Copyright © 2012, the Korean Surgical Society
J Korean Surg Soc 2012;82:110-115
Journal of the Korean Surgical Society
pISSN 2233-7903ㆍeISSN 2093-0488
Received August 9, 2011, Revised October 13, 2011, Accepted November 7, 2011
Correspondence to: Jeong Kyun Lee
Department of Surgery and Institute of Medical Science, Wonkwang University College of Medicine, 344-2 Sinyong-dong, Iksan 570-749,
Tel: ＋82-63-859-1492, Fax: ＋82-63-855-2386, E-mail: email@example.com
cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons
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Application of single incision laparoscopic surgery for
appendectomy in children
Dong Baek Kang, Seung Hyun Lee, Seok Youn Lee, Jung Taek Oh, Dong Eun Park, Cheol Lee1,
Duk Hwa Choi1, Won Cheol Park, Jeong Kyun Lee
Departments of Surgery and 1Anesthesiology, Digestive Disease Research Institute and Institute of Medical Science, Wonkwang
University College of Medicine, Iksan, Korea
Purpose: Recently, single incision laparoscopic surgery (SILS) has been popular in use with its progress studied for more
minimally invasive surgery and cosmetic improvement. We investigated the feasibility and efficacy of SILS for appendec-
tomy (SILS-A) in children and compare it with conventional laparoscopic appendectomy (C-LA). Methods: We studied, ret-
rospectively, adolescent patients who underwent C-LA or SILS-A. There were 25 patients in the C-LA group and 30 patients
in the SILS-A group. The clinical outcomes were compared between the groups. Results: The SILS-A procedures were per-
formed successfully in adolescent patients . There were no significant difference between the C-LA and SILS-A group with
respect to demographic data and post-operative outcomes. There was one complication (4%) in the C-LA group and two
complications (6.6%) in the SILS-A group, but there was no significant difference. Conclusion: SILS-A was technically fea-
sible and safe in children. Considering little postoperative scar and no difference in post-operative outcomes compared to
C-LA, SILA could be applicable in adolescent patients. Larger studies and further technical implements will be necessary to
assess the true benefit of this approach.
Key Words: Single incision, Laparoscopy, Child
Acute appendicitis is the most common disease requir-
ing emergency surgery in children. In numerous studies,
when conventional laparoscopic appendectomy (C-LA)
using 3 ports is compared with open appendectomy, it has
advantages of reduced pain, reduced hospital stay, and en-
hanced cosmetic effects [1-3]. Recently, as technology and
innovation continue to advance the field of minimally in-
vasive surgery, single incision laparoscopic surgery (SILS)
is being applied to diverse surgeries as a new technique for
minimal invasive surgery [4-7].
In studies comparing single incision laparoscopic sur-
gery for appendectomy (SILS-A) with a C-LA in adults, al-
though early pain was observed, the former was superior
from a cosmetic viewpoint, and the incidence of complica-
tions was not different. Thus, recently, it was reported as a
technique that could be performed safely in adults [8-10].
Application of SILS-A in children
However, studies on the application of SILS-A in chil-
dren are few, and recently, Oltmann et al.  showed that
SILS-A operating times in patients with non-perforated
appendicitis are somewhat longer than with C-LA, but
should decrease with improved instrumentation and
Therefore, we performed this study to examine the fea-
sibility and efficacy of SILS-A in children by comparing
SILS-A with C-LA.
The study was performed on 55 cases of appendicitis in
adolescent patients who underwent either a conventional
3-port laparoscopic appendectomy or single incision lapa-
roscopic surgery for appendectomy (SILS-A) by the same
surgeon from July 2009 to March 2011 at our hospital.
Patients receiving a C-LA were 25 cases, and SILS-A were
Among the patients who underwent SILS-A were 8 cas-
es of complicated appendicitis due to perforation or gan-
grenous appendicitis; 5 cases of which had one additional
port inserted to facilitate the manipulation of laparoscopy
This study was a retrospective review of medical
records. The technique of SILS-A was approved by the
Ethical Committee of our hospital.
Prior to surgery, abdominal ultrasonography or com-
puted tomography was performed on all patients. In re-
gard to surgical methods, C-LA, SILS-A, and laparotomy,
were explained to the guardians, after which the method
was selected by the patients themselves and their guar-
Complicated appendicitis is defined as cases showing
gangrene or perforation changes detected by surgical
findings or histological findings, or cases with an abscess
in the vicinity of the appendix.
