Pediatr Surg Int DOI 10.1007/s00383-015-3680-5
ORIGINAL ARTICLE
Single-incision versus conventional laparoscopic appendicectomy in children: a systematic review and meta-analysis Lingling Zhao • Zhenqi Liao • Shaoguang Feng Peng Wu • Guorong Chen
•
Accepted: 3 February 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Single-incision laparoscopic appendectomy (SILA) has been considered as an alternative to conventional laparoscopic appendectomy (CLA). The aim of this systematic review and meta-analysis was to compare clinical outcomes between single-incision laparoscopic appendicectomy and conventional laparoscopic appendicectomy in children. Methods An electronic search of EMBASE, PubMed, MEDLINE was performed. Operative time, length of hospital stay, postoperative complications including wound infection, intra-abdominal infection, ileus in SILA and CLA were pooled and compared by meta-analysis. Results Twelve studies (4 randomized controlled trials, 1 prospective study and 7 retrospective studies) that included 2,109 pediatric patients were studied. Of these patients, 933 and 1,176 patients had undergone SILA and CLA, respectively. There was significant shorter length of hospital stay for SILA compared with CLA in children; however, pooling the results for SILA and CLA revealed no significant difference in operative time and postoperative complications.
L. Zhao G. Chen (&) Department of Pathology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China e-mail: [email protected]; [email protected] Z. Liao Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou 215000, Jiangsu, China S. Feng P. Wu Department of Pediatric Surgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
Conclusion Compared with CLA, SILA has the advantage of shorter hospital stay. However, SILA failed to show any obvious advantages over CLA in operative time and postoperative complications including wound infection, intra-abdominal infection, and ileus. Keywords Laparoscopic appendectomy Single-incision Meta-analysis Children
Introduction As surgical techniques have developed and the demand for procedures that cause less pain and have better cosmetic outcome, more and more surgeons draw their attention to minimally invasive techniques. The single-incision laparoscopic appendectomy (SILA) was first reported in 1992 and quickly became a novel member of the minimally invasive surgery [1]. It has been regarded as the next evolution in minimally invasive surgery field. SILA was usually performed through a single umbilical incision. Therefore, it can reduce the trauma of surgical access compared to traditional open and conventional laparoscopic appendectomy (CLA) [2]. Several studies have suggested that SILA is comparable to CLA in terms of operative time, length of hospital stay and complications. Besides, SILA was considered as having the potential of improving cosmesis, decreasing wound pain and shortening postoperative recovery compared with conventional laparoscopic appendectomy (CLA) [3–5]. Although SILA demonstrates some potential advantages over CLA and open appendectomy, some surgeons do not approve this surgical approach. Furthermore, considerable argument still exists regarding the real benefits of SILA over CLA in pediatric patients. Therefore, it remains
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unclear if SILA will actually decrease operative times, length of hospital stay or complication rates compared with CLA in children. Clinical outcomes following SILA and CLA in children with acute appendicitis were pooled to provide results for comparison in this systematic review and meta-analysis.
ratios (ORs). Statistical Heterogeneity was assessed using the Chi square test with significance set at P \ 0.10. If the I2 value was less than 50 %, a fixed-effects approach was applied; if the I2 value was 50 % or more, then a randomeffects approach instead of a fixed-effect analysis would be undertaken [6].
Materials and methods
Results
Search strategy
The initial search strategy identified 213 citations and 26 of them were retrieved for full text review. Twelve trials met total inclusion criteria (Fig. 1): Knott et al. [7], Perez et al. [8], St Peter et al. [9], Huang et al. [10], Uchida et al. [11], Nicole et al. [12], Lee et al. [13], Rocourt et al. [14], Langness et al. [15], Chandler et al. [16], Muensterer et al. [17], Kang et al. [18]. The 12 selected studies (4 randomized controlled trials, 1 prospective study and 7 retrospective studies) included 2,109 participants. Of these pediatric patients, 933 received SILA and 1,176 received CLA. Table 1 outlines basic demographic data from each included study, including study style, male:female sex ratio and BMI (kg/m2) or weight (kg) in each group. Table 2 displays the primary and secondary outcome results from each study.
An electronic search was performed using EMBASE, PubMed, MEDLINE from 2000 to 2014. The search terms single-incision, transumbilical, three-port, conventional, laparoscopic surgery, children and appendectomy were used individually and in combination. References, reviews and meta-analyses were then scanned for additional articles. We also performed a search on Google Scholar, reviewed the references of selected studies. Study selection Children with histologically confirmed acute appendicitis who received SILA or CLA were recruited. Inclusion criteria: (1) clinical trails that compared single-incision versus conventional laparoscopic appendicectomy between 2000 and 2014; (2) children younger than 18 years with acute appendicitis; (3) original data included some of the following: operative time, length of hospital stay, postoperative recovery, and postoperative complications. Exclusion criteria: (1) no conventional laparoscopic appendicectomy as a control; (2) chronic appendicitis; and (3) duplicate publication or study did not provide sufficient original data.
