A Proposal for an Evidence-Based Patients' Selection in Single Incision Laparoscopic Appendectomy

Single incision laparoscopic appendectomy (SILA) is gaining interest in the surgical community, as the procedure is possibly easier than single incision laparoscopic cholecystectomy (SILC), without the potential boost of iatrogenic injuries which might characterize the initial series and the learning curve (1). Anyway, even the rate of overall morbidity for SILA might be higher than that of classical laparoscopic appendectomy (LA) (2). These numbers force to restrict the application of SILA to highly selected patients in which the benefits of a single access overweight the possible disadvantages in terms of morbidity. Clinical evidence and consensus development conferences have stated, so far, Grade A recommendation for LA only in pre-menopausal women, and its application in complicated appendicitis is still debated (3). Different devices have been approved for the use in singleincision surgery, but the cheaper and effective seems to be the “glove-port” (4). The obvious lack of triangulation is a minor problem in a mobile organ like the appendix is, but it can be bypassed with the use of a suspension for the appendix (trans-parietal stitches or supplemental miniport) or with flexible and angulated instruments. Although most of the procedures can be completed with a standard LA instrumentation, it surely implies a learning curve for the surgeon, who can be forced to a new crosshanded or left-handed dissection and has to deal with an annoying conflict between hands and stalks: this issue is ameliorated with the use of 5 mm-30 degrees cameras, which, although, carry a slight minor quality of the intraoperative vision, and (like in needlescopy) might compromise the result in complicated cases (5). On the basis of these considerations founded on the existing evidence, in our surgical unit we established strict criteria of inclusion in scheduling single port-appendectomy. This protocol has been started as LA has become the rule Published by Kowsar Corp, 2013. cc 3.0.