|Year : 2013 | Volume
| Issue : 2 | Page : 76-79
SILACIG: A novel technique of single-incision laparoscopic appendicectomy based on institutional experience of 29 cases
SK Uday1, P R K Bhargav2
1 Department of General Surgery, Mamata Medical College and Hospital (MMC/MGH), Khammam, India
2 Department of Endocrine Surgery, Mamata Medical College and Hospital (MMC/MGH), Khammam, India
|Date of Submission||30-Mar-2012|
|Date of Acceptance||08-Aug-2012|
|Date of Web Publication||22-Apr-2013|
P R K Bhargav
Endocrine and Metabolic Surgery, Mamata Medical College and Superspeciality Hospital, Khammam
Source of Support: None, Conflict of Interest: None
Introduction: More reports of single-incision laparoscopic appendectomy are appearing in literature as it is an improvement over multiport laparoscopy in further reducing the trauma to abdomen. But, most of techniques require expensive gadgets like commercial ports and manoeuverable instruments, which are not available at many centres. In this context, a feasibility study of our own operative technique of single-incision laparoscopic appendectomy with less expensive conventional instrumentation was conducted at a single centre. Materials and Methods: This prospective study was carried out in tertiary care teaching institute of a semi-urban area in South India over a period of 1 year from March 2011 to February 2012. Twenty-nine patients of appendicitis were included in this study. Based on the principles of single-incision laparoscopy, we developed a glove port utilizing readily available operation theatre equipment. Results: Mean operative time was 56±12 minutes. Mean age of subjects was 34±15 years. M: F ratio was 2:1. There was no significant perioperative morbidity or mortality. Mean follow-up period was 8 months. Conclusion: Our initial experience with this technique of single-incision laparoscopic appendectomy demonstrates its feasibility, safety at a very low cost.
Keywords: Appendicectomy, glove port, single incision laparoscopy
|How to cite this article:|
Uday S K, Bhargav P. SILACIG: A novel technique of single-incision laparoscopic appendicectomy based on institutional experience of 29 cases. J Min Access Surg 2013;9:76-9
|How to cite this URL:|
Uday S K, Bhargav P. SILACIG: A novel technique of single-incision laparoscopic appendicectomy based on institutional experience of 29 cases. J Min Access Surg [serial online] 2013 [cited 2020 Aug 11];9:76-9. Available from: http://www.journalofmas.com/text.asp?2013/9/2/76/110967
| ¤ Introduction|| |
Appendicectomy is a one of the commonly performed procedures in General surgical practice. It can be performed by various methods. Open surgery and multiport laparoscopic appendicectomy are well accepted procedures and practiced routinely. Single Incision Laparoscopic Surgery (SILS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) are under evaluation. Various devices are used in single-port surgery including SILS port (Covidien), Uni-X  and R-port,  but their use increases the cost of procedure substantially as they require specialized manoeuverable and roticulating instruments customized for SILS. This technical limitation precludes many centres, especially in developing countries, away from this procedure. Moreover, it requires a longer learning curve. In this context, we report our experience of single-incision-laparoscopic appendicectomy using a cost-effective inhouse made glove port complemented with conventional laparoscopic instruments.
| ¤ Material and Methods|| |
This is a prospective interventional study conducted in a General Surgery Department of a Teaching institute in semi-urban area of Southern India. A total of 29 patients of Appendicitis operated over a period of 1 year from March 2011 to February 2012 were included in the study. Inclusion criteria for the procedure were clinically and/ or ultrasonographically diagnosed acute and chronic appendicitis, medically fit patients for anaesthesia and consenting patients. An informed consent was taken from all the patients. The study complied with international ethical norms as per Helsinki Declaration-Ethical Principles for Medical Research involving Human Subjects, 2004.
Preparation of inhouse glove port (IGp)
It was prepared with a single treated latex glove, 1 flexible and smaller inner ring such as a sterilized plastic bangle (inner diameter = 3 cm) and a rigid outer ring with larger diameter (Inner diameter = 6 cm). Inner ring was placed within the wrist portion of glove fold and outer ring was placed within the palm portion of glove fold. One 10-mm and two 5-mm trocars were fixed to three fingers of gloves [Figure 1].
|Figure 1: (a) Inhouse made glove port with glove and conventional ports; (b) Schematic line diagram of the SILS port|
Click here to view
In all patients general inhalational anaesthesia with endotracheal intubation was used. Position of the patient, operating team and monitor trolly were same as that for the conventional multiport technique. A single supraumbilical curved incision measuring 2.5 cm was given. In all cases we have used an IGp. The inner ring portion of IGp was introduced in to peritoneal cavity through the incision and pneumoperitoneum was created. The outer ring portion remained outside the abdominal wall. This position makes glove port self retaining after pneumoperitoneum [Figure 2]. Entire peritoneal cavity was visualized to confirm the diagnosis and note the position of appendix. Appendix was caught with babcock forceps and meso-appendix was cauterized using bipolar diathermy. Base of the appendix was secured with three catgut endo-loops and cut between two proximal and one distal loops [Figure 3]. Appendix was retrieved by putting it in one of the unused finger of glove and glove finger was isolated by tying it with thread at base [Figure 4]. Glove port was removed after deflating the pneumoperitoneum. Incision was closed with 2-0 prolene suture.
