See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/259499918

Acute appendicitis: What is the gold standard of treatment?

Article  in  World Journal of Gastroenterology · December 2013

DOI: 10.3748/wjg.v19.i47.8799 · Source: PubMed

CITATIONS READS

27 2,607

9 authors, including:

Cesare Ruffolo Michele Antoniutti

University-Hospital of Padova Azienda ULSS numero 9 Treviso
159 PUBLICATIONS   1,985 CITATIONS    19 PUBLICATIONS   247 CITATIONS   

SEE PROFILE SEE PROFILE

Marco Massani Ezio Caratozzolo

AULSS2 Marca Trevigiana Treviso 21 PUBLICATIONS   190 CITATIONS   
78 PUBLICATIONS   699 CITATIONS   
SEE PROFILE
SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Management of liver trauma in high volume center View project

The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit View
project

All content following this page was uploaded by Marco Massani on 10 November 2016.

The user has requested enhancement of the downloaded file.

 Online Submissions: http://www.wjgnet.com/esps/ World J Gastroenterol 2013 December 21; 19(47): 8799-8807
bpgoffice@wjgnet.com ISSN 1007-9327 (print) ISSN 2219-2840 (online)
doi:10.3748/wjg.v19.i47.8799 © 2013 Baishideng Publishing Group Co., Limited. All rights reserved.

EDITORIAL

Acute appendicitis: What is the gold standard of treatment?

Cesare Ruffolo, Alain Fiorot, Giulia Pagura, Michele Antoniutti, Marco Massani, Ezio Caratozzolo,
Luca Bonariol, Francesco Calia di Pinto, Nicolò Bassi

Cesare Ruffolo, Alain Fiorot, Giulia Pagura, Michele An- treatment of acute appendicitis.
toniutti, Marco Massani, Ezio Caratozzolo, Luca Bonariol,
Francesco Calia di Pinto, Nicolò Bassi, Ⅱ Deparment of Sur-
gery (Ⅳ Unit), Regional Hospital “Ca’ Foncello”, 31100 Treviso, Ruffolo C, Fiorot A, Pagura G, Antoniutti M, Massani M, Cara-
Italy tozzolo E, Bonariol L, Calia di Pinto F, Bassi N. Acute appendici-
Author contributions: Fiorot A and Pagura G equally contrib-
tis: What is the gold standard of treatment? World J Gastroenterol
uted to this paper; all authors contributed to conception and de-
sign, acquisition of data, draft and revision of the article and final 2013; 19(47): 8799-8807 Available from: URL: http://www.
approval of the version to be published. wjgnet.com/1007-9327/full/v19/i47/8799.htm DOI: http://dx.doi.
Correspondence to: Cesare Ruffolo, MD, PhD, Ⅱ Deparment org/10.3748/wjg.v19.i47.8799
of Surgery (Ⅳ Unit), Regional Hospital “Ca’ Foncello”, Piazza
Ospedale 1, 31100 Treviso, Italy. cruffolo@hotmail.com
Telephone: +39-422-322480 Fax: +39-422-322480
Received: June 3, 2013 Revised: September 20, 2013
Accepted: October 19, 2013 INTRODUCTION
Published online: December 21, 2013 In 1894, McBurney[1] described a new technique for the
management of acute appendicitis: this method is still
used when an open approach is required.
McBurney’s procedure represented the gold-standard
Abstract for acute appendicitis until 1981, when Semm [2] per-
McBurney’s procedure represented the gold-standard formed the first laparoscopic appendectomy in Germany,
for acute appendicitis until 1981, but nowadays the a “culture shock” in general surgery since a revolutionary
number of laparoscopic appendectomies has progres- method was discovered by a gynecologist[3]. But a real
sively increased since it has been demonstrated to be “laparoscopic revolution” took place only in 1985 with
a safe procedure, with excellent cosmetic results and it the first laparoscopic cholecystectomy performed by
also allows a shorter hospitalization, a quicker and less Erich Muhe, using Semm’s technique and instruments.
painful postoperative recovery. The aim of this edito- Laparoscopy was not easily accepted since it was not con-
rial was to perform a review of the literature in order to sidered a safe procedure; nowadays laparoscopic surgery
address controversial issues in the treatment of acute is gaining a primary role in many surgical settings.
appendicitis. The number of laparoscopic appendectomies (LA)
has progressively increased since it has been demon-
© 2013 Baishideng Publishing Group Co., Limited. All rights
strated to be a safe procedure, with excellent cosmetic
reserved.
results; furthermore, LA allows a shorter hospitalization,
Key words: Acute appendicitis; Surgery; Laparoscopy a quicker and less painful postoperative recovery.
But is laparoscopic surgery the best choice for ap-
Core tip: There are still controversial issues in the pendectomy? Which are the correct surgical indications?
treatment of acute appendicitis such as comparison What are the results from the comparison between LA
between laparoscopic and open appendectomy and vs classic open appendectomy (OA)? Are there selected
the correct approach in special categories of patients. groups of patients in which one of these approaches
The aim of this editorial was to perform a review of the should be preferred? The aim of this editorial was to per-
literature in order to address controversial issues in the form a review of the literature in order to address these

