Skip to main content
SpringerLink
Log in

Single-incision versus three-port laparoscopic appendectomy for acute appendicitis: systematic review and meta-analysis of randomized controlled trials

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Three-port laparoscopic appendectomy (TPLA) has been shown superior to open appendectomy for acute appendicitis (AA); alternatively, single-incision laparoscopic appendectomy (SILA) is gaining popularity. The choice between SILA and traditional TPLA remains controversial. This meta-analysis of high-quality randomized controlled trials (RCTs) aims to compare efficacy and safety of SILA with TPLA for AA.

Methods

We searched MEDLINE, EMBASE, and the Cochrane Library for RCTs comparing SILA with TPLA. Reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases were also searched. Primary outcomes were operative time, postoperative complications, hospital duration, and days back to normal activities. Meta-analysis was conducted where possible comparing items using weighted mean differences (WMDs) and relative risks (RRs) according to type of data. Methodological quality was evaluated to assess bias risk.

Results

A total of 8 distinct RCTs comparing SILA (n = 616) with TPLA (n = 618) published from 2010 to 2013 were identified in our analysis. SILA took longer to conduct than TPLA (43 vs 38, WMD: 5.96, 95 % CI 2.54–9.38, P = 0.0006). Patients undergoing SILA needed more extra trocars addressed during operation (7 % vs 0 %, RR: 12.36, 95 % CI 3.83–39.90, P < 0.0001), but could return to full activities earlier (6 vs 7, WMD: −0.68, 95 % CI −1.10 to −0.26, P = 0.001). However, these differences were not clinically significant. All other parameters were comparable.

Conclusions

These results provide level 1a support for the clinical similarity that SILA is basically as feasible, effective and safe as TPLA when dealing with AA, although statistically, SILA takes longer to perform, requires more extra trocars, and benefits patients with faster recovery compared with TPLA. Further RCTs are needed to update our finding with advancement of surgical techniques and skills.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. McBurney C (1894) IV. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg 20(1):38–43

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  2. Semm K (1983) Endoscopic appendectomy. Endoscopy 15(2):59–64. doi:10.1055/s-2007-1021466

    Article  CAS  PubMed  Google Scholar 

  3. Wei B, Qi CL, Chen TF, Zheng ZH, Huang JL, Hu BG, Wei HB (2011) Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis. Surg Endosc 25(4):1199–1208. doi:10.1007/s00464-010-1344-z

    Article  PubMed  Google Scholar 

  4. Tiwari MM, Reynoso JF, Tsang AW, Oleynikov D (2011) Comparison of outcomes of laparoscopic and open appendectomy in management of uncomplicated and complicated appendicitis. Ann Surg 254(6):927–932. doi:10.1097/SLA.0b013e31822aa8ea

    Article  PubMed  Google Scholar 

  5. Wilasrusmee C, Sukrat B, McEvoy M, Attia J, Thakkinstian A (2012) Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg 99(11):1470–1478. doi:10.1002/bjs.8889

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  6. Chow A, Purkayastha S, Nehme J, Darzi LA, Paraskeva P (2010) Single incision laparoscopic surgery for appendicectomy: a retrospective comparative analysis. Surg Endosc 24(10):2567–2574. doi:10.1007/s00464-010-1004-3

    Article  PubMed  Google Scholar 

  7. Pelosi MA, Pelosi MA 3rd (1992) Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy). J Reprod Med 37(7):588–594

    CAS  PubMed  Google Scholar 

  8. Teoh AY, Chiu PW, Wong TC, Wong SK, Lai PB, Ng EK (2011) A case-controlled comparison of single-site access versus conventional three-port laparoscopic appendectomy. Surg Endosc 25(5):1415–1419. doi:10.1007/s00464-010-1406-2

    Article  PubMed  Google Scholar 

  9. Gill RS, Shi X, Al-Adra DP, Birch DW, Karmali S (2012) Single-incision appendectomy is comparable to conventional laparoscopic appendectomy: a systematic review and pooled analysis. Surg Laparosc Endosc Percutaneous Tech 22(4):319–327. doi:10.1097/SLE.0b013e31824f2cf8

    Article  Google Scholar 

  10. Pisanu A, Porceddu G, Reccia I, Saba A, Uccheddu A (2013) Meta-analysis of studies comparing single-incision laparoscopic appendectomy and conventional multiport laparoscopic appendectomy. J Surg Res. doi:10.1016/j.jss.2013.03.038

    Google Scholar 

  11. Ding J, Xia Y, Zhang ZM, Liao GQ, Pan Y, Liu S, Zhang Y, Yan Z (2013) Single-incision versus conventional three-incision laparoscopic appendicectomy for appendicitis: a systematic review and meta-analysis. J Pediatr Surg 48(5):1088–1098. doi:10.1016/j.jpedsurg.2013.01.026