General anesthesia was administered to all patients.
Simultaneously with the diagnosis of appendicitis, an an-
tibiotic, 2nd generation cephalosporin, was administered;
and for cases diagnosed as appendicitis associated with
complications, aminoglycoside and metronidazole were
In the supine position, the surgeon stood at the left low-
er area of the patient, leaning toward the lower ex-
tremities, and the first assistant manipulated the laparo-
scope on the right upper side of the surgeon. C-LA was
performed using 3-trocar techniques, a 10-mm trocar was
inserted through the vicinity of the umbilicus, a 5-mm tro-
car was inserted between the pubic bone and the middle of
the umbilicus, and another 5-mm trocar was inserted in
the vicinity of the McBurney point. The mesoappendix
was ligated and dissected by the application of a LigaSure
(Valleylab, Boulder, CO, USA) and electric coagulation.
The appendiceal base was ligated by the use of one Endo
loop (Ethicon Inc., Somerville, NJ, USA).
To prevent infection in the area of the trocar insertion,
the surgeon removed the resected appendix to the ex-
tracorporeal area using a Lap-bag (Sejong Medical, Paju,
Korea) through the 10-mm trocar area. The abdominal
cavity was washed with saline. Afterward, for cases show-
ing perforation or severe inflammation, such as an abscess
in the vicinity of the appendix, sufficient drainage after
surgery was achieved by installing a Jackson-pratt drain
through the 3rd trocar.
SILS-A was performed in the supine position under
general anesthesia, and in the umbilical area, according to
the open incision method, a 1.5- to 2-cm vertical incision
was made. If the umbilical area was severely dirty or mal-
odorous, avoiding the center of the umbilical area, in the
area above the umbilical area or based on the umbilical
area, a half-moon incision window 1.5- to 2-cm in size was
made. When the insertion route to the abdominal cavity
was secured, a wound retractor (Alexis, Applied Medical
Resources Co., Rancho Santa Margarita, CA, USA) was
inserted. One 5-mm trocar for use with a 30o, 5-mm lapa-
roscopic camera (Karl-Storz, Tuttlingen, Germany) and
the injection of CO2 gas, two homemade 5-mm trocars to
reduce collisions of the tips of the trocars during SILS-A,
and a three-way catheter to remove smoke generated dur-
ing the use of the electric coagulator were fixed using silk
in the finger area of the surgical gloves to prevent the leak-
age of the air.
For cases difficult to resect because of perforation or se-
vere inflammation, such as an abscess in the vicinity of the
Dong Baek Kang, et al.
appendix and requiring drainage, an additional 5-mm tro-
car was inserted in the vicinity of the McBurney point.
Meso-appendectomy and appendectomy were per-
formed by using identical conventional laparoscopic
methods or extra-corporeal appendectomy when the cecal
base can be mobilized to the midline.
In the 6 cases of intra-corporeal SILS-A, after the re-
section of the appendix, the resected appendix was added
to the finger of the glove that was no longer required and
ligated with a forcep.
If the appendix was big or contamination was severe, it
was removed to the extracorporeal area using the Lap-bag;
the abdominal cavity was washed, and the wound re-
tractor was removed. If drainage was required, a 5-mm
trocar was inserted in the vicinity of the McBurney point,
and a Jackson-pratt drain was installed.
In the 24 cases of extra-corporeal SILS-A, the tip of the
appendix or mesentery is grasped. The insufflation is re-
leased and the appendix is extruded through the um-
bilicus while removing the glove. The appendix is brought
out of the wound until the cecal base can be grasped with
a Babcock clamp and appendectomy is performed in the
standard open fashion (Fig. 1).
In all patients, a patient-controlled analgesia (Accufu-
sor, WooYoung Medical, Jincheon, Korea) was used. The
patient-controlled analgesia, 18 μg/kg of fentanyl and 3
mg/kg of Keromin (Ketorolac Tromethamine, Hana
Pharm Co., Hwasung, Korea) were diluted with metoclo-
pramide and saline to a 100-mL volume and injected. For
cases presenting with severe pain, higher than 5 points on
a verbal numerical rating scale, despite the use of pa-
tient-controlled analgesia, as additional analgesic, Kero-
min was injected intravenously.
Statistical analysis was performed by using the
Student’s t-test and the chi-square test with the SPSS ver.
17.0 (SPSS Inc., Chicago, IL, USA). P-values lower than
0.05 were considered to be statistically significant.