WJG|www.wjgnet.com 8799 December 21, 2013|Volume 19|Issue 47|

 Ruffolo C et al . Acute appendicitis

controversial issues. The only remarkable difference was that the patients who
underwent OA presented earlier symptoms and received
a more timely diagnosis of ⅡA than the patients who
OPEN VS LAPAROSCOPIC underwent LA (6 d in OA group vs 11 d in LA group)[9].
APPENDECTOMY A multivariate analysis has shown that development
of abscesses has a higher correlation with the initial diag-
Many comparative studies have already demonstrated the
nosis than with the type of surgical approach. The evalu-
advantages of LA over OA in terms of length of hospi-
ation of selected patients demonstrated a 30% increase
tal stay, use of postoperative analgesics and earlier return
of the risk of ⅡA for every decade of life. This could be
to work[4]. The most controversial issues of these studies
clinically relevant because it suggests the need for care-
have been taken into consideration.
ful monitoring of elderly patients who initially presented
complicated appendicitis, since they are at higher risk for
Surgical-site infection postoperative ⅡA[9]. Finally an explanation for the for-
Surgical-site infection (SSI) rate was significantly lower in mation of ⅡA could be found in the surgical technique
the LA than in the OA group (1.6% vs 3.2% respectively) itself: currently, surgeons performing LA tend to apply
and this gap between the two groups increased in severe
irrigation more freely; therefore, contaminating the entire
forms of appendicitis, such as gangrenous and perfo-
peritoneal cavity[10]; although irrigation as a cause of ⅡA
rated. Some authors estimated that one wound infection
is yet controversial.
could be prevented for every 23.7 patients treated with
LA, instead of OA[5]: this can be explained with the use
of the extraction bag (endo-bag) in LA, which prevents Incisional hernia
the direct contact between the infected appendix, the The incidence of incisional hernia is low in both tech-
wound edges and the inflamed tissues around the appen- niques (0.7% in OA group vs 1% in LA): the development
dix during its removal[5,6]. of post incisional hernias is higher with McBurney’s inci-
Other studies found a higher SSI rate in OA, but also sion, whereas in LA there are incisional hernias only in
a significantly higher intraabdominal abscess (ⅡA) rate in those patients who undergo conversion[11].
LA. The difference in the postoperative complications ac-
cording to the surgical technique were remarkable when Small bowel obstruction
inflammation of the appendix was more severe: in fact, Finally, as far as long-term complications are concerned,
when a periappendiceal abscess was present, there were some studies assessed that small bowel obstruction can
more cases of paralytic ileus (PI) in the LA group and present many years after surgery, especially for open ap-
more cases of SSI in the OA group. This result can be pendectomy. The prevalence of bowel obstruction after
due to the leakage of infected substances, the appendiceal appendectomy increased from 0.63% after 1 year, to
stump not being inverted and the resection side being 0.97% after 10 years, to 1.30% after 30 years of follow
exposed in the intraabdominal cavity during the removal up[11]. In a randomized study, a second look laparoscopy
of the appendix in LA[7]. Some authors suggest that the was performed on 40 patients who had histological con-
use of an Endo-GIA stapler could help minimize these firmation of acute appendicitis, 3 mo after the first op-
adverse effects[8]. Finally, these differences are not statisti- eration: there were adhesions in the 80% of patients that
cally significant in case of gangrenous or/and perforated underwent OA, but only in 10% of LA group[5]. There-
appendicitis[7]. fore, LA seems to be associated with an easier second-
look procedure and a minor infertility rate due to less
Intraabdominal abscess adhesions[12].
In an interesting study that considered 2464 patients, 52 Among long-term complications, small bowel ob-
experienced postoperative abscesses. The patients with struction has a very low incidence, between 0.33% and
a diagnosis of complicated appendicitis had a significant 1.51% in OA. It is known that the risk is higher with
correlation with a higher incidence of intraabdominal negative appendectomy or appendectomy through a
abscess development (67% in complicated appendicitis vs midline laparotomic incision. Then, the choice of LA in
25% in uncomplicated appendicitis, P = 0.01). The ma- suspected appendicitis is correct because it avoids un-
jority of abscesses developed in the pelvis (41%), espe- necessary appendectomy if the appendix is normal and it
cially in those patients who had complicated rather than prevents unnecessary wide incisions[13].
uncomplicated appendicitis (63% vs 18% respectively, P
= 0.01). It is interesting to notice how the formation of
an ⅡA in patients with a diagnosis of complicated ap- SUSPECTED APPENDICITIS
pendicitis did not differ significantly between those who The differential diagnosis of most of the surgical abdom-
underwent LA and those who underwent OA (5.9% vs inal emergencies is based on clinical grounds, laboratory
4.1% respectively, P = 0.44). Moreover, in patients with data and diagnostic imaging. The problem, however, is to
complicated appendicitis there was no significant increase obtain a correct diagnosis of the exact localization of the
in presenting symptoms or in the severity of the case lesion to determine surgical indications and to decide the
history, quite independently from the surgical approach. best surgical approach. Laparoscopy is a valuable instru-

