Journal of Pediatric Surgery (2010) 45, 1208 1212 www.elsevier.com/locate/jpedsurg Single-incision laparoscopic surgery: feasibility for pediatric appendectomies Sarah C. Oltmann a, Nilda M. Garcia b, Brenda Ventura c,ianmitchell a, Anne C. Fischer b, a Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA b Department of Pediatric Surgery, University of Texas Southwestern Medical Center/Children's Hospital Dallas, Dallas, TX 75235, USA c Department of Pediatric Surgery, Childrens Medical Center, Dallas, TX, USA Received 13 February 2010; accepted 22 February 2010 Key words: Single-incision laparoscopic surgery; Pediatric surgery; Appendectomy; Single-access surgery Abstract Introduction: Single-incision laparoscopic surgery (SILS) is a novel area of minimally invasive surgery using a single incision. The end result is a lone incision at the umbilicus for a perceived scarless abdomen. We report our early experience using the SILS technique for appendectomies in the pediatric population. Methods: A retrospective chart review was performed on our first patients to undergo SILS appendectomy (SILS-A) or laparoscopic appendectomy (LAP-A) during the same period at a freestanding children's hospital. Results: Thirty-nine patients were reviewed. Nineteen patients underwent SILS-A (8.7 ± 0.76 [SEM] years old), and 20 patients underwent LAP-A (10.5 ± 0.87 years old, 2-17). Ages were 19 months to 14 years in the SILS-A group, with 21% (4 patients) not older than 6 years. Median weight for SILS-A was 32 kg (14.5-80.3). Twelve patients had acute nonperforated appendicitis (62%). Mean duration of operation was 58 ± 5.6 (30-135) minutes vs 43 ± 3.6 (30-85) minutes for standard LAP-A. Two patients were converted to a transumbilical appendectomy, one for inability to maintain a pneumoperitoneum and one for extensive adhesions. Postoperative complications consisted of one wound seroma. No wound infections, hernias, readmissions, or difference in length of stay were noted. Conclusion: The SILS approach for acute appendicitis is feasible in the pediatric population even in patients as young as 19 months. Operating room times are somewhat longer than with LAP-A, but should decrease with improved instrumentation and experience. Larger studies and further technical refinements are needed before its widespread implementation. 2010 Elsevier Inc. All rights reserved. As technology and innovation continue to advance the field of minimally invasive surgery, the use of single-incision laparoscopic surgery (SILS) is gaining popularity as a Corresponding author. Tel.: +1 214 456 6040; fax: +1 214 456 6320. E-mail address: anne.fischer@childrens.com (A.C. Fischer). method to achieve a perceived scarless abdomen by placing the single incision within the umbilicus. Applications have been previously described using this approach for various general, bariatric, urologic, and pediatric surgical procedures [1-16]. The industry has recognized the market appeal of this technique, driven by public pressure for improved cosmesis, 0022-3468/$ see front matter 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.02.088
SILS for pediatric appendectomies and has already developed specialty cameras, ports, and instruments. In addition, despite the lack of literature supporting this surgical approach, health care systems have already begun to advertise their ability to perform various procedures by this technique. The early history of laparoscopic (LAP) cholecystectomy was fraught with surgeons minimally or untrained in this technique starting to implement it before all risks of the procedure were recognized and well understood. With time and in response to an increase in bile duct injuries, techniques were optimized to ensure visualization of critical structures to minimize iatrogenic injury. To avoid the potential dangers associated with the rapid change in practice without evidence-based support, a controlled study of SILS approach needs to be performed to ensure that it is equivalent in safety to already familiar LAP approaches. Additional long-term studies are necessary to determine if there are benefits to SILS beyond those of the LAP approach, as well as if there are differences in cost or complications. As laparoscopic appendectomy (LAP-A) is one of the most common LAP procedures in the pediatric population, we asked if a SILS approach for appendectomy (SILS-A) is both safe and feasible in the pediatric population. 