|Figure 3: Intraperitoneal view showing cutting of appendix between endoloops|
Click here to view
|Figure 4: Specimen retrieval through a glove finger (arrows)-(a) Inside view, (b) External view|
Click here to view
We have documented the technical details, difficulties and outcome in all the cases.
| ¤ Results|| |
In present study, 29 patients underwent this procedure. Among these, 23 patients had acute and 6 had recurrent appendicitis. Mean age was 25.5 ±15 years. Male to female ratio was 2:1. Mean operative time was 56±12 minutes. There were no significant intraoperative complications. Three patients required additional hypogastric port for various reasons. In two patients dissection was difficult due to retrocaecal position of appendix and in one patient dense adhesions precluded the procedure. There was no mortality. Almost 84% patients were discharged on 2 nd postoperative day with oral diet. The appendicectomy specimen were histopathologically confirmed and was suggestive of appendiceal inflammation. There were no postoperative complications at mean 8-months follow-up. The perioperative details are shown in [Table 1].
| ¤ Discussion|| |
Appendicectomy is a commonly performed procedure in the general surgical practice.  Open surgical technique and multiport laparoscopic approach are well accepted and performed frequently in many centres. There is substantial reduction in morbidity with usage of multiport over open technique. Ongoing attempts and active surgical research to further reduce the morbidity has lead to introduction of novel endoscopic techniques such as SILS and NOTES. , The technique of NOTES is not yet standardized and yet to be accepted widely, as it requires opening of normal viscera and chances of contamination. The single-incision laparoscopic surgery has been used in cholecystectomy,  nephrectomies,  adrenalectomies,  lap-band stomach surgery,  and surgery for many other diseases. Also, there have been reports about single-incision laparoscopic appendectomy being useful based on precedents. , Most of the SILS procedures have been performed employing advanced, commercial ports like SILS port (Covidien), Uni-X and R-port and a range of advanced hand instruments like curved or articulating instruments.  But, it increases the cost of the procedure and appropriate use of SILS-specific instruments demands a steep learning curve. To overcome these drawbacks, few surgeons have tried SILS appendicectomy using conventional laparoscopic instruments, ,, where they have used multiple ports through a single incision  or through a noncommercial SILS ports. ,
Bhatia et al. reported single-incision laparoscopic appendicectomy using single umbilical incision, where they used conventional laparoscopic instruments. In addition to it they used a needlescopic instrument to catch the appendix. Jeen et al. used a glove port, but they used lanceonate retractor to expand incision and then surgical glove was applied on the retractor. They used ultrasonic scalpel to cut the mesoappendix. The appendix was retrieved along with glove and then replaced by another glove. Kung et al. in their series used homemade port system using a 5-mm trocar, two pipes with an elastic rubber hose attached to the distal pipe. Appendix was retrieved through one of the unused glove finger. Chandles NM et al. reported a comparative study between SILS appendicectomy and multiport appendecectomy, in which they performed the former procedure successfully in 50 patients utilizing commercial Covidien and Triport systems with shorter operative time of 33.8 minutes.  Fujisaki et al. reported a case of SILS appendicectomy using Covedien port, but with Endo GIA 30 stapler.  The comparison of technical details and results between our study with other series is shown in [Table 2].
|Table 2: Comparision between different series of SILS appendicectomy with SILS port|
Click here to view
Performing SILS by these technical modifications is associated with its own set of disadvantages such as leakage of CO 2 , sword fighting of instruments, Chopstick effect, lack of triangulation, retrieval of specimen, Swiss cheese hernia, etc.  Thus, surgeon performing SILS without advanced instruments is forced to withstand these technical difficulties. To overcome these difficulties, we have attempted our technique of single incision laparoscopic appendicectomy, where we used IGp and conventional laparoscopic instruments.
In the present technique, the cost of Glove port was INR 60 as compared to INR 15,000 to 50,000 (approx) for commercial SILS ports. The equipments used to make this Glove port are very cheap and readily available in any hospital. There was no port site gas leak as the glove gets snugly fitted to the incision, once pneumoperitoneum is created. As the ports were placed in the fingers of glove, there was more freedom for the movement of instruments. Although various methods of specimen retrieval such as endobag retrieval,  Fisherman technique,  etc., are described, we used a simple method of retrieving it through one of unused glove finger. This has added advantage of retrieving specimen without port site contact. This latter feature reduces the chances of port site infection in gangrenous or severe appendicitis. Disadvantage is that there is chance of glove tear during insertion and removal of instruments, as occurred in two of our cases, where it required changing of the port. Even with the replacement of glove port, this was very inexpensive and reproducible. In comparison to other similar techniques utilizing either glove ports or commercial SILS ports, this technique is less cumbersome and less expensive, thus replicable.