WJG|www.wjgnet.com 8800 December 21, 2013|Volume 19|Issue 47|

 Ruffolo C et al . Acute appendicitis

ment in the case of suspected appendicitis allowing the scess according to the surgical technique; therefore in the
surgeon to correctly evaluate the intraperitoneal condi- presence of an initial diagnosis of complicated appen-
tion of practically every single patient[14]. dicitis with a severe clinical background there is a higher
At first, considering its exploratory nature and its probability of developing an abscess regardless of the
diagnostic accuracy, besides the advantage of a shorter adopted surgical approach[9].
time of hospitalization and reduction of pain on day 1[15], In another 5-year non randomized study considering
LA can be considered the first choice in suspected ap- 1133 patients of which 244 had a complicated appendici-
pendicitis, especially in particular categories, such as pre- tis (and among them, 175 underwent LA and 69 OA), LA
menopausal women. In fact, in these patients, in the pres- patients had a shorter operative time (55 min vs 70 min),
ence of right lower quadrant pain, differential diagnosis reduced length of stay (5 d vs 6 d) and a lower incidence
between acute appendicitis, ectopic pregnancy and pelvic of SSI (0.6% vs 10%)[10]. In the case of complicated ap-
inflammatory disease (PID), is necessary. A laparoscopic pendicitis (gangrenous or perforated), the laparoscopic
exploration of the abdominal cavity allows a rapid and approach also reduced postoperative pain[20].
safe diagnosis; for the former two affections laparoscopy
also represents a therapeutic option, while in the latter
one, samples for culture may also be taken, with the ad- SPECIAL CATEGORIES OF PATIENTS
vantage of avoiding “negative” appendectomies, with a There are clinical settings in which laparoscopy may be
high diagnostic accuracy (96% in women and 100% in the preferred approach: obese patients, immunocompro-
men)[16]. mised patients and elderly patients.
Morino et al[17] evaluated, in a prospective, randomized, In obese patients, in fact, laparoscopy is undeniably
single-institution trial, the role of early laparoscopy in the useful[21], considering at first the difficult exposure of the
management of nonspecific abdominal pain (NSAP) in right lower quadrant during OA, which may require large,
young women. NSAP was defined as an abdominal pain morbidity-prone incisions that are at risk of infections
in right iliac or hypogastric area lasting more than 6 h and of wound complications[5,22]. It is known that BMI is
and less than 8 d, without fever, leukocytosis, or obvious a risk factor for SSI[23]. Furthermore, obese patients have
peritoneal signs and uncertain diagnosis after physical ex- a higher risk of incisional hernias: laparoscopic approach
amination and baseline investigations including abdomi- reduces the risk of incisional hernia[24].
nal sonography. Patients were randomly assigned to early Immunocompromised patients include heart trans-
(< 12 from admission) laparoscopic group or to clinical planted patients and those who received immunosup-
observation group. Compared with active clinical obser- pressive therapy for autoimmune diseases, cancer and
vation, early laparoscopy did not show a clear benefit in AIDS; the risk of infections is higher and the immunity
women with NSAP. A higher number of diagnosis and response could be partial and ineffective due to immu-
a shorter hospital stay in the laparoscopic group did not nodepression. Therefore, these patients may not exhibit
lead to a significant reduction in symptoms recurrences at the typical signs and symptoms of appendicitis and may
1 year. only have a barely positive examination[25]. In these pa-
LA may be performed safely in pregnant patients with tients laparoscopic approach represents the best option:
appendicitis according to the Society of American Gastro- compared with OA, LA is characterized by a lower rate
intestinal and Endoscopic Surgeons (SAGES) guidelines[18]. of postoperative complications (10.36% in LA group vs
22.56% in OA group), a shorter hospitalization (2.9 d
vs 4.9 d) and a lower mortality (0.16% vs 0.61%). These
COMPLICATED APPENDICITIS results can be observed in both uncomplicated and com-
Excellent results are mentioned in several studies about plicated appendicitis, with a considerably lower incidence
the use of LA in complicated appendicitis, though a high- of complications (27.52% in LA group vs 57.50% in OA
er incidence of intraabdominal abscesses has been no- group) and a shorter hospital stay (5.92 d in LA group vs
ticed. Some studies have demonstrated that LA is almost 9.67 d in OA group)[26].
totally comparable to OA as far as operating time, hospi- Finally, elderly patients might significantly benefit
tal stay and postoperative complications are concerned. from a laparoscopic approach[24]; in these patients it is
The rate of postoperative ⅡA was significantly higher in quite difficult to collect anamnestic data, in addition to a
LA when compared with OA (respectively, 14% vs 0%), mild abdominal examination and to laboratory and radio-
while wound infection and pulmonary complication rate logical tests which might not be so diriment. Laparoscopy
were significantly lower (respectively 2.3% vs 8.2% in OA can clarify the diagnosis and also represent a good thera-
group and 0% vs 4.9% in LA group)[19]. peutical strategy[27].
The incidence rate of ⅡA increases considerably
when a periappendiceal abscess or a postoperative il-
eus are present. Particularly, the incidence of ⅡA in INFLAMMED APPENDICEAL STUMP
complicated appendicitis increases remarkably (67% in Stump appendicitis is the acute inflammation of the re-
complicated vs 25% in uncomplicated appendicitis): in sidual portion of the appendix and is a rare complication
these patients, there are no significant differences in the of incomplete appendectomy[28].
postoperative outcome or in the development of the ab- Due to the relevant recurrence rate, a second appen-