    Article  PubMed  Google Scholar 

  12. Li P, Chen ZH, Li QG, Qiao T, Tian YY, Wang DR (2013) Safety and efficacy of single-incision laparoscopic surgery for appendectomies: a meta-analysis. World J Gastroenterol 19(25):4072–4082. doi:10.3748/wjg.v19.i25.4072

    Article  PubMed Central  PubMed  Google Scholar 

  13. Rehman H, Rao AM, Ahmed I (2011) Single incision versus conventional multi-incision appendicectomy for suspected appendicitis. Cochrane Database Syst Rev 7:CD009022. doi:10.1002/14651858.CD009022.pub2

  14. Gao J, Li P, Li Q, Tang D, Wang DR (2013) Comparison between single-incision and conventional three-port laparoscopic appendectomy: a meta-analysis from eight RCTs. Int J Colorectal Dis. doi:10.1007/s00384-013-1726-5

    Google Scholar 

  15. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA 283(15):2008–2012

    Article  CAS  PubMed  Google Scholar 

  16. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535. doi:10.1136/bmj.b2535

    Article  PubMed Central  PubMed  Google Scholar 

  17. Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R (2005) Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg 242(3):439–448; discussion 448–450

  18. Emshoff R, Bertram S, Emshoff I (2011) Clinically important difference thresholds of the visual analog scale: a conceptual model for identifying meaningful intraindividual changes for pain intensity. Pain 152(10):2277–2282. doi:10.1016/j.pain.2011.06.003

    Article  PubMed  Google Scholar 

  19. Grobmyer SR, Pieracci FM, Allen PJ, Brennan MF, Jaques DP (2007) Defining morbidity after pancreaticoduodenectomy: use of a prospective complication grading system. J Am Coll Surg 204(3):356–364. doi:10.1016/j.jamcollsurg.2006.11.017

    Article  PubMed  Google Scholar 

  20. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13. doi:10.1186/1471-2288-5-13

    Article  PubMed Central  PubMed  Google Scholar 

  21. Moher D, Pham B, Jones A, Cook DJ, Jadad AR, Moher M, Tugwell P, Klassen TP (1998) Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? Lancet 352(9128):609–613. doi:10.1016/S0140-6736(98)01085-X

    Article  CAS  PubMed  Google Scholar 

  22. Clarke M, Horton R (2001) Bringing it all together: Lancet-Cochrane collaborate on systematic reviews. Lancet 357(9270):1728. doi:10.1016/S0140-6736(00)04934-5

    Article  CAS  PubMed  Google Scholar 

  23. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557–560. doi:10.1136/bmj.327.7414.557

    Article  PubMed Central  PubMed  Google Scholar 

  24. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188

    Article  CAS  PubMed  Google Scholar 

  25. Malik M, McCormack K, Krukowski ZH, McDonald A, McPherson G, Cook JA, Ahmed I, Group SS (2012) Single port/incision laparoscopic surgery compared with standard three-port laparoscopic surgery for appendicectomy: a randomised controlled trial. Trials 13:201. doi:10.1186/1745-6215-13-201

    Article  PubMed Central  PubMed  Google Scholar 

  26. Knott EM, Gasior AC, Holcomb GW 3rd, Ostlie DJ, St Peter SD (2012) Impact of body habitus on single-site laparoscopic appendectomy for nonperforated appendicitis: subset analysis from a prospective, randomized trial. J Laparoendosc Adv Surg Tech A 22(4):404–407. doi:10.1089/lap.2012.0056

    Article  PubMed  Google Scholar 

  27. Park JH, Hyun KH, Park CH, Choi SY, Choi WH, Kim DJ, Lee S, Kim JS (2010) Laparoscopic vs transumbilical single-port laparoscopic appendectomy; results of prospective randomized trial. J Korean Surg Soc 78(4):213–218

    Article  Google Scholar 

  28. St Peter SD, Adibe OO, Juang D, Sharp SW, Garey CL, Laituri CA, Murphy JP, Andrews WS, Sharp RJ, Snyder CL, Holcomb GW 3rd, Ostlie DJ (2011) Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial. Ann Surg 254(4):586–590. doi:10.1097/SLA.0b013e31823003b5

    Article  PubMed  Google Scholar 

  29. Teoh AY, Chiu PW, Wong TC, Poon MC, Wong SK, Leong HT, Lai PB, Ng EK (2012) A double-blinded randomized controlled trial of laparoendoscopic single-site access versus conventional 3-port appendectomy. Ann Surg 256(6):909–914. doi:10.1097/SLA.0b013e3182765fcf