Primary outcome measures Operative time Operative time was reported in ten studies [7–11, 13, 15– 18]. Meta-analysis demonstrated no statistically significant in mean operating time for SILA compared with CLA (95 % CI -0.22 to 7.76; P = 0.06) (Fig. 2a). There was
Data extraction Two authors independently extracted data from the list of the included studies, and a third reviewer was required for a final decision in the case of any discrepancies. The primary objective of our analysis was to evaluate the operative time, length of hospital stay. Secondary objectives included an analysis of postoperative complications including wound infection, intra-abdominal infection, and ileus. Statistical analysis Review Manager (RevMan) software ver. 5.3 was used for data statistical analysis. For continuous variables, we calculated mean differences (MDs) with 95 % confidence intervals (CIs). For dichotomous variables, we used odds
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Fig. 1 Diagram of workflow in the systematic review
Pediatr Surg Int Table 1 Characteristics of the 12 selected studies Author (year)
Study style
Group
Age
SILA
CLA
SILA
CLA
Male/female
BMI (kg/m2) or weight (kg)
SILA
SILA
CLA
CLA
Knott et al. [7]
RCT
135
139
11.0 ± 3.5
10.9 ± 3.4
72:63
70:69
41.1 ± 26.4
44.7 ± 26.5
Perez et al. [8]
RCT
25
25
8.7 ± 0.6
8.9 ± 0.6
10:15
15:10
23.0 ± 3.1
22.8 ± 2.8
St Peter et al. [9]
RCT
180
180
11.1 ± 3.5
11.1 ± 3.3
99:81
92:88
19.4 ± 4.9
19.6 ± 4.5
Huang et al. [10]
RCT
30
30
8.9 ± 1.8
8.1 ± 2.4
18:12
19:11
27.6 ± 3.8
25.4 ± 4.7
Uchida et al. [11]
Retrospective
40
48
10.3 ± 2.60
10.5 ± 2.76
24:16
31:17
32.3 ± 9.75
33.7 ± 11.3
Nicole et al. [12]
Retrospective
122
41
11.2 ± 3.7
11.4 ± 3.4
69:53
26:15
NR
NR
Lee et al. [13] Rocourt et al. [14]
Prospective Retrospective
31 132
114 240
10.5 ± 3.6 9.4 ± 3.3
11.1 ± 4.1 10.1 ± 3.8
22:9 73:59
72:42 157:83
48.2 ± 18.4 NR
42.9 ± 17.1 NR
Langness et al. [15]
Retrospective
83
138
10.58
9.7
52:31
83:55
NR
NR
Chandler et al. [16]
Retrospective
50
45
11.1 ± 3.6
11.7 ± 3.8
26:24
34:11
43.3 ± 19
50.9 ± 29
Muensterer et al. [17]
Retrospective
75
151
11
NR
NR
NR
45
NR
Kang et al. [18]
Retrospective
30
25
9.3 ± 4.0
8.7 ± 3.5
17:13
14:11
NR
NR
RCT randomized controlled trial, NR not reported, SILA single-incision laparoscopic appendicectomy, CLA conventional laparoscopic appendicectomy
Table 2 The primary and secondary outcome of the 12 selected studies Author
Operative time (min)
Length of hospital stay (days)
Wound infection
SILA
SILA
CLA
SILA
CLA 3
CLA
Knott et al. [7]
34.00 ± 13.60
29.60 ± 13.6
0.92 ± 0.24
0.94 ± 0.3
2
Perez et al. [8]
46.80 ± 3.70
34.80 ± 2.50
NR
NR
1
0
St Peter et al. [9] Huang et al. [10]
35.20 ± 14.50 64.33 ± 3.11
29.80 ± 11.6 53.0 ± 2.88
0.95 ± 0.26 4.00 ± 0.84
0.92 ± 0.28 4.50 ± 1.17
6 0
3 0
0
2
Uchida et al. [11]
71.4 ± 37.4
73.0 ± 29.6
5.65 ± 2.53
6.80 ± 2.78
Nicole et al. [12]
NR
NR
2.0 ± 0.2
4.1 ± 0.6
Lee et al. [13]
41.8 ± 9.6
37.9 ± 11.7
2.6 ± 1.2
3.7 ± 1.9
1
6
Rocourt et al. [14]
NR
NR
NR
NR
1
1
Langness et al. [15]
42.8 ± 18.2
52.3 ± 24
1.3 ± 1.2
2.6 ± 3.5
Chandler et al. [16]
33.8 ± 9
26.3 ± 7.5
1.1 ± 0.4
1.2 ± 0.5
4
1
Muensterer et al. [17]
37 ± 12
44 ± 20
NR
NR
3
1
Kang et al. [18]
46.2 ± 18.5
40.5 ± 15.2
NR
NR
Intra-abdominal infection
Ileus
SILA
CLA
SILA
CLA
0
1
0
2
0
3
0
1
5
9
2
2
SILA single-incision laparoscopic appendicectomy, CLA conventional laparoscopic appendicectomy
evidence of significant statistical heterogeneity (I2 = 94 %). A sensitivity analysis was conducted where four studies were excluded and the meta-analysis of the remaining 6 studies shown a significant increase in mean operative time in SILA (Fig. 2b).
