Systematic review

Systematic review and meta-analysis of single-incision versus conventional multiport appendicectomy S. R. Markar1 , A. Karthikesalingam2 , F. Di Franco1 and A. M. Harris1 1

Department of Laparoscopic and Upper Gastro-Intestinal Surgery, Hinchingbrooke Healthcare NHS Trust, Huntingdon, and 2 Department of General Surgery, St George’s Hospital, London, UK Correspondence to: Mr S. R. Markar, Department of Laparoscopic and Upper Gastro-Intestinal Surgery, Hinchingbrooke Healthcare NHS Trust, Hinchingbrooke Park, Huntingdon PE29 6NT, UK (e-mail: [email protected]) Background: The aim of this systematic review and meta-analysis was to compare clinical outcomes

following single-incision laparoscopic appendicectomy (SILA) and conventional multiport laparoscopic appendicectomy (CLA) for the treatment of acute appendicitis. Methods: An electronic search of MEDLINE, Embase, Web of Science and Cochrane Library databases was performed. Publications were included if they were clinical trials randomizing patients with appendicitis to SILA or CLA. Outcome measures evaluated included operating time, length of hospital stay, total postoperative complications, and, specifically, wound infection, intra-abdominal collection and ileus. Weighted mean difference was calculated for the effect size of SILA on continuous variables, and pooled odds ratios were calculated for discrete variables. Results: The literature search identified seven randomized clinical trials that met the inclusion criteria for meta-analysis. In total, 1108 appendicectomies were included, 555 SILA and 553 CLA procedures. There were no significant differences between the groups in the incidence of total postoperative complications, wound infection, intra-abdominal collection, ileus or length of hospital stay. However, SILA was associated with a significantly longer operating time compared with CLA (weighted mean difference 6·96 (95 per cent confidence interval 3·79 to 10·12) min; P < 0·001). Insertion of an additional port was required in 7·6 per cent of patients undergoing SILA. Conclusion: SILA is a safe procedure for the treatment of acute appendicitis, with comparable clinical outcome to CLA when undertaken by experienced laparoscopic surgeons. Paper accepted 7 August 2013 Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9296

Introduction

The first laparoscopic appendicectomy for acute appendicitis was performed by Semm in 19831 . Since then there has been a steady increase in the uptake of laparoscopic appendicectomy2 , with the benefits including decreased postoperative wound infection, pain, length of hospital stay and an improved cosmetic result with less scarring and adhesion formation3,4 . Furthermore, laparoscopic appendicectomy has real clinical benefits in specific patient cohorts, including obese patients, children and elderly patients5 – 7 . In more recent years, surgeons have hypothesized that the benefits of laparoscopic surgery may be enhanced by reducing the number of abdominal incisions to one (singleincision laparoscopic surgery, SILS) or none (naturalorifice transluminal endoscopic surgery, NOTES). The published evidence regarding SILS has focused on cholecystectomy, as this is most commonly an elective procedure allowing randomization8 , where the laparoscopic  2013 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd

approach has demonstrated a clear benefit over open surgery9 . Appendicectomy for acute appendicitis is one of the most commonly performed surgical procedures10 , and thus single-incision laparoscopic appendicectomy (SILA) has become the subject of more recent investigation. To date there have been several randomized clinical trials (RCTs) with limited patient numbers, comparing SILA with conventional multiport laparoscopic appendicectomy (CLA). The aim of this systematic review and meta-analysis of these RCTs was to provide pooled results to allow comparison of clinical outcomes following SILA with the standard CLA for the treatment of acute appendicitis. Methods

An electronic search was performed using Embase, MEDLINE, Web of Science and the Cochrane Library (Issue 1, 2013) databases from 1966 to 2013. The search terms ‘laparoscopy’, ‘single incision’, ‘single port’, ‘single British Journal of Surgery 2013; 100: 1709–1718

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Studies identified from initial search n = 715

Duplicate records and records excluded after review of title and abstracts n = 676

Studies selected based on abstract and title search for full-text article assessment n = 39

Full-text articles excluded (not RCTs) n = 31

Full-text articles included in study n = 8

Studies excluded as subset analysis of previously reported series n = 1

Total studies included in data meta-analysis n = 7

PRISMA flow diagram showing the systematic search and selection strategy. RCT, randomized clinical trial

