Surgical Endoscopy

, Volume 30, Issue 11, pp 4917–4923 | Cite as

One-trocar versus multiport hybrid laparoscopic appendectomy: What’s the best option for children with acute appendicitis? Results of an international multicentric study

  • Ciro EspositoEmail author
  • Maria Escolino
  • Holger Till
  • Mirko Bertozzi
  • Giovanna Riccipetitoni
  • Alessandro Settimi
  • Francois Varlet



One-trocar laparoscopic appendectomy (OTA) is routinely adopted in children with acute appendicitis. In case of a difficult appendectomy, it is necessary to add additional trocar/s to safely complete the procedure. This technique is called multiport hybrid laparoscopic appendectomy (HLA). We aimed to compare the outcome of multiport HLA versus OTA.


We retrospectively reviewed the data of 1,092 patients underwent LA in 5 European centers of pediatric surgery in the last 5 years. We compared 2 groups: G1 of 575 patients (52.6 %) (average age 10 years) underwent OTA and G2 of 517 patients (47.4 %) (average age 8.2 years) underwent multiport HLA.


No intra-operative complications occurred in both groups. An additional pathology was treated in 12 cases (8 Meckel’s diverticulum, 2 carcinoids, 2 ovarian cysts) in G2. Operative time was significantly shorter in G2 compared to G1 (47.8 vs 58.6 min; p < .001). The average analgesic requirement was significantly shorter in G2 compared to G1 (44 vs 56 h; p < .001). As for postoperative complications, the incidence of port-site infections was similar between the two groups, while the incidence of postoperative abdominal abscesses (PAA) was significantly higher in G1 compared to G2 (4.7 vs 0.2 %; p < .001). The cosmetic outcome was excellent in all patients of both groups. A subgroup analysis between complicated and uncomplicated appendicitis showed that only in complicated cases, the average operative time, the average VAS pain score, the average analgesic requirements and the incidence of PAA were significantly higher in OTA group compared to multiport HLA group (p < .001).


Our results suggest that OTA is a valid and safe procedure for the uncomplicated cases, while additional trocars are required in case of complicated appendicitis. Multiport HLA significantly reduces the operative time, the incidence of abdominal abscesses and the analgesic requirements compared to OTA.


Appendectomy Trocars Hybrid Ports Children 


Compliance with ethical standards


Drs Ciro Esposito, Maria Escolino, Holger Till, Mirko Bertozzi, Giovanna Riccipetitoni, Alessandro Settimi, and Francois Varlet declare that they have no conflicts of interest or financial ties to disclose.