(Fig. 3). Statistical (I2 = 83 %).
heterogeneity
was
evidence
Secondary outcome measures Wound infection
Length of hospital stay Eight studies [7, 9–13, 15, 16] reported data on length of hospital stay with standard deviations to perform a metaanalysis. Meta-analysis demonstrated a statistically significant decrease in mean length of hospital stay for SILA compared with CLA (95 % CI -0.63 to 0.14; P = 0.002)
The incidence of postoperative wound infection was reported in eight studies [7–9, 11, 13, 14, 16, 17]. There were 18 wound infections (2.7 %) in the SILA group and 17 (1.8 %) in the CLA group. Meta-analysis demonstrated no statistically significant difference between the SILA and CLA group (95 % CI 0.77–3.01; P = 0.002) (Fig. 4).
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Fig. 2 a Forest plot comparing operative time for children treated with SILA versus CLA. b Sensitivity analysis of operative time for children treated with SILA versus CLA
Fig. 3 Forest plot comparing length of hospital stay for children treated with SILA versus CLA
There was no evidence of statistical heterogeneity (I2 = 0 %).
significant difference between the groups (95 % CI 0.42–2.61; P = 0.92) (Fig. 5) There was no evidence of statistical heterogeneity (I2 = 0 %).
Intra-abdominal infection Postoperative ileus The incidence of postoperative intra-abdominal infection was reported in three studies [8, 14, 17]. There were seven infection (1.8 %) in the SILA group and twelve (2.1 %) in the CLA group. Meta-analysis demonstrated no statistically
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The incidence of postoperative ileus was reported in three studies [8, 14, 17]. There were no case of ileus in the SILA group and six (3.2 percent) in the CLA group. Meta-
Pediatr Surg Int
Fig. 4 Forest plot comparing postoperative wound infection for children treated with SILA versus CLA
Fig. 5 Forest plot comparing postoperative intra-abdominal infection for children treated with SILA versus CLA
Fig. 6 Forest plot comparing postoperative ileus for children treated with SILA versus CLA
analysis demonstrated no statistically significant difference between each group (95 % CI 0.42–2.61; P = 0.21) (Fig. 6). There was no evidence of statistical heterogeneity (I2 = 0 %).
Discussion Acute appendicitis remains as one of the most common gastrointestinal emergency in children. Currently, laparoscopic surgery has been considered as the gold standard
procedure for many abdominal operations. Recently, with more and more surgeons focusing on single-incision laparoscopic surgery (SILS), this kind of surgical procedure has improved a lot in the minimally invasive surgical field [15]. Due to the advantage of reducing the trauma of surgical access and cosmetic benefits, single-incision laparoscopic appendicectomy (SILA) has been widely accepted in the past few years among surgeons [19, 20]. To evaluate the safety and efficacy of SILA in the treatment of pediatric appendicitis, the authors collected 12 published studies to perform a meta-analysis.