Fig. 1

site’ ‘SILS’, ‘LESS’, ‘Appendectomy’, ‘Appendicectomy’, ‘laparo-endoscopic’ and medical subject headings (MeSH) terms ‘Laparoscopy’(MeSH), ‘Appendectomy’(MeSH) and ‘Single incision’(MeSH) were used in combination with the Boolean operators AND or OR. Two authors performed electronic searches independently in March 2013. The electronic search was supplemented by a hand-search of published abstracts from meetings of the Surgical Research Society, Society of Academic and Research Surgery, Association of Surgeons of Great Britain and Ireland, Society of American Gastro-Intestinal and Endoscopic Surgeons, and European Association of Endoscopic Surgeons from 2005 to 2013. The reference lists of articles obtained were also searched to identify further relevant citations. Finally, the search included the Current Controlled Trials Register (http://www.controlled-trials. Table 1

com) and the Cochrane Database of Controlled Trials. Abstracts of the citations identified by the search were then scrutinized by two of the authors to determine eligibility for inclusion in the meta-analysis. Publications were included if they were RCTs in which patients underwent either singleincision (SILS or laparoendoscopic single-site surgery) or multiport appendicectomy. Studies were excluded if they were non-comparative, retrospective, observational or non-randomized, or concerned NOTES procedures. SILA was defined as laparoscopic appendicectomy performed by a single incision. This encompassed studies that used multiport devices and studies that used two or three individual ports through a single incision. Standard three-port laparoscopic appendicectomy was used as the control in all studies, with ports most commonly placed infraumbilically, suprapubically, or in the left lower quadrant or right lower quadrant. The primary outcome measures for the meta-analysis were total postoperative complications, operating time and length of hospital stay. A postoperative complication was defined as a complication developing within 30 days of the procedure and that occurred as a direct result of the surgery. Secondary outcome measures were specific complications including wound infection, intra-abdominal collection and postoperative ileus.

Statistical analysis Data from eligible trials were entered into a computerized spreadsheet for analysis. Statistical analysis was performed using StatsDirect version 2.5.7 (StatsDirect, Altrincham, UK). Weighted mean difference was calculated for the effect size of single-incision laparoscopy on continuous variables such as operating time and length of hospital stay. Pooled odds ratios were calculated for the effect of single-incision laparoscopy on discrete variables such as postoperative complications, wound infection, intra-abdominal collection and postoperative ileus.

Patient demographics No. of patients

Reference

Country

Frutos et al.13 Lee et al.14 Park et al.15 Perez et al.16 Sozutek et al.17 St Peter et al.18 Teoh et al.19

Spain Korea Korea USA Turkey USA Hong Kong

Age (years)*

Sex ratio (M : F)

BMI (kg/m2 )*

Jadad score

SILA

CLA

SILA

CLA

SILA

CLA

SILA

CLA

3 3 2 2 2 2 5

91 116 20 25 25 180 98

93 113 20 25 25 180 97

28·0(11·0) 28·4(15·4) 25·0 8·7(0·6) 30·6(12·4) 11·1(3·5) 39·2(15·6)

31·0(12·4) 28·5(17·2) 27·2 8·9(0·6) 30·0(11·0) 11·1(3·3) 40·7(15·7)

42 : 49 64 : 52 9 : 11 10 : 15 12 : 13 99 : 81 58 : 40

47 : 46 68 : 45 8 : 12 15 : 10 7 : 18 92 : 88 59 : 38

23·8(4·0) 21·4(43·2) – – 23·2(3·8) 19·4(4·9) –

24·0(3·8) 22·7(4·4) – – 23·1(2·6) 19·6(4·5) –

*Values are mean(s.d.). SILA, single-incision laparoscopic appendicectomy; CLA, conventional laparoscopic appendicectomy; BMI, body mass index.