WJG|www.wjgnet.com 8801 December 21, 2013|Volume 19|Issue 47|

 Ruffolo C et al . Acute appendicitis

dectomy 3 mo after the outbreak of inflammation, could conservative strategy. The analysis of seventeen studies
be necessary. In a histopathological study Gahukamble revealed that conservative management, with or without
demonstrated that 13 of the 14 removed appendices had interval appendectomy, was associated with less overall
a pervious lumen with a higher risk of recurrent appen- complication rates, less reoperations and similar hospital
dicitis. More recently authors focused the problem of a stay compared with urgent appendectomy.
very long stump also on patients undergoing LA; in fact, In the absence of high quality studies, laparoscopic or
the presence of an excessively long appendiceal stump traditional appendectomy is still the treatment of choice
could be at risk of recurrence also in these patients. Pain for acute appendicitis; some in-progress prospective
in the lower right abdominal quadrant in a patient that studies[34,37] could be helpful in understanding the role of
has undergone LA does not rule out a second episode of conservative management.
acute appendicitis[29]. The possibility of a recurring ap-
pendiceal stump abscess as a complication of LA is high.
When performing LA, the appendiceal stump should be NORMAL APPENDIX: LAPAROSCOPIC
as short as possible and its ligation should not determine MANAGEMENT
ischemia of the stump[30].
Negative or white appendectomy refers to the removal
The tactical modification of appendiceal stump clo-
of non-inflamed appendix and is performed in about
sure, replacing the invaginating suture that nowadays has 15%-25% of patients undergoing surgery for suspected
become the procedure of choice consists in a single en- acute appendicitis[38]. White appendectomy rate is declin-
doligature. Alternatively, there are methods which make ing over time as cited by large studies, due to the availabil-
use of an endostapler, endoligature (endo-loop), metal ity of computed tomography and laparoscopy[39]; in open
clips, bipolar endocoagulation and polymeric clips. All the surgery, the appendix is generally always removed[40].
different techniques have advantages and disadvantages Thanks to the widespread use of laparoscopy, lapa-
depending on the different stages of acute appendicitis; roscopic management of normal appendix represents a
so, the right knowledge about the possible methods and dilemma for the surgeon and no guidelines are available
the appropriate choice between them according to every in this field[41]. When laparoscopy is performed for sus-
single case allows a safe and efficient management of pa- pected appendicitis, exploration is negative in 8%-15%
tients as well as a reduction in hospital costs[31]. but in up to 27% another condition is diagnosed[40]. The
Drainage placement, ultrasound and perhaps an risks of leaving in situ an apparent normal appendix are:
exploratory-therapeutical laparoscopy could be very use- later appendicitis, misdiagnosed subclinical or ‘‘endo’’-
ful in the management of this complication[30]. Finally the appendicitis, missed appendiceal malignancy (carcinoid),
use of CT imaging allows a precise definition of the sur- risk of patient confusion and persisting symptoms[42]. At
rounding anatomy, in particular of the length of the ap- present, the laparoscopic strategy in front of a normal
pendiceal stump[32]. Several authors identify the removal appendix remains controversial.
of the whole appendiceal stump as the major suggested
mean to avoid recurrence of appendicitis[33].
Conversions from laparoscopic to laparotomic
appendectomy
CONSERVATIVE MANAGEMENT OF In case of conversion, it is useful to perform an adequate
laparotomic incision and an accurate and complete
ACUTE APPENDICITIS abdominal toilette. The conversion of perforated ap-
Acute appendicitis is one of the most frequent condi- pendicitis is often burdened with a higher postoperative
tions seen in a surgical department; urgent appendectomy morbidity [60% in conversion appendectomy (CA), 22%
is considered the treatment of choice because of the low in LA and 38% in OA][8].
incidence of major complications and the relative rapid- A recent study in 2011, which included 745 patients
ity of operation and hospital stay. Nevertheless surgical that underwent LA or OA, asserts that conversion rate
treatment exposes the patient to risks due to general was about 8.6% and mentions that the first cause of con-
anaesthesia and other complications such as surgical site version was the presence of a severe acute inflammatory
infection, adhesions and intestinal obstruction, incisional process (38.7% of the factors which determine conver-
hernia, infertility in female and pneumonia[34]; in this set- sion to OA during operation). In this study, 77.42% of
ting, the role of conservative treatment with antibiotics the patients that underwent CA had previous abdominal
has been investigated in literature. surgery and only 25.81% had a conversion due to adhe-
A recent Cochrane review assessed five low to mod- sions.
erate quality randomized controlled trials[35]; with the Conversion was necessary especially in women over
limit of the analyzed studies, surgical approach remains 65 years old (4.30% rather than 4.02% in the rest of
the gold standard treatment for acute uncomplicated ap- patients)[43]. It is quite interesting that surgeons who per-
pendicitis. Another large meta-analysis compared the two formed at least 50 LA through their study period had a
strategies in the scenario of complicated appendicitis, higher CA rate and this could reflect their will to attempt
abscess or phlegmon[36]; in this case, radiologic-assisted LA in the greatest part of patients, even in not strictly
drainage of appendiceal abscess could be another helpful indicated cases. At the same time the number of conver-