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The meta-analysis revealed no significant differences between SILA and CLA in the operative time and postoperative complications including wound infection, intraabdominal infection, and ileus. These results propose that SILA is a relative safe surgical procedure with similar postoperative outcomes compared with CLA. The obvious difference observed between the groups was the shorter length of hospital stay in SILA compared with CLA. This may be due to the fast recovery of gastrointestinal function in SILA. Besides, SILA may have the potential of decreasing wound pain and thus lead to shorter length of hospital stay because of the reduction of the number of incisions compared to CLA. Recently, a systematic review and meta-analysis conducted by Clerveus et al. [21] demonstrated SILA was associated with longer operative time than CLA. These differences could be mainly due to the complexity of the SILA technique and the lower overall experience with this technique among surgeons. Although our meta-analysis reveals no significant differences in mean operative time between two groups, a sensitivity analysis revealed a significant increase in mean operative time in SILA. Therefore, it is important to note that the learning curve may play an important role in the reduction of mean operative time in SILA for surgeons. For example, the study conducted by Sozutek and his colleagues [22] showed a reduction in the mean operating time for SILA from 55 to 32 min. Besides, the increasing of new or modified surgical techniques may in part be responsible for the shortening of operative time in SILA [23]. To fully assess the safety of SILA in pediatric patients, three complications were selected and analyzed in our meta-analysis. The meta-analysis revealed no significant difference between SILA and CLA in the incidences of wound infection, intra-abdominal infection and ileus. Several previous studies suggested the concern about higher risk of postoperative wound infection because of the extracorporeal appendectomy in SILA [24, 25], which appears to be the most serious complication to SILA [9]. However, our meta-analysis revealed that the incidences of wound infection were not significantly different, even when no specific measures were taken to protect the umbilical skin during division of the appendix [9]. Umbilical hernia may be regarded as another potential concern of single-incision laparoscopic surgery. In theory, the larger umbilical incision could lead to higher incidence of postoperative umbilical hernias, however, all of the twelve included studies showed no occurrence of umbilical hernia in both groups. This may be due to the fact that the followup in most studies was too short. Therefore, new studies with a longer follow-up should be performed. Our systematic review and meta-analysis does have some limitations. On one hand, the overall methodologic
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quality and reporting of the included trials in children was poor. Some included studies had rather small sample size. On the other hand, there was evidence of statistical heterogeneity among different studies in terms of operative time and length of hospital stay. In conclusion, our study suggests that SILA is a feasible and safe surgical procedure alternative to CLA for pediatric patients with appendicitis. It reveals significantly shorter hospital stay and potential comparable operative time, postoperative complications such as wound infection, intraabdominal infection, and ileus compared with CLA. However, most of the studies included in our meta-analysis were retrospective studies. Therefore, more prospective randomized controlled trials are needed in children to draw a more convincing conclusion.
References 1. Nguyen NT, Hinojosa MW, Smith BR et al (2008) Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg 18(12):1628–1631 2. Chow A, Purkayastha S, Nehme J et al (2010) Single incision laparoscopic surgery for appendicectomy: a retrospective comparative analysis. Surg Endosc 24(10):2567–2574 3. Cho MS, Min BS, Hong YK et al (2011) Single-site versus conventional laparoscopic appendectomy: comparison of shortterm operative outcomes. Surg Endosc 25:36–4010 4. Yu J, Wang YN, Hu YF et al (2011) Single-incision laparoscopic appendectomy performed above the pubic symphysis—a new scarless approach. Minim Invasive Ther Allied Technol 20:18–21 5. Raakow R, Jacob DA (2011) Initial experience in laparoscopic single-port appendectomy: a pilot study. Dig Surg 28:74–79 6. Hauser W, Bernardy K, Uceyler N et al (2009) Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA 301:198–209 7. Knott EM, Gasior AC, Holcomb GW 3rd et al (2012) Impact of body habitus on single-site laparoscopic appendectomy for nonperforated appendicitis: subset analysis from prospective, randomized trial. J Laparoendosc Adv Surg Tech 22(4):404–407 8. Perez EA, Piper H, Burkhalter LS et al (2013) Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis. Surg Endosc 27(4):1367–1371 9. St Peter SD, Adibe OO, Juang D et al (2011) Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial. Ann Surg 254(4):586–590 10. Wu K, Yang L, Wu A et al (2015) Single-site laparoscopic appendectomy in children using conventional instruments: a prospective, randomized, control trial. Pediatr Surg Int 31(2):167–171. doi:10.1007/s00383-014-3636-1 11. Deie Kyoichi, Uchida Hiroo, Kawashima Hiroshi et al (2013) Single-incision laparoscopic-assisted appendectomy in children:exteriorization of the appendix is a key component of a simple and cost-effective surgical technique. Pediatr Surg Int 29:1187–1191 12. Chandler Nicole M, Ghazarian Sharon R, King Tracy M et al (2014) Cosmetic outcomes following appendectomy in children: a comparison of surgical techniques. J Laparoendosc Adv Surg Tech 24(8):584–588