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Table 2

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Single-incision laparoscopic appendicectomy procedure and histology of appendix Conversion to open procedure

Reference

SILA technique

Frutos et al.13

SILSTM port (Covidien, Mansfield, Massachusetts, USA) – triple entry port Octoport (Dalim Surgnet, Seoul, Korea) – triple entry port Surgical glove used as the single port with an extra-small wound retractor (ALEXIS wound retractor XS; Applied Medical, Rancho Santa Margarita, California, USA) Single supraumbilical skin incision and 3 × 5-mm fascial incisions in a triangular orientation at umbilicus SILSTM port (Covidien) – triple entry port Single vertical incision through centre of umbilicus and 2–3 × 5-mm fascial incisions 13-mm transumbilical incision; two 5-mm ports and one 10-mm port inserted

Lee et al.14 Park et al.15

Perez et al.16

Sozutek et al.17 St Peter et al.18 Teoh et al.19

Additional ports

Perforated/gangrenous/ abscess appendicitis

SILA

CLA

SILA

CLA

0 (0)

0 (0)

14 (15)

12 (13)

0 (0)

0 (0)

18 (15·5)

28 (24·8)

1 (5)

0 (0)

0 (0)

1 (5)

0 (0)



0 (0)

0 (0)

5 (20)

3 (12)

1 (4) 18 (10·0)

0 (0) 0 (0)

0 (0) 0 (0)

4 (16) 0 (0)

6 (24) 0 (0)



8 (8)

3 (3)

42 (43)

45 (46)

1 (1) 12 (10·3)

Values in parentheses are percentages. All specimens were extracted using a specimen bag in all studies. SILA, single-incision laparoscopic appendicectomy; CLA, conventional laparoscopic appendicectomy; SILS, single-incision laparoscopic surgery.

Table 3

Primary outcome measures Complications†

Operating time (min)* Reference Frutos et al.13 Lee et al.14 Park et al.15 Perez et al.16 Sozutek et al.17 St Peter et al.18 Teoh et al.19

Length of hospital stay (h)*

SILA

CLA

SILA

CLA

SILA

CLA

38·1(13·5) 43·8(21·3) 63·5(13·2) 46·8(4·0) 32·6(9·9) 35·2(14·5) 63·2(27·2)

32·1(12·4) 35·8(18·9) 54·0(12·5) 34·8(3·1) 29·5(6·8) 29·8(11·6) 60·2(31·7)

4 17 2 1 1 6 14

4 20 2 0 1 4 9

18·9(9·8) 72·0(13·9) 86·4 40·3 26·4(7·2) 22·7(6·2) 84·7(70·1)

21·3(11·7) 72·0(17·0) 93·6 36·7 28·8(19·2) 22·2(6·8) 76·8(56·6)

45 (8·1)

40 (7·2)

Total

Values in parentheses are percentages unless indicated otherwise; *values are mean(s.d.). †A postoperative complication was defined as a complication developing within 30 days of the procedure and which occurred as a direct result of the surgery. SILA, single-incision laparoscopic appendicectomy; CLA, conventional laparoscopic appendicectomy.

Table 4

Secondary outcome measures Wound infection

Reference Frutos et al.13 Lee et al.14 Park et al.15 Perez et al.16 Sozutek et al.17 St Peter et al.18 Teoh et al.19 Total

Intra-abdominal collection

Ileus

SILA

CLA

SILA

CLA

SILA

CLA

0 6 1 0 1 6 8

0 12 1 0 1 3 5

0 6 0 0 0 0 4

0 2 1 0 0 1 3

0 1 0 0 0 – 2

1 1 1 0 0 – 4

22 (4·0)

22 (4·0)

10 (1·8)

7 (1·3)

3 (0·8)

7 (1·9)

Values in parentheses are percentages. SILA, single-incision laparoscopic appendicectomy; CLA, conventional laparoscopic appendicectomy.

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All pooled outcome measures were determined using random-effects models as described by DerSimonian and Laird11 . Heterogeneity among trials was assessed by means of the Cochran Q statistic, a null hypothesis in which P < 0·050 is taken to indicate the presence of significant heterogeneity12 . Egger’s test was used to assess the funnel plot for significant asymmetry, an indication of possible publication or other bias.