1. Methods After institutional review board approval (I032009-025), a retrospective review was performed on those patients who underwent the first single-incision LAP-As at our freestanding children's hospital from October 2008 to March 2009. All surgeries were performed by a single attending surgeon with assistance from either a pediatric fellow or senior surgical resident. Patients were alternated between LAP and SILS approach. Those cases performed during the night were performed laparoscopically because the night operating room (OR) support staff were not familiar with the SILS equipment. Charts were reviewed for patient demographics, presenting history, operative time, operative conversions, length of stay, complications, and patient follow-up. Comparisons were made with LAP-As performed during the same time frame by the same attending surgeon. To control the intraperitoneal portion of the procedure for both methods and ensure consistency, a stapler was used to amputate both the base of the appendix and the mesoappendix. A supraumbilical skin incision was made, and small skin flaps were raised to expose the abdominal wall fascia. Three 5-mm fascial incisions were then made in a triangular orientation at the umbilicus. Ports were inserted to varying depths to maximize working space and instrument range of motion within the peritoneal cavity. A 5-mm 45 laparoscope was inserted through the middle port. A 5-mm articulating dissector and a 5-mm articulating grasper were placed through the lateral ports. Once the base of the appendix was dissected free, the camera was switched to the left lateral port. The middle and right 5-mm ports were removed, and the fascial incisions were connected to accommodate a 12-mm port for use of a stapler. For the first 3 procedures, a modified approach was used, with an additional right lower quadrant stab incision used to insert a 3-mm Babcock directly into the peritoneal cavity to provide appendiceal retraction while stapling across the appendix base. For the remaining procedures, a true SILS approach was used by inserting the 3-mm Babcock alongside the existing umbilical fascial incisions without a port. The appendix specimen was removed through the 12-mm port with an ENDOBAG (Covidien, Mansfield, MA). The LAP-As were all done in standard 3-port fashion. Statistical analysis was performed with Student's t test or Mann-Whitney using GraphPad Prism 5.01 for Windows (GraphPad Software, San Diego, CA). Data are shown as mean ± SEM, with range when appropriate, or as median with range, unless otherwise specified. A P value of b.05 was determined to be statistically significant. 2. Results 1209 Between October 2008 and March 2009, a total of 19 patients underwent a SILS-A with a mean age of 8.7 ± 0.76 years (19 months-14 years); 20 with a mean age of 10.5 ± 0.87 years (2-17 years) underwent LAP-A during the same time frame (Table 1). The age distribution of these 2 populations was not statistically different (P =.10). Our SILS-A population was 63% male (n = 12) and had a median Table 1 Demographic data and operative comparison for SILS and LAP procedures SILS-A LAP-A P value No. of cases 19 21 Mean age ± SEM, 8.7 ± 0.76 10.5 ± 0.87 0.0955 y (range) (1.16-14) (2-17) Male 12 (63%) 12 (60%) 0.85 Female 7 (37%) 8 (40%) 0.85 Median weight, 32 (14.5-80.3) 45.25 (12-101) 0.1643 kg (Range) Acute nonperforated 12 (63%) 13 (70%) 0.8313 appendicitis Interval 6 (31.6%) 1 (5%) 0.346 appendectomy Mean OR time, min 58 ± 5.6 41.5 ± 3.2 Median OR time, 53 (30-135) 37.5 (30-85) 0.0045 min Conversions 2 (10%) 0 Complications 1 (5%) 0 Median length of stay, d 1 (1-3) 1 (1-6)