Pediatr Surg Int 13. Lee Seung Eun, Choi Yoo Shin, Kim Beom Gyu et al (2014) Single port laparoscopic appendectomy in children using glove port and conventional rigid instruments. Ann Surg Treat Res 86(1):35–38 14. Kulaylat AN et al (2014) Transumbilical laparoscopic-assisted appendectomy is associated with lower costs compared to multiport laparoscopic appendectomy. J Pediatr Surg. doi:10.1016/j. jpedsurg.2014.03.016 15. Langness SM, Hill SJ, Wulkan ML (2011) Single-site laparoscopic appendectomy: a comparison to traditional laparoscopic technique in children. Am Surg 77(7):961–964 16. Chandler NM, Danielson PD (2010) Single-incision laparoscopic appendectomy vs multiport laparoscopic appendectomy in children: a retrospective comparison. J Pediatr Surg 45:2186–2190 17. Muensterer OJ, Puga Nougues C, Adibe OO et al (2010) Appendectomy using single-incision pediatric endosurgery for acute and perforated appendicitis. Surg Endosc 24:3201–3204 18. Kang KC, Lee SY, Kang DB et al (2010) Application of single incision laparoscopic surgery for appendectomies in patients with complicated appendicitis. J Korean Soc Coloproctol 26:388–394 19. Ahmed K, Wang TT, Patel VM et al (2011) The role of singleincision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc 25(2):378–396
20. Vidal O, Valentini M, Ginesta` C et al (2010) Laparoendoscopic single-site surgery appendectomy. Surg Endosc 24:686–691 21. Clerveus Michael, Morandeira-Rivas Antonio, Moreno-Sanz Carlos et al (2014) Systematic review and meta-analysis of randomized controlled trials comparing single incision versus conventional laparoscopic appendectomy. World J Surg 38:1937–1946 22. Sozutek A, Colak T, Dirlik M, Ocal K, Turkmenoglu O, Dag A (2013) A prospective randomized comparison of single-port laparoscopic procedure with open and standard 3-port laparoscopic procedures in the treatment of acute appendicitis. Surg Laparosc Endosc Percutan Tech 23:74–78 23. Burjonrappa SC, Nerkar H (2012) Teaching single-incision laparoscopic appendectomy in pediatric patients. JSLS 16:619–622 24. Ponsky TA, Diluciano J, Chwals W et al (2009) Early experience with single-port laparoscopic surgery in children. J Laparoendosc Adv Surg Tech A 19:551–553 25. Garey CL, Laituri CA, Ostlie DJ et al (2011) Single incision laparoscopic surgery in children: one institution’s experience. J Pediatr Surg 46:904–907
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ORIGINAL ARTICLE
Single-incision versus conventional laparoscopic appendicectomy in children: a systematic review and meta-analysis Lingling Zhao • Zhenqi Liao • Shaoguang Feng Peng Wu • Guorong Chen
•
Accepted: 3 February 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Single-incision laparoscopic appendectomy (SILA) has been considered as an alternative to conventional laparoscopic appendectomy (CLA). The aim of this systematic review and meta-analysis was to compare clinical outcomes between single-incision laparoscopic appendicectomy and conventional laparoscopic appendicectomy in children. Methods An electronic search of EMBASE, PubMed, MEDLINE was performed. Operative time, length of hospital stay, postoperative complications including wound infection, intra-abdominal infection, ileus in SILA and CLA were pooled and compared by meta-analysis. Results Twelve studies (4 randomized controlled trials, 1 prospective study and 7 retrospective studies) that included 2,109 pediatric patients were studied. Of these patients, 933 and 1,176 patients had undergone SILA and CLA, respectively. There was significant shorter length of hospital stay for SILA compared with CLA in children; however, pooling the results for SILA and CLA revealed no significant difference in operative time and postoperative complications.
L. Zhao G. Chen (&) Department of Pathology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China e-mail: [email protected]; [email protected] Z. Liao Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou 215000, Jiangsu, China S. Feng P. Wu Department of Pediatric Surgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
Conclusion Compared with CLA, SILA has the advantage of shorter hospital stay. However, SILA failed to show any obvious advantages over CLA in operative time and postoperative complications including wound infection, intra-abdominal infection, and ileus. Keywords Laparoscopic appendectomy Single-incision Meta-analysis Children
Introduction As surgical techniques have developed and the demand for procedures that cause less pain and have better cosmetic outcome, more and more surgeons draw their attention to minimally invasive techniques. The single-incision laparoscopic appendectomy (SILA) was first reported in 1992 and quickly became a novel member of the minimally invasive surgery [1]. It has been regarded as the next evolution in minimally invasive surgery field. SILA was usually performed through a single umbilical incision. Therefore, it can reduce the trauma of surgical access compared to traditional open and conventional laparoscopic appendectomy (CLA) [2]. Several studies have suggested that SILA is comparable to CLA in terms of operative time, length of hospital stay and complications. Besides, SILA was considered as having the potential of improving cosmesis, decreasing wound pain and shortening postoperative recovery compared with conventional laparoscopic appendectomy (CLA) [3–5]. Although SILA demonstrates some potential advantages over CLA and open appendectomy, some surgeons do not approve this surgical approach. Furthermore, considerable argument still exists regarding the real benefits of SILA over CLA in pediatric patients. Therefore, it remains
123
Pediatr Surg Int
unclear if SILA will actually decrease operative times, length of hospital stay or complication rates compared with CLA in children. Clinical outcomes following SILA and CLA in children with acute appendicitis were pooled to provide results for comparison in this systematic review and meta-analysis.