Length of hospital stay Five studies13,14,17 – 19 reported data on length of hospital stay with standard deviations to permit analysis. Metaanalysis demonstrated no statistically significant difference between the groups (weighted mean difference −1·94 (95 per cent c.i. −5·08 to 1·21) h; P = 0·227) (Fig. 4). There was evidence of statistical heterogeneity (Cochran’s Q = 11·91; P = 0·018; I 2 = 66·4 per cent), but no evidence of bias (Egger = −1·03; P = 0·483).

Results

Secondary outcome measures

The literature search identified seven RCTs13 – 19 that met the inclusion criteria for meta-analysis. Fig. 1 shows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for the literature search. In total, 1108 appendicectomy operations were included, 555 by SILA and 553 by CLA. Table 1 outlines basic demographic data from each study, including patient age, male : female sex ratio and body mass index, which were similar between the groups. Table 2 provides a description of the SILA technique employed in each study, along with additional port insertion and description of appendix pathology. Tables 3 and 4 show the primary and secondary outcome results from each trial. Table 5 describes the inclusion and exclusion criteria for each study included in the meta-analysis.

Primary outcome measures Total postoperative complications The incidence of postoperative complications was reported in all seven studies13 – 19 . There were 45 complications (8·1 per cent) in the SILA group and 40 (7·2 per cent) in the CLA group. Meta-analysis demonstrated no statistically significant difference between the groups (pooled odds ratio 1·12, 95 per cent confidence interval (c.i.) 0·71 to 1·76; P = 0·631) (Fig. 2). There was no evidence of statistical heterogeneity (Cochran’s Q = 2·20; P = 0·901; I 2 = 0 per cent) or bias (Egger = 0·46; P = 0·404). Duration of surgery Duration of surgery was reported in all seven studies13 – 19 . Meta-analysis demonstrated a statistically significant increase in mean operating time for SILA compared with CLA (weighted mean difference 6·96 (95 per cent c.i. 3·79 to 10·12) min; P < 0·001) (Fig. 3). There was evidence of significant statistical heterogeneity (Cochran’s Q = 25·35; P < 0·001; I 2 = 76·3 per cent), but no evidence of bias (Egger = −2·37; P = 0·195).  2013 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd

Wound infection The incidence of postoperative wound infection was reported in all seven studies13 – 19 . There were 22 wound infections (4·0 per cent) in the SILA group and 22 (4·0 per cent) in the CLA group. Meta-analysis demonstrated no statistically significant difference between the groups (pooled odds ratio 0·99, 95 per cent c.i. 0·52 to 1·87; P = 0·977) (Fig. 5). There was no evidence of statistical heterogeneity (Cochran’s Q = 3·94; P = 0·415; I 2 = 0 per cent) or bias (Egger = 0·56; P = 0·703). Intra-abdominal collection The incidence of postoperative intra-abdominal collection was reported in all seven studies13 – 19 . There were ten collections (1·8 per cent) in the SILA group and seven (1·3 per cent) in the CLA group. Meta-analysis demonstrated no statistically significant difference between the groups (pooled odds ratio 1·39, 95 per cent c.i. 0·51 to 3·77; P = 0·519) (Fig. 6). There was no evidence of statistical heterogeneity (Cochran’s Q = 2·45; P = 0·485; I 2 = 0 per cent) or bias (Egger = −2·04; P = 0·146). Postoperative ileus The incidence of postoperative ileus was reported in six studies13 – 17,19 . There were three cases of ileus (0·8 per cent) in the SILA group and seven (1·9 per cent) in the CLA group. Meta-analysis demonstrated no statistically significant difference between the groups (pooled odds ratio 0·50, 95 per cent c.i. 0·14 to 1·70; P = 0·265) (Fig. 7). There was no evidence of statistical heterogeneity (Cochran’s Q = 0·35; P = 0·949; I 2 = 0 per cent) or bias (Egger = −0·18; P = 0·835). Additional port insertion during single-incision laparoscopic appendicectomy Meta-analysis of proportions showed that insertion of an additional port was required in 33 (7·6 per cent) of 432 SILA procedures (pooled proportion 0·07, 95 per cent c.i. 0·03 to 0·12). www.bjs.co.uk

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Table 5

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Inclusion and exclusion criteria

Reference

Inclusion criteria

Exclusion criteria

13

History of abdominal pain localized in right lower quadrant, or periumbilical pain, later focused to right lower quadrant, associated or not with nausea and/or vomiting