    Article  PubMed  Google Scholar 

  30. Frutos MD, Abrisqueta J, Lujan J, Abellan I, Parrilla P (2013) Randomized prospective study to compare laparoscopic appendectomy versus umbilical single-incision appendectomy. Ann Surg 257(3):413–418. doi:10.1097/SLA.0b013e318278d225

    Article  PubMed  Google Scholar 

  31. Kye BH, Lee J, Kim W, Kim D, Lee D (2013) Comparative study between single-incision and three-port laparoscopic appendectomy: a prospective randomized trial. J Laparoendosc Adv Surg Tech A 23(5):431–436. doi:10.1089/lap.2012.0284

    Article  PubMed  Google Scholar 

  32. Lee WS, Choi ST, Lee JN, Kim KK, Park YH, Lee WK, Baek JH, Lee TH (2013) Single-port laparoscopic appendectomy versus conventional laparoscopic appendectomy: a prospective randomized controlled study. Ann Surg 257(2):214–218. doi:10.1097/SLA.0b013e318273bde4

    Article  PubMed  Google Scholar 

  33. Perez EA, Piper H, Burkhalter LS, Fischer AC (2013) Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis. Surg Endosc 27(4):1367–1371. doi:10.1007/s00464-012-2617-5

    Article  PubMed  Google Scholar 

  34. 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 Percutaneous Tech 23(1):74–78. doi:10.1097/SLE.0b013e3182754543

    Article  Google Scholar 

  35. Schreiber JH (1987) Early experience with laparoscopic appendectomy in women. Surg Endosc 1(4):211–216

    Article  CAS  PubMed  Google Scholar 

  36. Ahmed K, Wang TT, Patel VM, Nagpal K, Clark J, Ali M, Deeba S, Ashrafian H, Darzi A, Athanasiou T, Paraskeva P (2011) The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc 25(2):378–396. doi:10.1007/s00464-010-1208-6

    Article  PubMed  Google Scholar 

  37. Prasad A (2010) Single incision laparoscopic surgery. World J Gastroenterol 16(21):2705–2706

    Article  PubMed Central  PubMed  Google Scholar 

  38. Muensterer OJ, Puga Nougues C, Adibe OO, Amin SR, Georgeson KE, Harmon CM (2010) Appendectomy using single-incision pediatric endosurgery for acute and perforated appendicitis. Surg Endosc 24(12):3201–3204. doi:10.1007/s00464-010-1115-x

    Article  PubMed  Google Scholar 

  39. Cho MS, Min BS, Hong YK, Lee WJ (2011) Single-site versus conventional laparoscopic appendectomy: comparison of short-term operative outcomes. Surg Endosc 25(1):36–40. doi:10.1007/s00464-010-1124-9

    Article  PubMed  Google Scholar 

  40. Vidal O, Valentini M, Ginesta C, Marti J, Espert JJ, Benarroch G, Garcia-Valdecasas JC (2010) Laparoendoscopic single-site surgery appendectomy. Surg Endosc 24(3):686–691. doi:10.1007/s00464-009-0661-6

    Article  PubMed  Google Scholar 

  41. Goel R, Buhari SA, Foo J, Chung LK, Wen VL, Agarwal A, Lomanto D (2011) Single-incision laparoscopic appendectomy: prospective case series at a single centre in Singapore. Surg Laparosc Endosc Percutaneous Tech 21(5):318–321. doi:10.1097/SLE.0b013e3182311bd9

    Article  Google Scholar 

Download references

Acknowledgments

This work was supported by: National Natural Science Foundation of China (81172036), and Foundation of Anhui Science and Technology Agency (12070403061). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We are grateful to the referees, and Profs. Wen-Xiu Han and Zhi-Jian Wei for critically reviewing this paper. We thank College of Public Hygiene of Anhui Medical University and the Information Center in the First Affiliated Hospital of Anhui Medical University for their contributions to our study.

Disclosures

Drs. A-Man Xu, Lei Huang, and Tuan-Jie Li have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Rd, Hefei, 230022, China

    A-Man Xu & Lei Huang

  2. Department of General Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, China

    Tuan-Jie Li

Authors
  1. A-Man Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lei Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tuan-Jie Li
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lei Huang.

Additional information

A-Man Xu and Lei Huang contributed equally to this work.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Xu, AM., Huang, L. & Li, TJ. Single-incision versus three-port laparoscopic appendectomy for acute appendicitis: systematic review and meta-analysis of randomized controlled trials. Surg Endosc 29, 822–843 (2015). https://doi.org/10.1007/s00464-014-3735-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-014-3735-z

Keywords

Search

Navigation