LETTER TO THE EDITOR Randomized Prospective Study to Compare Laparoscopic Appendectomy Versus Umbilical Single-incision Appendectomy To the Editor: ingle-incision laparoscopic surgery represents one of the current technical advances in minimally invasive surgery. Technical or therapeutic advances must confer benefits to our patients to justify their widespread implementation. I do not believe that the available randomized data provide evidence for an acceptable safety profile on the subject of single-incision appendectomy (SIA). This is in contrast to your conclusion.1 In regard of the immediate perioperative complications, you find no statistically
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significant difference between SIA and conventional laparoscopic appendectomy (CLA). You state that damage to the epigastric vessels is avoided in SIA. I do not dispute that, but in CLA first access to the peritoneum is achieved through the umbilicus while parietal trocar penetration lateral to the umbilicus can be done under video endoscopic guidance, avoiding damage to the epigastric vessels. You find a significant difference in postoperative pain, but also conclude that the clinical significance is more dubious, because the length of admission is not affected by this. I fail to find a notion on the length of your follow-up, although you mention that patients were enrolled in the period September 2009 to December 2010, and complications were divided into early (30 days), making the “true” incidence of incisional hernias impossible to determine. I believe that most surgeons agree that the average temporal dissociation between
surgical intervention and development of incisional hernia is at least some months (years, maybe?). Your results are interesting, but I fail to see the real advantages compared to CLA. If the true complication rate can be proven to be comparable to CLA, then the improved cosmesis and the marginally lesser postoperative pain would alone be strong arguments in favor of the single-incision approach. But safety must always outweigh cosmetic considerations. Anders Mark Christensen, BSc Aarhus University Hospital Aarhus C, Denmark [email protected]
REFERENCES 1. Frutos D, Abrisqueta J, Lujan J, et al. Randomized prospective study to compare laparoscopic appendectomy versus umbilical single-incision appendectomy. Ann Surg. 2013;257:413–418.
Disclosure: The author declares no potential conflicts of interest or financial ties to disclose. C 2013 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/13/26106-e0164 DOI: 10.1097/SLA.0000000000000452
e164 | www.annalsofsurgery.com
Annals of Surgery r Volume 261, Number 6, June 2015
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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significant difference between SIA and conventional laparoscopic appendectomy (CLA). You state that damage to the epigastric vessels is avoided in SIA. I do not dispute that, but in CLA first access to the peritoneum is achieved through the umbilicus while parietal trocar penetration lateral to the umbilicus can be done under video endoscopic guidance, avoiding damage to the epigastric vessels. You find a significant difference in postoperative pain, but also conclude that the clinical significance is more dubious, because the length of admission is not affected by this. I fail to find a notion on the length of your follow-up, although you mention that patients were enrolled in the period September 2009 to December 2010, and complications were divided into early (30 days), making the “true” incidence of incisional hernias impossible to determine. I believe that most surgeons agree that the average temporal dissociation between
surgical intervention and development of incisional hernia is at least some months (years, maybe?). Your results are interesting, but I fail to see the real advantages compared to CLA. If the true complication rate can be proven to be comparable to CLA, then the improved cosmesis and the marginally lesser postoperative pain would alone be strong arguments in favor of the single-incision approach. But safety must always outweigh cosmetic considerations. Anders Mark Christensen, BSc Aarhus University Hospital Aarhus C, Denmark [email protected]
REFERENCES 1. Frutos D, Abrisqueta J, Lujan J, et al. Randomized prospective study to compare laparoscopic appendectomy versus umbilical single-incision appendectomy. Ann Surg. 2013;257:413–418.
Disclosure: The author declares no potential conflicts of interest or financial ties to disclose. C 2013 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/13/26106-e0164 DOI: 10.1097/SLA.0000000000000452
e164 | www.annalsofsurgery.com
Annals of Surgery r Volume 261, Number 6, June 2015
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