Patients with history of cirrhosis or coagulation alterations Patients with clinical or radiological suspicion or appendicular pathology complicated by an abscess and/or local or diffused peritonitis Patients with septic shock

Signs of peritoneal irritation and abdominal defence in exploration of abdomen Age above 11 years

14

History of right lower quadrant pain or periumbilical pain migrating to right lower quadrant with nausea and/or vomiting Fever greater than 38◦ C and/or leucocytosis or more than 10 000 cells/ml Right lower quadrant guarding and tenderness on physical examination Appendix ultrasonography or abdominopelvic computed tomography performed to confirm the diagnosis All patients aged 16 years or above

15

Diagnosis made using physical examinations, laboratory studies and imaging studies (abdominal ultrasonography and abdominal–pelvic computed tomography)

16

Diagnosis of appendicitis Symptom duration determined to be less than 2 days Patients over 18 years of age undergoing appendicectomy Clinical symptoms and laboratory findings accepted as the main factors in determining the surgical decision Findings verified with ultrasonography or abdominal computed tomography in cases of suspected appendicitis

17

18

Children under the age of 18 years who required appendicectomy

19

Patients admitted for suspected acute appendicitis Age between 18 and 75 years Patients with a history of right lower quadrant pain or periumbilical pain migrating to the right lower quadrant Presence of right lower quadrant guarding Tenderness on physical examination Fever above 38◦ C and/or white cell count greater than 10 × 103 cells/ml

Discussion

Advocates of SILA have suggested that fewer abdominal incisions will increase the benefits of laparoscopic surgery  2013 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd

Patients with contraindications to laparoscopic surgery Patients with contraindications to general anaesthesia Pregnant patients Patients unable to sign informed consent form because of a mental disorder Patient’s refusal of laparoscopic surgery Abdominopelvic computed tomography or ultrasonography indicating intra-abdominal abscess History of cirrhosis and/or coagulation disorders and/or haemodynamically unstable patients Other contraindications to laparoscopic surgery or contraindications to general anaesthesia (severe cardiac and/or pulmonary disease) Inability to give informed consent owing to mental disability Pregnancy Appendiceal neoplasm Incomplete medical records History of cirrhosis or coagulation disorder Shock on admission Large ventral hernia History of laparotomy Severe cardiac or pulmonary disease Mental disability Pregnancy Complicated appendicitis (5 patients); perforated or abscess

Patients aged less than 18 years American Society of Anesthesiologists grade IV or V Pregnancy Anticoagulant therapy Negative intraoperative finding or abdominal finding other than appendicitis during surgery Patients found to have perforated appendicitis at laparoscopic appendicectomy Diagnosis of appendicitis was not clinically established Symptoms of more than 5 days and/or a palpable mass in right lower quadrant suggesting an appendiceal mass History of cirrhosis and coagulation disorders Generalized peritonitis Shock on admission Previous abdominal surgery Ascites Suspected or proven malignancy Contraindication to general anaesthesia (severe cardiac and/or pulmonary disease) Inability to give informed consent Pregnancy

including less postoperative pain, shorten the length of hospital stay and improve cosmesis20 . Surgeons who are sceptical regarding the merits of SILA suggest that it violates the principles of laparoscopic surgery, with no www.bjs.co.uk

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Odds ratio

Odds ratio

13

Frutos et al.

1·02 (0·18, 5·67)

Lee et al.14

0·80 (0·37, 1·72)

Park et al.15

1·00 (0·07, 15·21)

Perez et al.16

3·12 (0·03, infinity)

Sozutek et al.17

1·00 (0·01, 81·73)

St Peter et al.18

1·52 (0·35, 7·43)

Teoh et al.19

1·63 (0·62, 4·50)

Combined

1·12 (0·71, 1·76) 0·1 0·2

0·01

0·5

1

2

5

10

Increased in CLA

100

Increased in SILA

Forest plot comparing the incidence of postoperative complications following single-incision laparoscopic appendicectomy (SILA) versus conventional multiport laparoscopic appendicectomy (CLA). A DerSimonian–Laird random-effects model was used. Odds ratios are shown with 95 per cent confidence intervals (pooled odds ratio 1·12 (0·71 to 1·76); P = 0·631)

Fig. 2

Weighted mean difference

Weighted mean difference 13

13

Frutos et al.