  1. 1.
    Towfigh S, Chen F, Mason R et al (2006) Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis. Surg Endosc 20:495–499CrossRefPubMedGoogle Scholar
  2. 2.
    Stefen S, Edmund AM, Neugebauer Stefan S, Abe F, Bertrand M et al (2006) EAES guidelines for endoscopic surgery, twelve years evidence based surgery in Europe, vol 387. Springer, Berlin, p 9Google Scholar
  3. 3.
    Semm K (1983) Endoscopic appendectomy. Endoscopy 15:59–64CrossRefPubMedGoogle Scholar
  4. 4.
    Valla J, Ordorica-Flores RM, Steyaert H et al (1999) Umbilical one-puncture laparoscopic-assisted appendectomy in children. Surg Endosc 13:83–85CrossRefPubMedGoogle Scholar
  5. 5.
    Koontz CS, Smith LA, Burkholder HC et al (2006) Video-assisted transumbilical appendectomy in children. J Pediatr Surg 41:710–712CrossRefPubMedGoogle Scholar
  6. 6.
    Ates O, Hakguder G, Olguner M, Akgur FM (2007) Single-port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture. J Pediatr Surg 42:1071–1074CrossRefPubMedGoogle Scholar
  7. 7.
    Oltmann SC, Garcia NM, Ventura B et al (2010) Single-incision laparoscopic surgery: feasibility for pediatric appendectomies. J Pediatr Surg 45:1208–1212CrossRefPubMedGoogle Scholar
  8. 8.
    Valioulis I, Hameury F, Dahmani L et al (2001) Laparoscope-assisted appendectomy in children: the two-trocar technique. Eur J Pediatr Surg 11:391–394CrossRefPubMedGoogle Scholar
  9. 9.
    Esposito C (1998) One-trocar appendectomy in pediatric surgery. Surg Endosc 12:177–178CrossRefPubMedGoogle Scholar
  10. 10.
    Chow A, Purkayastha S, Nehme J, Darzi LA, Paraskeva P (2010) Single incision laparoscopic surgery for appendicectomy: a retrospective comparative analysis. Surg Endosc 24:2567–2574CrossRefPubMedGoogle Scholar
  11. 11.
    Panait L, Bell RL, Duffy AJ, Roberts KE (2009) Two-port laparoscopic appendectomy: minimizing the minimally invasive approach. J Surg Res 153:167–171CrossRefPubMedGoogle Scholar
  12. 12.
    Konstadoulakis MM, Gomatos IP, Antonakis PT et al (2006) Two-trocar laparoscopic-assisted appendectomy versus conventional laparoscopic appendectomy in patients with acute appendicitis. J Laparoendosc Adv Surg Tech A 16:27–32CrossRefPubMedGoogle Scholar
  13. 13.
    Schier F (1998) Laparoscopic appendectomy with 1.7-mm instruments. Pediatr Surg Int 14:142–143CrossRefPubMedGoogle Scholar
  14. 14.
    Rao MM, Rao RK (2004) Two-port and single port laparoscopic appendicectomy. J Indian Med Assoc 102:360, 362, 364Google Scholar
  15. 15.
    Aziz O, Athanasiou T, Tekkis PP et al (2006) Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg 243:17–27CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Slim K, Pezet D, Chipponi J (1998) Laparoscopic or open appendectomy? Critical review of randomized, controlled trials. Dis Colon Rectum 41:398–403CrossRefPubMedGoogle Scholar
  17. 17.
    D’Alessio A, Piro E, Tadini B, Beretta F (2002) One-trocar transumbilical laparoscopic-assisted appendectomy in children: our experience. Eur J Pediatr Surg 12:24–27CrossRefPubMedGoogle Scholar
  18. 18.
    Golebiewski A, Losin M, Murawski M, Wiejek A, Lubacka D, Czauderna P (2013) One, two or three port appendectomy—a rational approach. Videosurg Miniinv 8(3):226–231CrossRefGoogle Scholar
  19. 19.
    Chandler NM, Danielson PD (2010) Single-incision laparoscopic appendectomy vs multiport laparoscopic appendectomy in children: a retrospective comparison. J Pediatr Surg 45:2186–2190CrossRefPubMedGoogle Scholar
  20. 20.
    St Peter SD, Adibe OO, Juang D et al (2011) Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial. Ann Surg 254:586–590CrossRefPubMedGoogle Scholar
  21. 21.
    Olijnyk JG, Goncalves Pretto G, da Costa P, Filho O, Koboldt Machado F, Silva Chalub SR, Totti Cavazzola L (2014) Two-port laparoscopic appendectomy as transition to laparoendoscopic single site surgery. J Minim Access Surg 10(1):23–26CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Perry ZH, Netz U, Mizrahi S, Lantsberg L, Kirshtein B (2010) Laparoscopic appendectomy as an initial step in independent laparoscopic surgery by surgical residents. J Laparoendosc Adv Surg Tech A 20:447–450CrossRefPubMedGoogle Scholar
  23. 23.
    Chiu CC, Wei PL, Wang W, Chen RJ, Chen TC, Lee WJ et al (2006) Role of appendectomy in laparoscopic training. J Laparoendosc Adv Surg Tech A 16:113–118CrossRefPubMedGoogle Scholar
  24. 24.
    Visnjic S (2008) Transumbilical laparoscopically assisted appendectomy in children. High-tech low-budget surgery. Surg Endosc 22:1667–1671CrossRefPubMedGoogle Scholar
  25. 25.
    Esposito C, Mattioli G, Monguzzi GL, Montinaro L, Riccipetitoni G, Aceti R et al (2002) Complications and conversions of pediatric videosurgery: the Italian multicentric experience on 1689 procedures. Surg Endosc 16:795–798CrossRefPubMedGoogle Scholar
  26. 26.
    Delarue A, Guys JM, Louis-Borrione C, Simeoni J, Esposito C (1994) Pediatric endoscopic surgery: pride and prejudice. Eur J Pediatr Surg 4:323–326CrossRefPubMedGoogle Scholar
  27. 27.
    Markar SR, Blackburn S, Cobb R, Karthikesalingam A, Evans J, Kinross J, Faiz O (2012) Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children. J Gastrointest Surg 16:1993–2004CrossRefPubMedGoogle Scholar
  28. 28.
    St Peter SD, Adibe OO, Iqbal CW, Fike FB, Sharp SW, Juang D et al (2012) Irrigation versus suction alone during laparoscopic appendectomy for perforated appendicitis: a prospective randomized trial. Ann Surg 256:581–585CrossRefPubMedGoogle Scholar
  29. 29.
    Cho J, Park I, Lee D, Sung K, Baek J, Lee J (2015) Risk factors for postoperative intra-abdominal abscess after laparoscopic appendectomy: analysis for consecutive 1,817 experiences. Dig Surg 32:375–381CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Ciro Esposito
    • 1
    Email author
  • Maria Escolino
    • 1
  • Holger Till
    • 2
  • Mirko Bertozzi
    • 3
  • Giovanna Riccipetitoni
    • 4
  • Alessandro Settimi
    • 1
  • Francois Varlet
    • 5
  1. 1.Department of Translational Medical SciencesFederico II University of NaplesNaplesItaly
  2. 2.Department of Pediatric SurgeryMedical University of GrazGrazAustria
  3. 3.Department of Pediatric SurgeryUniversity of PerugiaPerugiaItaly
  4. 4.Department of Pediatric SurgeryBuzzi HospitalMilanItaly
  5. 5.Department of Pediatric SurgeryCentre Hospitalier Universitaire, Hopital NordSaint-ÉtienneFrance

Personalised recommendations