The ratio of males to females for the patients who under-
went SILS-A was 17 : 13; their mean age was 9.3 ± 4.0 years.
In the group that underwent a C-LA, the ratio of males to
females was 14 : 11; their mean age was 8.7 ± 3.5 years.
In patients who underwent SILS-A, 8 patients had com-
plicated appendicitis; additional trocar had to be inserted
for severe inflammation, abscess and drainage (5 patients),
but none of those cases were converted to 3-port laparo-
scopic appendectomy or a laparotomy. In the group that
underwent a C-LA, 7 patients had complicated appendici-
tis; none of those cases were converted to laparotomy.
The operation time of the group that underwent SILS-A
was 46.2 ± 18.5 minutes; C-LA was 40.5 ± 15.2 minutes.
Although the time was longer for the group that under-
went SILS-A, no statistically significant differences were
detected (P = 0.067).
The hospitalization periods after surgery of the group
that underwent SILS-A were 4.0 ± 1.5 days, and that of the
group that underwent C-LA, 3.8 ± 2.0 days. The hospital-
ization period showed no statistically significant diffe-
The frequency of additional analgesics administered to
SILS-A group was 1.2 ± 1.5 times, and that for C-LA group
was 0.8 ± 0.5 times. The frequency of additional analgesics
in SILS-A group was higher than C-LA but showed no
statistically significant difference (P = 0.078) (Table 1).
In regard to postoperative complications, in SILS-A
group, seroma in the umbilical area developed in 2 pa-
tients, and in C-LA group, seroma and ileus developed si-
multaneously in 1 patient. They recovered after con-
servative management (Table 2). Fig. 2 is immediate post-
operative scar after SILS-A in a 9-year-old female patient
with gangrenous type appendicitis.
Since the first laparoscopic appendectomy was re-
ported by Semm  in Germany for an appendix without
inflammation, it has been performed by numerous sur-
geons. In comparison with open appendectomy, laparo-
scopic appendectomy have the benefits of reduction of
postsurgical pain, decreased operative trauma resulting in
quicker recovery, shorter hospital stays, and improved
cosmesis. As a result, it is now widely performed in adults
as well as pediatric patients by many practicing surgeons
Application of SILS-A in children
C-LA (n = 25) SILS-A (n = 30)
Overall, n (%)
C-LA, three-port conventional laparoscopic appendectomy; SILS-
A, single incision laparoscopic surgery for appendectomy.
a)Wound seroma and ileus was in same patient.
Table 2. Postoperative complications in C-LA and SILS-A
Fig. 2. Immediate post-operative scar after single incision laparo-
scopic surgery for appendectomy in 9-year-old female patient with
gangrenous type appendicitis.
Fig. 1. Extra-corporeal appendectomy in single incision laparo-
scopic surgery for appendectomy.
(n = 25)
(n = 30)
Mean OP time (min)
Hospital stay (day)
No. of IV pain control
8.7 ± 3.5
40.5 ± 15.2
3.8 ± 2.0
0.8 ± 0.5
9.3 ± 4.0
46.2 ± 18.5
4.0 ± 1.5
1.2 ± 1.5
Values are presented as number or mean ± SD.
OP, operation; C-LA, three ports conventional laparoscopic
appendectomy; SILS-A, single incision laparoscopic surgery for
a)Perforated or gangrenous type appendicitis.
Table 1. Demographic data and operative comparison between
C-LA and SILS-A in children
As laparoscopic minimal invasive surgery draws atten-
tion, interest in no-scar surgical methods is on the rise.
Together with the development of equipment, Natural
Orifice Transluminal Endoscopic Surgery, single-trocar or
single incision surgical methods have been applied to di-
verse diseases in the abdominal cavity [4-7,13]. Although
it differs slightly depending on the surgeon, single in-
cision laparoscopic surgery for appendectomy makes an
incision window through the umbilicus in most cases. It is
applied to appendectomy as a new technique of minimal
invasive surgery because the umbilicus is located in the
middle of the abdomen, so diverse intra-abdominal ap-
proaches can be performed; blood vessels and nerves are
absent, so incision windows can be readily created; even
after surgery, wounds become depressed within the um-
bilicus and, thus, may be considered as an existing con-
genital scar [8-10,14].