1210 S.C. Oltmann et al. weight of 32 kg (14.5-80.3 kg), in comparison with our LAP- A population that was 60% male (n = 12) and had a median weight of 45.25 kg (12-101 kg). Although both groups had an equivalent number of acute nonperforated appendicitis cases (60%), approximately 32% of the SILS-A were performed as an interval procedure, compared with only 5% of the LAP-A (P =.0346). Median operative time for SILS-A was 53 minutes (30-135 minutes), compared with that for the LAP-A group that was 38 minutes (30-85 minutes, P =.0045) (Table 1). Two SILS-A patients were converted to a transumbilical approach (10%), one secondary to dense adhesions and the other secondary to inability to maintain a pneumoperitoneum. This did not result in any change in skin incision size, and the final incision remained along the border of the umbilicus. None of the LAP-A patients required conversion. One SILS-A complication was noted, a wound seroma that was successfully managed expectantly. No complications were noted in the LAP-A group. No readmissions, intraabdominal abscesses, or hernias were noted on follow-up for either group. Median follow-up to date is 6½ months (5-10½ months), with no evidence of the development of incisional hernia. 3. Discussion We report on the first pediatric series of a pure SILS approach for appendectomy in the pediatric population. Previously reported series in the pediatric population used a modified approach with the use of a suture sling [1]. In addition, a few reports have been published in the adult literature demonstrating the feasibility of this approach [5,9]. Comparing our experience with the previously reported 38 patients with a modified SILS approach by Ateş et al [1], we have a smaller study size, but include patients as young as 19 months of age, where abdominal domain is limited. To maximize instrument work space within the peritoneal cavity, a to-and-fro movement involving insertion and withdrawal of the instrument through the port is used. This makes up for the limited lateral movement available with a SILS approach, in addition to the smaller abdominal domain of the child. The patient demographics of the SILS-A group and the LAP-A group were comparable, with similar age, weight, and sex distributions. Most patients from both groups had acute nonperforated appendicitis; however, the SILS-A approach was used with greater frequency for interval appendectomy (32% vs 5%, P =.0346). Although interval appendectomy is performed in an elective setting, the operation is not technically easier than that for acute nonperforated appendicitis because of adhesions. The fact that the interval appendectomy can be successfully performed with a SILS approach further supports its feasibility as an operative option in the pediatric population. During our study period, median operative times between our groups (53 vs 38 minutes, P =.0045) differed significantly, although both were comparable with nationally reported LAP-A times [17]. As this is very early in our experience with this technique, the prolonged time reflects the learning curve of the surgeon and the OR staff who are just becoming familiar with the SILSspecific instrumentation needs. With more experience, we anticipate operative times for SILS-A to become comparable with LAP-A in the near future. The median time was 62 minutes for our first 12 cases and 40 minutes for our last 7. Advanced LAP skills are needed for this approach, as the ability to triangulate the instruments (done with traditional laparoscopy) is lost owing to the clustered location of the ports at a single skin incision. The clustered ports also result in potential for clashing of instruments both externally and internally. To minimize the bulk associated with the camera, a 90 light source is attached to allow the cords to run parallel with the instruments instead of perpendicular to it (Fig. 1). Visualization with the camera is also altered from traditional laparoscopy, as it is looking parallel to the working instruments. Angled lenses and articulating LAP instruments and/or cameras can help overcome this challenge, but come with their own learning curve. Articulating instruments may be of limited use in the toddler and preschool population, as the working space within their small abdomens is unlikely to accommodate the additional room needed for the manipulation of these tools. As shown with the evolution of our technique, those first learning SILS should initially work with a modified approach. This allows the surgeon to adjust to the unique technical challenges of the SILS approach. As the surgeon improves his or her skills, he or she can gradually decrease the number of separate port sites until all can be contained within the same incision. The result is Fig. 1 External view of ports clustered at the umbilicus. Note close proximity of instrument handles, as well as the 90 light source (white arrow).