ratios (ORs). Statistical Heterogeneity was assessed using the Chi square test with significance set at P \ 0.10. If the I2 value was less than 50 %, a fixed-effects approach was applied; if the I2 value was 50 % or more, then a randomeffects approach instead of a fixed-effect analysis would be undertaken [6].
Materials and methods
Results
Search strategy
The initial search strategy identified 213 citations and 26 of them were retrieved for full text review. Twelve trials met total inclusion criteria (Fig. 1): Knott et al. [7], Perez et al. [8], St Peter et al. [9], Huang et al. [10], Uchida et al. [11], Nicole et al. [12], Lee et al. [13], Rocourt et al. [14], Langness et al. [15], Chandler et al. [16], Muensterer et al. [17], Kang et al. [18]. The 12 selected studies (4 randomized controlled trials, 1 prospective study and 7 retrospective studies) included 2,109 participants. Of these pediatric patients, 933 received SILA and 1,176 received CLA. Table 1 outlines basic demographic data from each included study, including study style, male:female sex ratio and BMI (kg/m2) or weight (kg) in each group. Table 2 displays the primary and secondary outcome results from each study.
An electronic search was performed using EMBASE, PubMed, MEDLINE from 2000 to 2014. The search terms single-incision, transumbilical, three-port, conventional, laparoscopic surgery, children and appendectomy were used individually and in combination. References, reviews and meta-analyses were then scanned for additional articles. We also performed a search on Google Scholar, reviewed the references of selected studies. Study selection Children with histologically confirmed acute appendicitis who received SILA or CLA were recruited. Inclusion criteria: (1) clinical trails that compared single-incision versus conventional laparoscopic appendicectomy between 2000 and 2014; (2) children younger than 18 years with acute appendicitis; (3) original data included some of the following: operative time, length of hospital stay, postoperative recovery, and postoperative complications. Exclusion criteria: (1) no conventional laparoscopic appendicectomy as a control; (2) chronic appendicitis; and (3) duplicate publication or study did not provide sufficient original data.
Primary outcome measures Operative time Operative time was reported in ten studies [7–11, 13, 15– 18]. Meta-analysis demonstrated no statistically significant in mean operating time for SILA compared with CLA (95 % CI -0.22 to 7.76; P = 0.06) (Fig. 2a). There was
Data extraction Two authors independently extracted data from the list of the included studies, and a third reviewer was required for a final decision in the case of any discrepancies. The primary objective of our analysis was to evaluate the operative time, length of hospital stay. Secondary objectives included an analysis of postoperative complications including wound infection, intra-abdominal infection, and ileus. Statistical analysis Review Manager (RevMan) software ver. 5.3 was used for data statistical analysis. For continuous variables, we calculated mean differences (MDs) with 95 % confidence intervals (CIs). For dichotomous variables, we used odds
123
Fig. 1 Diagram of workflow in the systematic review
Pediatr Surg Int Table 1 Characteristics of the 12 selected studies Author (year)
Study style
Group
Age
SILA
CLA
SILA
CLA
Male/female
BMI (kg/m2) or weight (kg)
SILA
SILA
CLA
CLA
Knott et al. [7]
RCT
135
139
11.0 ± 3.5
10.9 ± 3.4
72:63
70:69
41.1 ± 26.4
44.7 ± 26.5
Perez et al. [8]
RCT
25
25
8.7 ± 0.6
8.9 ± 0.6
10:15
15:10