WJG|www.wjgnet.com 8802 December 21, 2013|Volume 19|Issue 47|

 Ruffolo C et al . Acute appendicitis

sions decreases progressively throughout the career of a tive time is longer both for LA and for OA (47 min vs
surgeon and his equipe[43]. 38 min for LA and 49 min vs 44 min for OA): this could
Another study indicates the presence of a generalized be explained considering the intrinsic didactic nature of
purulent peritonitis as the only significant risk factor for academic hospitals which inevitably causes a little delay in
conversion. Moreover, although patients with previous the operations. Finally in both types of hospitals, hospi-
abdominal surgery are at higher risk of conversion, this is talization for LA was shortened by 1 d[48].
not significantly correlated with sex and age. Converted A parameter to assess the value of a surgical approach
patients are at higher risk of relaparotomy and incisional is long-term quality of life. A German study determined
hernia, independently of the duration of the operation[11]. how a group of patients - including both LA and OA -
Finally, for patients that underwent LA with compli- perceived their quality of life 7 years after appendectomy,
cations requiring reintervention following laparoscopy, through the administration of a specific questionnaire.
there is the possibility of a relaparoscopy for a second The most satisfied patients were those who underwent
look: this has the advantage of maintaining the reduced LA, both for the quick recovery and for the cosmetic re-
morbidity allowed by the first operation. Relaparoscopy is sult[49]. Another work obtained information about overall
very useful for abscess drainage, because it provides the satisfaction by a telephone interview: the LA group had
accurate identification of the causes, for example in case fewer complications and returned earlier to work (median
of appendicular stump insufficiency[44]. 13 d for OA vs 8 d for LA)[13].

