. We bring the three holes together by cutting fascial bridges between them and suturing fascial edges with simple stitches under direct vision, thus reducing the risk of port-related bleeding [16] and incisional hernia [17]. In our study, patients with complicated appendicitis were excluded. To ensure a successful operation for acute ruptured appendicitis with a localized abscess or diffuse peritonitis, the appendix should be removed and the peritoneal cavity thoroughly washed, with complete mobilization of the intestinal loops to prevent formation of residual intraabdominal collections. The insertion of one or more intraabdominal drains also can be necessary in some cases.

5 690 Surg Endosc (2010) 24: In this study, exteriorization of an intraabdominal drain through the umbilical wound was not considered due to an increased risk of cutaneous infection at this level and the possibility of incisional hernia. Moreover, insertion of a 5- mm trocar at the hypogastric level may help in safe handling of intestinal loops and would facilitate placement of a drain through the cutaneous orifice. Currently, we believe that the pure transumbilical approach cannot guarantee a complete satisfactory result for these complicated patients. The current results in our series of LESS appendectomies were comparable with those reported for laparoscopic appendectomy [18]. In a systematic review of laparoscopic versus open surgery for suspected appendicitis [19], the duration of surgery for the laparoscopic procedure ranged between 35.7 and 86 min. In our study, the mean duration of LESS appendectomy was 51 min. In terms of postoperative pain on day 1, our median VAS of 2 was slightly lower than the 2.9 and 3.9 reported by others [19, 20]. Oral intake was initiated within the first 24 h for all patients, which is consistent with the experience of other authors [19]. The mean hospital stay of 2.4 days also is in agreement with the expected duration of hospitalization for this group of urgent surgical patients. Different studies describing transumbilical appendectomy have been published in the literature. In 1996, Kala et al. [12] performed the procedure through one umbilical port with extracorporeal section of the appendicular structures. A large variety of umbilical procedures with or without exteriorization of the appendix have been reported in clinical series of pediatric patients [14, 21, 22]. A group at the University of Naples [14] described transumbilical appendectomy using a single trocar and a flexible laparoscope with extracorporeal section of appendicular structures. However, the authors indicate the need to use supplemental trocars or to perform a small laparotomy in McBurney s point when important appendicular inflammations or intraperitoneal adherences in the right iliac fosse are found. The most recently published study in 2009 by Hong et al. [5] describes transumbilical appendectomy with intracorporeal section of the appendicular structures (as also made by us) by using an own-made single-port system with an extra-small wound retractor. These authors also have used this technique for 15 well-selected patients with cholelithiasis [22]. We used three standard access ports and standard instruments through the same umbilical incision without using any single-port device. In summary, LESS appendectomy was technically feasible and safe, representing a reproducible alternative to standard laparoscopic appendectomy. However, this novel laparoscopic approach will benefit from technical improvements of instruments specifically designed for this application. Further prospective studies comparing singleand multiple-access laparoscopic appendectomy for a larger number of patients are required to confirm the current promising results. Acknowledgments The authors are grateful to Covidien Spain, S.L., for logistic support, and to Marta Pulido, MD, for editing of the manuscript and editorial assistance. References 1. Hansson LE, Laurell H, Gunnarsson U (2008) Impact of time in the development of acute appendicitis. Dig Surg 25: Kessler N, Cyteval C, Gallix B, Lesnik A, Blayac PM, Pujol J, Bruel JM, Taourel P (2004) Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology 230: Semm K (1983) Endoscopic appendectomy. 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