23.0 ± 3.1
22.8 ± 2.8
St Peter et al. [9]
RCT
180
180
11.1 ± 3.5
11.1 ± 3.3
99:81
92:88
19.4 ± 4.9
19.6 ± 4.5
Huang et al. [10]
RCT
30
30
8.9 ± 1.8
8.1 ± 2.4
18:12
19:11
27.6 ± 3.8
25.4 ± 4.7
Uchida et al. [11]
Retrospective
40
48
10.3 ± 2.60
10.5 ± 2.76
24:16
31:17
32.3 ± 9.75
33.7 ± 11.3
Nicole et al. [12]
Retrospective
122
41
11.2 ± 3.7
11.4 ± 3.4
69:53
26:15
NR
NR
Lee et al. [13] Rocourt et al. [14]
Prospective Retrospective
31 132
114 240
10.5 ± 3.6 9.4 ± 3.3
11.1 ± 4.1 10.1 ± 3.8
22:9 73:59
72:42 157:83
48.2 ± 18.4 NR
42.9 ± 17.1 NR
Langness et al. [15]
Retrospective
83
138
10.58
9.7
52:31
83:55
NR
NR
Chandler et al. [16]
Retrospective
50
45
11.1 ± 3.6
11.7 ± 3.8
26:24
34:11
43.3 ± 19
50.9 ± 29
Muensterer et al. [17]
Retrospective
75
151
11
NR
NR
NR
45
NR
Kang et al. [18]
Retrospective
30
25
9.3 ± 4.0
8.7 ± 3.5
17:13
14:11
NR
NR
RCT randomized controlled trial, NR not reported, SILA single-incision laparoscopic appendicectomy, CLA conventional laparoscopic appendicectomy
Table 2 The primary and secondary outcome of the 12 selected studies Author
Operative time (min)
Length of hospital stay (days)
Wound infection
SILA
SILA
CLA
SILA
CLA 3
CLA
Knott et al. [7]
34.00 ± 13.60
29.60 ± 13.6
0.92 ± 0.24
0.94 ± 0.3
2
Perez et al. [8]
46.80 ± 3.70
34.80 ± 2.50
NR
NR
1
0
St Peter et al. [9] Huang et al. [10]
35.20 ± 14.50 64.33 ± 3.11
29.80 ± 11.6 53.0 ± 2.88
0.95 ± 0.26 4.00 ± 0.84
0.92 ± 0.28 4.50 ± 1.17
6 0
3 0
0
2
Uchida et al. [11]
71.4 ± 37.4
73.0 ± 29.6
5.65 ± 2.53
6.80 ± 2.78
Nicole et al. [12]
NR
NR
2.0 ± 0.2
4.1 ± 0.6
Lee et al. [13]
41.8 ± 9.6
37.9 ± 11.7
2.6 ± 1.2
3.7 ± 1.9
1
6
Rocourt et al. [14]
NR
NR
NR
NR
1
1
Langness et al. [15]
42.8 ± 18.2
52.3 ± 24
1.3 ± 1.2
2.6 ± 3.5
Chandler et al. [16]
33.8 ± 9
26.3 ± 7.5
1.1 ± 0.4
1.2 ± 0.5
4
1
Muensterer et al. [17]
37 ± 12
44 ± 20
NR
NR
3
1
Kang et al. [18]
46.2 ± 18.5
40.5 ± 15.2
NR
NR
Intra-abdominal infection
Ileus
SILA
CLA
SILA
CLA
0
1
0
2
0
3
0
1
5
9
2
2
SILA single-incision laparoscopic appendicectomy, CLA conventional laparoscopic appendicectomy
evidence of significant statistical heterogeneity (I2 = 94 %). A sensitivity analysis was conducted where four studies were excluded and the meta-analysis of the remaining 6 studies shown a significant increase in mean operative time in SILA (Fig. 2b).
(Fig. 3). Statistical (I2 = 83 %).
heterogeneity
was
evidence
Secondary outcome measures Wound infection
Length of hospital stay Eight studies [7, 9–13, 15, 16] reported data on length of hospital stay with standard deviations to perform a metaanalysis. Meta-analysis demonstrated a statistically significant decrease in mean length of hospital stay for SILA compared with CLA (95 % CI -0.63 to 0.14; P = 0.002)
The incidence of postoperative wound infection was reported in eight studies [7–9, 11, 13, 14, 16, 17]. There were 18 wound infections (2.7 %) in the SILA group and 17 (1.8 %) in the CLA group. Meta-analysis demonstrated no statistically significant difference between the SILA and CLA group (95 % CI 0.77–3.01; P = 0.002) (Fig. 4).
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Pediatr Surg Int
Fig. 2 a Forest plot comparing operative time for children treated with SILA versus CLA. b Sensitivity analysis of operative time for children treated with SILA versus CLA
Fig. 3 Forest plot comparing length of hospital stay for children treated with SILA versus CLA
There was no evidence of statistical heterogeneity (I2 = 0 %).
significant difference between the groups (95 % CI 0.42–2.61; P = 0.92) (Fig. 5) There was no evidence of statistical heterogeneity (I2 = 0 %).