Reviewing the reports that compared single incision
laparoscopic surgery with a conventional 3-port laparo-
scopic appendectomy in adults, the former was found to
reduce scars in addition to having the advantages of a
3-port laparoscopic appendectomy; thus, it is advanta-
geous for cosmetic improvement. Nonetheless, short-
comings, long operation time, and substantial early post-
surgical pain, have been reported [8-10].
Oltmann et al.  reported that single incision laparo-
scopic surgery for appendectomy is both feasible and safe
across the pediatric age range. Although operating room
times are somewhat longer than with conventional 3-port
laparoscopic appendectomy, they concluded that it
should decrease with improved instrumentation and ex-
To overcome the longer operative time, we used a 30o,
Dong Baek Kang, et al.
5-mm laparoscopic camera to minimalize collisions with
and interference between the laparoscopic surgical equip-
ment and the laparoscopic camera. For cases in which col-
lision and interference phenomenon between laparo-
scopic surgical equipment and laparoscopic cameras oc-
cur, in the view of 30° - 5-mm laparoscopic cameras, lapa-
roscopic manipulation was made easy by using the flexi-
ble laparoscopic Roticulator Grasper, Dissector, and Shear
(Covidien, Norwalk, CT, USA).
Finally, we adapted extra-corporeal appendectomy
when the cecal base could be mobilized to the midline. In
24 out of 30 patients (80%) extra-corporal appendectomy
was applicable, but in 6 patients (20%) it was not appli-
cable due to non-mobile cecum and adhesion. We think
that it is an important point to choose intra or extra-cor-
poreal appendectomy whether the cecum is mobile or not.
In the cases of mobile cecum, extra-corporeal appendec-
tomy method in adolescent patients is a appropriate meth-
od to avoid unnecessary manipulation and reduce oper-
Extra-corporeal laparoscopic appendectomy using sin-
gle umbilical incision, initially published by Pelosi and
Pelosi , may offer some advantage in terms of expense.
Removal of the appendix extracorporeally in the manner
of conventional surgery eliminates need for expensive
devices. Visnjic  reported that transumbilical ex-
tra-corporeal laparoscopically assisted appendectomy op-
erative time in children was shorter and cost less than con-
ventional 3 port laparoscopic appendectomy. Hence, they
called this method “High-tech low-budget surgery.”
Through such methods as those discussed above, single
incision laparoscopic surgery for appendectomy in chil-
dren can even be applied to appendicitis patients; and the
operation time may not be significantly longer.
Kang et al.  reported that early pain was more severe
in single incision laparoscopic surgery for appendectomy
in adults than it was in a conventional 3-port laparoscopic
appendectomy. This might be caused by the fact that al-
though the skin incision in the umbilical area is small, the
actual length of the fascia incision is longer, and through a
small incision window, laparoscopic equipment is used si-
multaneously, which irritates the incision window.
Visnjic  also reported that in transumbilical ex-
tra-corporeal laparoscopically assisted appendectomy in
children, the administration of rescue analgesia was not
statistically different than in conventional 3-port laparo-
In our study, similarly, in the single incision laparo-
scopic surgery for appendectomy in children, analgesic
administration was significantly greater, and this is
thought to be associated with shorter operation time and
less fascial irritation by performing extra-corporeal lapa-
Postoperative complications in patients who under-
went single incision laparoscopic surgery for appendec-
tomy were treated without significant side effects or com-
plications, except wound problems. A seroma in the um-
bilical area developed in 2 patients (6.6%) and treated in
In the report of Oltmann et al. , they reported the in-
cidence of wound complication was 5.2% (1/19), and
Visnjic  was 13.7% (4/29). The higher incidence of port
site infection could be expected in single incision laparo-
scopic surgery for appendectomy than conventional
3-port laparoscopic appendectomy, especially in extra-
corporeal appendectomy due to the exposure and manip-
ulation of the appendix on the incision site. Therefore, an
adjusted operative technique using minimal, gentle move-
ments, and adequate wound protection is required. We
routinely used a wound retractor for wound protection,
and wound seroma, not wound infection, developed in
only 2 cases.
In conclusion, single incision laparoscopic surgery for
appendectomy in children is technically feasible and safe.
Considering little postoperative scar and no difference of
post-operative outcomes compared to conventional 3-port
laparoscopic appendectomy, single incision laparoscopic
surgery for appendectomy in children could be appli-
cable. Larger studies and further technical implements
will be necessary to assess the true benefit of this
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article
Application of SILS-A in children Download full-text
This paper was supported by Wonkwang University
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