Frutos et al.

14

Lee et al.

Lee et al.14 15

Park et al.

Sozutek et al.17

Perez et al.16

St Peter et al.18

Sozutek et al.17 St Peter et al.18

Teoh et al.19

19

Teoh et al.

Combined Combined −10

0

Increased in CLA

10

−10 −20 Increased in CLA

100

0

10

30 20 Increased in SILA

Increased in SILA

Forest plot comparing length of hospital stay for single-incision laparoscopic appendicectomy (SILA) versus conventional multiport laparoscopic appendicectomy (CLA). A DerSimonian–Laird random-effects model was used. Weighted mean differences are shown with 95 per cent confidence intervals (pooled weighted mean difference −1·94 (−5·08 to 1·21) h; P = 0·227)

Fig. 4

Forest plot comparing mean operating time for single-incision laparoscopic appendicectomy (SILA) versus conventional multiport laparoscopic appendicectomy (CLA). A DerSimonian–Laird random-effects model was used. Weighted mean differences are shown with 95 per cent confidence intervals (pooled weighted mean difference 6·96 (3·79 to 10·12) min; P < 0·001)

Fig. 3

instrument triangulation, poor ergonomics and increased operating time21 . Currently there is heterogeneity in the techniques employed for SILS, including the insertion of a triport device through a single fascial incision or multiple fascial incisions with the insertion of two or three 5-mm ports. A systematic review and pooled analysis of

nine non-randomized studies comparing SILA with CLA demonstrated no significant differences in operating time, length of hospital stay, pain scores, or conversion and complication rates22 . The authors concluded that there was a need for RCTs to clarify the potential benefits of SILA.

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Odds ratio

Odds ratio

13

Frutos et al.

(excluded)

Lee et al.14

0·46 (0·14, 1·39)

Park et al.15

1·00 (0·01, 82·58)

Perez et al.16

(excluded)

Sozutek et al.17

1·00 (0·01, 81·73)

St Peter et al.18

2·03 (0·43, 12·74)

Teoh et al.19

1·64 (0·45, 6·59)

Combined

0·99 (0·52, 1·87) 0·01

0·1 0·2

0·5

1

2

5

Increased in CLA

10

100

Increased in SILA

Forest plot comparing the incidence of wound infections following single-incision laparoscopic appendicectomy (SILA) versus conventional multiport laparoscopic appendicectomy (CLA). A DerSimonian–Laird random-effects model was used. Odds ratios are shown with 95 per cent confidence intervals (pooled odds ratio 0·99 (0·52 to 1·87); P = 0·977)

Fig. 5

Odds ratio

Odds ratio

Frutos et al.13 Lee et al.

(excluded)

14

3·03 (0·52, 31·16)

Park et al.15

0·32 (0·00, 39·00)

Perez et al.16

(excluded) 17

(excluded)

18

0·33 (0·00, 39·00)

Sozutek et al. St Peter et al. 19

Teoh et al.

1·33 (0·22, 9·34)

Combined

1·39 (0·51, 3·77) 0·2

0·5

1

2

Increased in CLA

5

10

100 Increased in SILA

Forest plot comparing the incidence of intra-abdominal collection following single-incision laparoscopic appendicectomy (SILA) versus conventional multiport laparoscopic appendicectomy (CLA). A DerSimonian–Laird random-effects model was used. Odds ratios are shown with 95 per cent confidence intervals (pooled odds ratio 1·39 (0·51 to 3·77); P = 0·519)

Fig. 6

The aim of the present systematic review and metaanalysis of RCTs was to compare clinical outcomes following SILA and CLA for the treatment of acute appendicitis. The meta-analysis demonstrated no significant differences between the groups in the overall incidence of postoperative complications, and specifically of wound infection, intra-abdominal collection, ileus and length of hospital stay. These results suggest that SILA is a safe procedure with similar postoperative outcomes to

those of CLA. The only observed difference between the groups was the longer operating time associated with SILA. This may be due to the lack of triangulation and inefficient ergonomics associated with SILA, which make it a more technically challenging procedure than CLA. However, it is also important to note that there is a learning curve and often the need for new or modified instrumentation associated with the adoption of a new surgical technique23,24 , which may in part be responsible