Laparoscopic appendectomy: Techniques

LAPAROSCOPY VS LAPAROTOMY: Recently several methods have been proposed to per-
WHICH FACTORS DETERMINE form appendectomy in a laparoscopic fashion. In the
most popular approach, 3 abdominal wall incisions are
SURGEON'S DECISION? performed to insert instruments in the abdominal cavity.
It is known that laparoscopic approach is more expen- According to the patients’ demand of scar-free surgery,
sive, as many studies have reported: an American study new minimally invasive methods have been developed.
evaluated hospital cost behaviour in the years 2000-2005,
including all patients undergoing both LA and OA. Costs Traditional laparoscopic appendectomy [3 port(s) lap-
for LA are 22% higher in uncomplicated and 9% higher aroscopic appendectomy]: In conventional laparoscopic
in complicated appendicitis. They estimate that in 2005 appendectomy, 3 ports are used to place instruments in
exclusive use of open appendectomy would have saved the abdomen (Figure 1). The laparoscope is inserted in
93 million dollars: this finding is particularly important the umbilicus and pneumoperitoneum is induced; the
because appendectomy is a common routine operation site of the other 2 trocars for operative instruments is
in all hospitals. The authors suggest OA as the gold stan- variable, according to the surgeon’s preference and abil-
dard for acute appendicitis, reserving LA only for special ity. The most used locations for trocars are: the lower left
categories of patients[45]. quadrant and suprapubic or lower left quadrant and lower
Cothren et al[46] compared the costs for LA and OA, right quadrant or suprapubic and lower right quadrant or
which were significantly higher for LA: the authors noted both trocars placed on the “bikini line” (suprapubic)[50].
that the total costs for LA were higher although operative Nevertheless, the trocars are inserted respecting the trian-
time and stay in hospital were not so different between gulation rule, with the appendix at the apex of a triangle.
the two methods. Higher costs for LA might be due to The umbilical port is 5-12 mm in diameter while the oth-
the use of specific disposable surgical material for lapa- ers are generally 5 mm large[51].
roscopy. During surgical procedure, many methods are used
Another important factor for the hospital costs is to amputate and extract the appendix and to perform
the severity of illness of the patients at the initial diag- proper hemostasis; the routinely use of peritoneal irriga-
nosis[47]. Even if more expensive, throught the years LA tion and drainage placement is not recommended[52]. The
has become more common because there are undeniable number of trocars can be reduced to 2 using the “puppe-
benefits in hospitalization time and in recovery time: this teer technique”; in this variant, the appendix is suspended
way, higher costs are balanced out by a more precocious using transabdominal threads[53].
return to work of working patients. Recently, one study A laparoscopic surgeon must be skilled with the
found that predicted costs for LA were 1856$ lower than open approach; in fact, open appendectomy represent
for OA while the postoperative complication rate did not the first step in the training of an operator who desires
differ significantly[47]. to perform laparoscopic appendectomy. But when is the
Another crucial factor which influences the choice learning curve completed? It is generally accepted that it
between LA and OA is the training and experience of is completed after 20 operations[54].
surgical equipe. An interesting study compares the expe- To improve the cosmetic result, needlescopic ap-
rience in academic-affiliated and community hospitals. pendectomy has been developed; this term refers to an
The rate of LA and OA in the two kinds of hospitals is evolution of conventional laparoscopy. The only differ-
quite the same, but in academic-affiliated ones the opera- ence between the two regards the instruments’ diameter,