We propose a term single-incision laparoscopic appendicectomy with conventional instruments and indigenous glove port (SILACIG) for this procedure.
| ¤ Conclusions|| |
The present study shows that:
- The SILACIG is a novel technique using an inhouse made glove port and conventional instruments instead of commercial and specialized instrumentation.
- The SILACIG technique is a cost-effective, feasible and safe procedure.
- It is a practical procedure for unaffordable patients and resource limited set-ups of developing countries, provided personnel with laparoscopic expertise are available.
| ¤ References|| |
|1.||Vidal O, Valentini M, Ginesta C, Marti J, Espert JJ, Benarroch G, et al. Laparoendoscopic single-site surgery appendectomy. Surg Endosc 2010;24:686-91. |
|2.||Rane A, Rao P, Rao P. Clinical evaluation of a novel laparoscopic port (R-PORTTM) in urology and evolution of the single laparoscopic port procedure (SLIPP) and one port umbilical surgery (OPUS) Eur Urol 2008;7:193. |
|3.||Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1996;132:910-25. |
|4.||Bucher P, Ostermann S, Pugin F, Morel PE. E-NOTES appendectomy versus transvaginal appendectomy: Similar cosmetic results but shorter complete recovery? Surg Endosc 2009;23:916-7. |
|5.||Rolanda C, Lima E, Pêgo JM, Henriques-Coelho T, Silva D, Moreira I, et al. Third-generation cholecystectomy by natural orifices: Transgastric and transvesical combined approach. Gastrointest Endosc 2007;65:111-7. |
|6.||Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incision outside the umbilicus. J Laparoendosc Adv Surg Tech A 1999;9:361-4. |
|7.||Raman JD, Bagrodia A, Cadeddu JA. Single-incision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: A comparison of perioperative outcomes and short-term measures of convalescence. Eur Urol 2009;55:1198-204. |
|8.||Walz MK, Groeben H, Alesina PF. Single-access retroperitoneoscopic adrenalectomy (SARA) versus conventional retroperitoneoscopic adrenalectomy (CORA): A case-control study. World J Surg 2010;34:1386-90. |
|9.||Teixeira J, McGill K, Binenbaum S, Forrester G. Laparoscopic single-site surgery for placement of an adjustable gastric band: Initial experience. Surg Endosc 2009;23:1409-14. |
|10.||Kim JW, Park JS, Chang IT, Choi YS, Song HJ, Kim BG. The initial experience with a single incision laparoscopic appendectomy. J Korean Soc Coloproctol 2009;25:312-7. |
|11.||Lee YS, Kim JH, Moon EJ, Kim JJ, Lee KH, Oh SJ, et al. Comparative study on surgical outcomes and operative costs of transumbilical single-port laparoscopic appendectomy versus conventional laparoscopic appendectomy in adult patients. Surg Laparosc Endosc Percutan Tech 2009;19:493-6. |
|12.||Kössi J, Luostarinen M. Initial Experience of the Feasibility of Single-Incision Laparoscopic Appendectomy in Different Clinical Conditions. Diagn Ther Endosc 2010;2010:240260. |
|13.||Bhatia P, Sabharwal V, Kalhan S, John S, Deed JS, Khetan M. Single-incision multi-port laparoscopic appendectomy: How I do it. J Minim Access Surg 2011;7:28-32. |
|14.||Lee JA, Sung KY, Lee JH, Lee do S. Laparoscopic appendectomy with a single incision in a single institute. J Korean Soc Coloproctol 2010;26:260-4. |
|15.||Kang KC, Lee SY, Kang DB, Kim SH, Oh JT, Choi DH, et al. Application of single incision laparoscopic surgery for appendectomies in patients with complicated appendicitis. J Korean Soc Coloproctol 2010;26:388-94. |
|16.||Chandles NM, Danielson PD. Single incision laparoscopic appendectomy Vs multiport laparoscopic appendectomy in children: A retrospective comparison. J Pediatr Surg 2010;45:2186-90. |
|17.||Fujisaki M, Kawahara H, Watanabe K, Ushigome T, Toyama Y, Yanagisaaw S. Single- Incision Laparoscopic Appendicectomy with the SILS Port TM . Jikeikai Med J 2011;58:83-7. |
|18.||Rao PP, Rao PP, Bhagwat S. Single-incision laparoscopic surgery-current status and controversies. J Minim Access Surg 2011;7:6-16. |
|19.||Jain PK, Sedman P. Appendix retrieval after laparoscopic appendectomy: A safe and inexpensive technique. Surg Laparosc Endosc Percutan Tech 2003;13:322-4. |
|20.||Saad M. Fisherman's technique, introducing a novel method for using the umbilical port for removal of appendix during laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2007;17:422-4. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]