SILS for pediatric appendectomies Fig. 2 minimization of the surgical scar to fit within the confines of the umbilicus (Fig. 2). Within the pediatric literature, few uses have been published for SILS approach, whereas the general surgery literature describes appendectomy, cholecystectomy, colectomy, and adjustable gastric banding [5-9]. For the pediatric patient, multiple additional procedures have potential for SILS approach [1-4,16]. Pediatric surgeons need to play an active role in the developing the SILS approach for these additional procedures, as well as encouraging the industry to produce instruments specific to pediatric needs. Currently, there are 2 different methods for singleincision access. One involves the use of traditional, lowprofile LAP ports that are clustered within a single skin incision but enter the peritoneal cavity through separate fascial incisions, as we have described here. Ports can be interchanged and adjusted to fit the needs of the procedure, and the fascial incisions remain small. The second method involves the use of specialized ports created to provide multiple channels through a single port for one, larger fascial incision. The SILS port (Covidien) currently comes in only one size/dimension intended for adult patients. It may prove to be too cumbersome for smaller patients, and the larger fascial incision may result in greater postoperative pain. In conclusion, SILS-A is both feasible and safe across the pediatric age range. Larger prospective trials are warranted to establish criteria and optimal techniques and to document improved operative times before its widespread application in the pediatric population. References Postoperative incision, 1 month after surgery. [1] Ateş O, Hakgüder G, Olguner M, et al. Single-port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture. J Pediatr Surg 2007;42:1071-4. [2] Ponsky TA, Lukish JR. Single site laparoscopic gastrostomy with a 4-mm bronchoscopic optical grasper. J Pediatr Surg 2008;43:412-4. [3] Ostlie DJ, Miller KA, Woods RK, et al. Single cannula technique and robotic telescopic assistance in infants and children who require laparoscopic Nissen fundoplication. J Pediatr Surg 2008;38:111-5. [4] Martinez-Ferro M, Duarte S, Laje P. Single port thoracoscopy for the treatment of pleural empyema in children. J Pediatr Surg 2004;39: 1194-6. [5] Nguyen NT, Reavis KM, Hinojosa MW, et al. A single-port technique for laparoscopic extended stapled appendectomy. Surg Innov 2009;16: 78-81. [6] Oltmann SC, Rivas H, Varela E, et al. Single-incision laparoscopic surgery: case report of SILS adjustable gastric banding. Surg Obes Relat Dis 2009;5:362-4. [7] Ersin S, Firat O, Sozbilen. Single-incision laparoscopic cholecystectomy: is it more than a challenge? Surg Endosc 2009 [in press]. [8] Merchant AM, Lin E. Single-incision laparoscopic right hemicolectomy for a colon mass. Dis Colon Rectum 2009;52:1021-4. [9] Hong TH, Kim HL, Lee YS, et al. Transumbilical single-port laparoscopic appendectomy (TUSPLA): scarless intracorporeal appendectomy. J Laparoendo Adv Surg Tech 2009;19:75-8. [10] Nguyen NT, Hinojosa MW, Smith BR, et al. Single laparoscopic incision transabdominal (SLIT) surgery adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg 2008;18: 1628-31. [11] Teixeira J, McGill K, Binenbaum S, et al. Laparoscopic single-site surgery for placement of an adjustable gastric band: initial experience. Surg Endosc 2009; in press. [12] Desai MM, Rao PP, Aron M, et al. Scarless single port transumbilical nephrectomy and pyeloplasty: first clinical report. BJU Int 2008;101: 83-8. [13] Ponsky LE, Cherullo EE, Sawyer M, et al. Single access site laparoscopic radical nephrectomy: initial clinical experience. J Endourol 2008;22:1-3. [14] Goel R, Kaouk J. Single port access renal cryoablation (SPARC): a new approach. Eur Urol 2008;53:1204-9. [15] Raman JD, Cadeddu JA, Rao P, et al. Single-incision laparoscopic surgery: initial urological experience and comparison with naturalorifice transluminal endoscopic surgery. BJU Int 2008. [16] Kaouk J, Palmer J. Single-port laparoscopic surgery: initial experience in children for varicocelectomy. BJU Int 2008;102:97-9. [17] Aziz O, Athanasiou T, Tekkis PP, et al. Laparoscopic versus open appendectomy in children a meta-analysis. Ann Surg 2006;243:17-27. Discussion 1211 Andrew Holland (Sydney, Australia): I noticed that you had caught a number of interval appendectomies and the indications for those remain controversial. Were those patients who required conversion to open procedure the patients that were having interval appendectomies or in the acute group? Sarah Oltmann, MD (Dallas, TX) (response): They were actually in the acute group. The difficulty in maintaining pneumoperitoneum was secondary to the port being placed a little bit too close together, causing a leak. Andrew Holland, MD: Are interval appendectomies a routine practice at your institution? Sarah Oltmann, MD (response): It's dependent on the attending surgeon. If the appendix is perforated and the
1212 S.C. Oltmann et al. child is very sick with evidence of a large fluid collection intraabdominally, there is a consistent approach to initially attempt interval appendectomy. If the patient doesn't improve with drainage at that point, then he would undergo appendectomy. Steven Stylianos, MD (Miami, FL): At Miami Children's, we operate on 500 children per year with appendicitis; and the overwhelming majority are done with an old-fashioned sidearm scope. We pull the appendix through the umbilicus, and the procedure takes about 18 to 20 minutes.