WJG|www.wjgnet.com 8803 December 21, 2013|Volume 19|Issue 47|

 Ruffolo C et al . Acute appendicitis

visceral injury and port site hernia due to the presence

of a unique abdominal wall incision: for this reason it is
known as “scarless” surgery. In a recent randomized con-
trolled trial, SILS was associated with higher post-oper-
tative pain and more intravenous analgesics requirement;
better wound cosmesis and higher satisfaction scores
were also observed[62]. On the other hand it also has some
technical challenges, like loss of triangulation (the corner-
Laparoscope stone of laparoscopy) and instrument crowding (sword
fighting)[63]. Although it is a technical challenge, in skilled
hands, it is considered a safe procedure; patients seem to
appreciate when a SILS approach is performed because
surgical incisions are hidden in the umbilicus. Recent
Appendix studies compared SILS and conventional laparoscopic
Instruments appendectomy: no significative differences in the opera-
tive time, length of hospital stay, post operative pain and
complication were observed[64,65].
The red cross represents the trocar site
The learning curve of single incision laparoscopic
appendectomy is between 5 to 10 cases[66]. To reduce
Figure 1 Traditional laparoscopic appendectomy: 3 ports are used to the need of special materials and the costs, SILS can be
place instruments in the abdomen. performed using nonarticulating instruments and con-
ventional trocars: early data suggests that it can represent
in fact in the needlescopic approach 3-mm or less trocars an economic and safe option, even if operative time is
are used[55]. The first needlescopic appendectomy was longer[67]. In this approach, an adequate follow-up to de-
performed in 1994. The use of smaller trocars poten- tect the risk of post-incisional hernia is needed because
tially reduces postoperative pain and length of hospital many trocars are inserted in a very small area. There are
stay due to minor abdominal wall incisions[56]; patients also original ideas to reduce costs, i.e., the use of a surgi-
can quickly return to normal activity. On the other hand, cal glove like a multi-lumen port where instruments pass
this technique is more challenging for surgeons with a via the cutting fingers[63]. However, it is very difficult to
risk of longer duration of surgery and higher conversion determine the costs of SILS[68].
rate[57]; these disadvantages will probably disappear after Lacking of available evidence, no recommendations
an appropriate learning curve and an increase of surgi- can be made on the effectiveness of SILS vs conventional
cal skill. Needlescopic appendectomy is likely to be more multi-incision laparoscopic appendectomy[69].
expensive than the traditional approach due to equipment
costs[58]. This fascinating laparoscopic evolution is not Natural orifice transluminal endoscopic surgery: In 2004
routinely recommended because of the lack of scientific Rao et al[70] described a new real “scarless” procedure
evidence: large randomized controlled trials are necessary. performing a transgastric appendectomy. Natural Orifice
It can, however, represents an option in selected patients, Transluminal Endoscopic Surgery (NOTES) represents
like young women. the forefront of laparoscopic surgery and the next world-
wide focus on minimally invasive surgery[71]; using a mul-
Single-incision laparoscopic surgery: The continuous tichannel endoscope, the access to the peritoneal cavity is
evolution of laparoscopic surgery and the ambition of obtained via natural orifices like vagina, rectum, stomach
better cosmetic results always tend to less invasive pro- and bladder. This technique allows to perform many sur-
cedures. Single Incision Laparoscopic Surgery (SILS) for gical operations without visible scars; avoiding abdominal-
acute appendicitis in children began in 1992[59]. The de- wall incisions, postoperative pain is minor and recovery is
velopment and diffusion of this technique was quite slow faster. SILS is considered a bridge between conventional
due to the lack of adequate instruments; healthcare en- multi-ports laparoscopy and NOTES.
gineering ideated multilumen ports, special laparoscopes Regarding acute appendicitis, in female patients a
and articulating instruments to facilitate the surgeon’s transvaginal approach can be used (TVA, TransVaginal
work[60]. SILS is now diffused in many surgical specialties Appendectomy); an incision performed in the posterior
and skilled surgeons can perform several operations in fornix of vagina permits the access to the peritoneal cav-
this way, i.e., adrenalectomy, Heller myotomy, large bowel ity (Figure 2).
surgery, splenectomy, bariatric surgery[61]. A prospective study comparing TVA to traditional
In SILS, a multi-luminal and single port device is 3-port laparoscopic appendectomy showed significantly
placed transumbilically: through this device, laparoscope less post-operative analgesia demand (Patient Controlled
and instruments can reach the abdominal cavity. The Analgesia morphine utilization) and faster return to
proposed advantages of SILS are better cosmetic results, normal activity; compared with the conventional laparo-
reduced wound infection, postoperative pain, bleeding, scopic approach there were no differences in the length