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Odds ratio

Odds ratio

Frutos et al.13

0·34 (0·00, 39·86)

Lee et al.14

0·97 (0·01, 77·12)

Park et al.15

0·32 (0·00, 39·00)

Perez et al.16

(excluded)

Sozutek et al.17

(excluded)

Teoh et al.19

0·48 (0·04, 3·48)

Combined

0·50 (0·14, 1·70) 0·01

0·1 0·2

0·5

Increased in CLA

1

2

5

10

100

Increased in SILA

Forest plot comparing the incidence of ileus following single-incision laparoscopic appendicectomy (SILA) versus conventional multiport laparoscopic appendicectomy (CLA). A DerSimonian–Laird random-effects model was used. Odds ratios are shown with 95 per cent confidence intervals (pooled odds ratio 0·50 (0·14 to 1·70); P = 0·265)

Fig. 7

for the result seen in this meta-analysis. Sozutek and colleagues17 noted a reduction in the mean operating time for SILA, from 55 to 32 min, during their study. Previously the present authors have demonstrated, by meta-analysis of RCTs, no significant differences in postoperative outcomes for single-incision laparoscopic cholecystectomy and conventional multiport laparoscopic cholecystectomy8 . However, as in the present study, the only difference between the groups was a significantly increased operating time for SILS. A further important confounding variable was the operating surgeons’ previous laparoscopic experience. Six13 – 16,18,19 of the seven studies described the previous experience of the operating surgeons, all of whom were attending or consultant surgeons. Two studies15,19 also provided information on previous laparoscopic experience, which was more than 100 laparoscopic procedures for all attending surgeons participating in the trial. The evidence presented in this meta-analysis suggests that surgeons with an extensive laparoscopic experience can perform SILA safely. However, there is currently no strong evidence to support the widespread application of SILA to general surgical practice, where appendicectomy is one of the most commonly performed emergency operations, often performed by surgeons in training. Clearly the ability of surgeons in training to learn the SILS approach is an area for future investigation, particularly regarding appendicectomy, along with the learning curve required for proficiency. The contraindication to meta-analysis of postoperative pain in this study was the heterogeneous methodology

employed for pain assessment in the included studies, which did not allow meaningful pooled analysis. However, all seven studies did provide some method of pain assessment in the postoperative period, with mixed results suggesting that SILA does not improve postoperative pain when compared with CLA. Three studies15,18,19 demonstrated increased postoperative pain associated with SILA, three14,16,17 showed similar postoperative pain between the groups, and only one study13 suggested that SILA reduced postoperative pain compared with CLA. It is important to note that only one of the studies included in this analysis was a double-blind trial19 , and thus patients’ assessment of pain may be increased by the larger umbilical skin incision associated with SILA. Of the seven randomized studies included in this meta-analysis, only three14,15,19 included an assessment of cosmetic outcome. Lee and co-workers14 used a fivepoint patient cosmetic satisfaction scale and demonstrated similar scores for both groups (4·0 for SILA versus 3·3 for CLA; P = 0·128). Similarly, Park et al.15 used a four-point scale to assess patient cosmetic satisfaction and showed no significant difference between the groups. Teoh and colleagues19 used a 100-point scale and demonstrated that SILA was associated with significantly improved wound cosmetic and patient satisfaction scores. This may suggest that future studies in this area should attempt to use more sophisticated cosmetic and patient satisfaction assessment tools if subtle differences between SILA and CLA are to be elucidated. Two studies16,18 that contributed 410 children were included in this meta-analysis, and clearly the final