Intra-abdominal infection Postoperative ileus The incidence of postoperative intra-abdominal infection was reported in three studies [8, 14, 17]. There were seven infection (1.8 %) in the SILA group and twelve (2.1 %) in the CLA group. Meta-analysis demonstrated no statistically
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The incidence of postoperative ileus was reported in three studies [8, 14, 17]. There were no case of ileus in the SILA group and six (3.2 percent) in the CLA group. Meta-
Pediatr Surg Int
Fig. 4 Forest plot comparing postoperative wound infection for children treated with SILA versus CLA
Fig. 5 Forest plot comparing postoperative intra-abdominal infection for children treated with SILA versus CLA
Fig. 6 Forest plot comparing postoperative ileus for children treated with SILA versus CLA
analysis demonstrated no statistically significant difference between each group (95 % CI 0.42–2.61; P = 0.21) (Fig. 6). There was no evidence of statistical heterogeneity (I2 = 0 %).
Discussion Acute appendicitis remains as one of the most common gastrointestinal emergency in children. Currently, laparoscopic surgery has been considered as the gold standard
procedure for many abdominal operations. Recently, with more and more surgeons focusing on single-incision laparoscopic surgery (SILS), this kind of surgical procedure has improved a lot in the minimally invasive surgical field [15]. Due to the advantage of reducing the trauma of surgical access and cosmetic benefits, single-incision laparoscopic appendicectomy (SILA) has been widely accepted in the past few years among surgeons [19, 20]. To evaluate the safety and efficacy of SILA in the treatment of pediatric appendicitis, the authors collected 12 published studies to perform a meta-analysis.
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The meta-analysis revealed no significant differences between SILA and CLA in the operative time and postoperative complications including wound infection, intraabdominal infection, and ileus. These results propose that SILA is a relative safe surgical procedure with similar postoperative outcomes compared with CLA. The obvious difference observed between the groups was the shorter length of hospital stay in SILA compared with CLA. This may be due to the fast recovery of gastrointestinal function in SILA. Besides, SILA may have the potential of decreasing wound pain and thus lead to shorter length of hospital stay because of the reduction of the number of incisions compared to CLA. Recently, a systematic review and meta-analysis conducted by Clerveus et al. [21] demonstrated SILA was associated with longer operative time than CLA. These differences could be mainly due to the complexity of the SILA technique and the lower overall experience with this technique among surgeons. Although our meta-analysis reveals no significant differences in mean operative time between two groups, a sensitivity analysis revealed a significant increase in mean operative time in SILA. Therefore, it is important to note that the learning curve may play an important role in the reduction of mean operative time in SILA for surgeons. For example, the study conducted by Sozutek and his colleagues [22] showed a reduction in the mean operating time for SILA from 55 to 32 min. Besides, the increasing of new or modified surgical techniques may in part be responsible for the shortening of operative time in SILA [23]. To fully assess the safety of SILA in pediatric patients, three complications were selected and analyzed in our meta-analysis. The meta-analysis revealed no significant difference between SILA and CLA in the incidences of wound infection, intra-abdominal infection and ileus. Several previous studies suggested the concern about higher risk of postoperative wound infection because of the extracorporeal appendectomy in SILA [24, 25], which appears to be the most serious complication to SILA [9]. However, our meta-analysis revealed that the incidences of wound infection were not significantly different, even when no specific measures were taken to protect the umbilical skin during division of the appendix [9]. Umbilical hernia may be regarded as another potential concern of single-incision laparoscopic surgery. In theory, the larger umbilical incision could lead to higher incidence of postoperative umbilical hernias, however, all of the twelve included studies showed no occurrence of umbilical hernia in both groups. This may be due to the fact that the followup in most studies was too short. Therefore, new studies with a longer follow-up should be performed. Our systematic review and meta-analysis does have some limitations. On one hand, the overall methodologic
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quality and reporting of the included trials in children was poor. Some included studies had rather small sample size. On the other hand, there was evidence of statistical heterogeneity among different studies in terms of operative time and length of hospital stay. In conclusion, our study suggests that SILA is a feasible and safe surgical procedure alternative to CLA for pediatric patients with appendicitis. It reveals significantly shorter hospital stay and potential comparable operative time, postoperative complications such as wound infection, intraabdominal infection, and ileus compared with CLA. However, most of the studies included in our meta-analysis were retrospective studies. Therefore, more prospective randomized controlled trials are needed in children to draw a more convincing conclusion.
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