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cosmetic result of SILA cannot be ascertained in paediatric studies until the child has reached 18 years of age and the scar has grown with the patient. Assessment of cosmetic outcome and port-site herniation requires the commitment to long-term follow-up by surgeons performing SILA in children, and is an important area for future assessment. A further important consideration in choice of technique for appendicectomy is treatment cost-effectiveness. St Peter and co-workers18 were the only group to review cost as part of the analysis, and demonstrated significantly increased hospital charges associated with SILA: ¤13 110 ± 2980 (US$17 600 ± 4000; exchange rate 20 August 2013) versus ¤12 365 ± 2905 (US$16 600 ± 3900) for CLA (P = 0·005). Presumably this is due to a combination of equipment costs and increased operating time. Clearly further studies that factor in equipment, operative, analgesia and hospital costs are required to evaluate fully the cost-effectiveness of SILA compared with CLA. SILA violates the principles of laparoscopic surgery as it does not allow instrument triangulation. This often results in poor ergonomics, which may be reflected by the increased operating time seen for SILA, and also by the insertion of an additional port in 7 per cent of SILA procedures, even in the hands of experienced laparoscopic surgeons with a low open conversion rate. It is also important to acknowledge that there was a large degree of heterogeneity in the technique described as SILA within the studies included in this meta-analysis. There is currently little evidence available regarding the effectiveness of SILA in specific challenging patient cohorts, including obese and elderly patients, and those with multiple medical co-morbidities. This would be an interesting area of future research, given previous publications by the authors’ group5,7 demonstrating that the benefits of laparoscopic appendicectomy are maximized in obese and elderly patients. Some authors use a multiport device through a single fascial incision for the insertion of laparoscopic instruments, whereas others use three separate trocars through multiple fascial incisions. Both of these techniques may lead to weakening of the fascia, which in turn can lead to an increased incidence of incisional portsite hernia25 . This has not been demonstrated conclusively in previous studies26 , but may be a reflection of the shortterm follow-up methodology employed in most of the current literature regarding SILS. If SILA is to be practised more commonly, especially in children, the potential increased risk of port-site herniation must be a component of the consent process, and is an important area for future assessment in studies with longer-term follow-up. Given the low complication rate associated with standard multiport laparoscopic appendicectomy from the studies

included in this analysis, it may be difficult to demonstrate clearly an objective benefit to the use of SILS for acute appendicitis. Furthermore, it is important in emergency procedures such as appendicectomy not to sacrifice patient safety and clinical outcome in the search for improvements in more subjective outcome measures, such as cosmesis. An additional benefit of SILA, which was seen with CLA, is that it may serve as a useful training procedure to allow surgeons to gain greater proficiency before undertaking more complex SILS procedures, including colorectal resections and bariatric procedures, in the future. The results of this meta-analysis suggest that in the hands of experienced laparoscopic surgeons SILA can be performed safely and with similar postoperative outcomes to CLA. However, SILA is associated with a significantly increased operating time, and there is a need for future studies to examine the cost-effectiveness of this approach and the incidence of long-term complications such as port-site hernia.

 2013 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd

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Disclosure

The authors declare no conflict of interest. References 1 Semm K. Endoscopic appendectomy. Endoscopy 1983; 15: 59–64. 2 Tsui C, Klein R, Garabrant M. Minimally invasive surgery: national trends in adoption and future directions for hospital strategy. Surg Endosc 2013; 27: 2253–2257. 3 Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010; (10)CD001546. 4 Ouaissi M, Gaujoux S, Veyrie N, Deneve E, Brigand C, Castel B et al. Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature. J Visc Surg 2012; 149: e104–e114. 5 Southgate E, Vousden N, Karthikesalingam A, Markar SR, Black S, Zaida A. Laparoscopic vs open appendectomy in older patients. Arch Surg 2012; 147: 557–562. 6 Markar SR, Blackburn S, Cobb R, Karthikesalingam A, Evans J, Kinross J et al. Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children. J Gastrointest Surg 2012; 16: 1993–2004. 7 Markar SR, Venkat-Raman V, Ho A, Karthikesalingam A, Kinross J, Evans J et al. Laparoscopic versus open appendicectomy in obese patients. Int J Surg 2011; 9: 451–455. 8 Markar SR, Karthikesalingam A, Thrumurthy S, Muirhead L, Kinross J, Paraskeva P. Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy:

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British Journal of Surgery 2013; 100: 1709–1718

Systematic review and meta-analysis of single-incision versus conventional multiport appendicectomy.

The aim of this systematic review and meta-analysis was to compare clinical outcomes following single-incision laparoscopic appendicectomy (SILA) and ...
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