WJG|www.wjgnet.com 8804 December 21, 2013|Volume 19|Issue 47|

 Ruffolo C et al . Acute appendicitis

Urinary bladder HK, Shin R, Kim JS. Comparison of surgical-site infection

between open and laparoscopic appendectomy. J Korean
Posterior fornix of vagina Surg Soc 2012; 82: 35-39 [PMID: 22324044 DOI: 10.4174/
jkss.2012.82.1.35]
7 Lim SG, Ahn EJ, Kim SY, Chung IY, Park JM, Park SH, Choi
KW. A Clinical Comparison of Laparoscopic versus Open
Appendectomy for Complicated Appendicitis. J Korean Soc
Coloproctol 2011; 27: 293-297 [PMID: 22259744 DOI: 10.3393/
jksc.2011.27.6.293]
8 Piskun G, Kozik D, Rajpal S, Shaftan G, Fogler R. Compari-
son of laparoscopic, open, and converted appendectomy for
perforated appendicitis. Surg Endosc 2001; 15: 660-662 [PMID:
Rectum 11591963]
9 Asarias JR, Schlussel AT, Cafasso DE, Carlson TL, Kasp-
Figure 2 Notes procedure: Transvaginal approach is performed through renski MC, Washington EN, Lustik MB, Yamamura MS,
the posterior fornix of the vagina. Matayoshi EZ, Zagorski SM. Incidence of postoperative in-
traabdominal abscesses in open versus laparoscopic appen-
dectomies. Surg Endosc 2011; 25: 2678-2683 [PMID: 21416175
of stay and operative time[72]. There were no differences DOI: 10.1007/s00464-011-1628-y]
in pre- and post-operatively sexual function; no post- 10 Yau KK, Siu WT, Tang CN, Yang GP, Li MK. Laparoscopic
operative dispareunia was noted and TVA vs conventional versus open appendectomy for complicated appendicitis. J
Am Coll Surg 2007; 205: 60-65 [PMID: 17617333]
laparoscopy sexual outcome was comparable. Even 11 Swank HA, Eshuis EJ, van Berge Henegouwen MI, Bemel-
though the authors of this prospective study concluded man WA. Short- and long-term results of open versus lapa-
that TVA is a safe and feasible procedure in women with roscopic appendectomy. World J Surg 2011; 35: 1221-126;
acute non-perforated appendicitis, the authors of this discussion 1221-126; [PMID: 21472367 DOI: 10.1007/
review believe that large randomized controlled trials are s00268-011-1088-5]
12 Lehmann-Willenbrock E, Mecke H, Riedel HH. Sequelae
necessary before proposing this procedure to a young
of appendectomy, with special reference to intra-abdominal
woman. adhesions, chronic abdominal pain, and infertility. Gynecol
Obstet Invest 1990; 29: 241-245 [PMID: 2361629]
13 Kouhia ST, Heiskanen JT, Huttunen R, Ahtola HI, Kiviniemi
CONCLUSION VV, Hakala T. Long-term follow-up of a randomized clinical
Patient selection is important in both LA and OA. LA is trial of open versus laparoscopic appendicectomy. Br J Surg
2010; 97: 1395-1400 [PMID: 20632312 DOI: 10.1002/bjs.7114]
the preferred approach in immunocompromised, obese 14 Casciola L, Ceccarelli G, Bartoli A, D’Ajello F, Bellochi
and elderly patients. LA presents longer operative time, R, Valeri R, Rambotti M, Spaziani A, Mazzoli W, Di Zitti
but also a shortening of hospital stay, a better and earlier L. [Laparoscopic approach versus laparotomy for sus-
recovery and return to everyday occupations and to work pected acute appendicitis]. G Chir 2002; 23: 440-444 [PMID:
and, last but not least, a better cosmetic result. 12652921]
15 Sauerland S, Lefering R, Neugebauer EA. Laparoscopic ver-
sus open surgery for suspected appendicitis. Cochrane Data-
base Syst Rev 2002; (1): CD001546 [PMID: 11869603]
ACKNOWLEDGMENTS 16 Cariati A, Brignole E, Tonelli E, Filippi M, Guasone F, De
We are very grateful to Jean Jimenez, Researcher of Eng- Negri A, Novello L, Risso C, Noceti A, Giberto M, Giua R.
lish Language and Linguistics at the University of Cal- [Laparoscopic or open appendectomy. Critical review of the
literature and personal experience]. G Chir 2001; 22: 353-357
abria, for her help in reviewing the English language of
[PMID: 11816948]
this paper. 17 Morino M, Pellegrino L, Castagna E, Farinella E, Mao P.
Acute nonspecific abdominal pain: A randomized, controlled
trial comparing early laparoscopy versus clinical observa-
REFERENCES tion. Ann Surg 2006; 244: 881-86; discussion 881-86; [PMID:
1 McBurney C. IV. The Incision Made in the Abdominal Wall 17122613]
in Cases of Appendicitis, with a Description of a New Meth- 18 Pearl J, Price R, Richardson W, Fanelli R. Guidelines for
od of Operating. Ann Surg 1894; 20: 38-43 [PMID: 17860070] diagnosis, treatment, and use of laparoscopy for surgical
2 Semm K. Endoscopic appendectomy. Endoscopy 1983; 15: problems during pregnancy. Surg Endosc 2011; 25: 3479-3492
59-64 [PMID: 6221925] [PMID: 21938570 DOI: 10.1007/s00464-011-1927-3]
3 Litynski GS. Kurt Semm and the fight against skepticism: 19 Pokala N, Sadhasivam S, Kiran RP, Parithivel V. Compli-
endoscopic hemostasis, laparoscopic appendectomy, and cated appendicitis--is the laparoscopic approach appropri-
Semm’s impact on the “laparoscopic revolution”. JSLS 1998; ate? A comparative study with the open approach: outcome
2: 309-313 [PMID: 9876762] in a community hospital setting. Am Surg 2007; 73: 737-41;
4 Ohtani H, Tamamori Y, Arimoto Y, Nishiguchi Y, Maeda K, discussion 741-2 [PMID: 17879676]
Hirakawa K. Meta-analysis of the results of randomized con- 20 Garg CP, Vaidya BB, Chengalath MM. Efficacy of laparos-
trolled trials that compared laparoscopic and open surgery copy in complicated appendicitis. Int J Surg 2009; 7: 250-252
for acute appendicitis. J Gastrointest Surg 2012; 16: 1929-1939 [PMID: 19393776 DOI: 10.1016/j.ijsu.2009.04.007]
[PMID: 22890606] 21 Markar SR, Venkat-Raman V, Ho A, Karthikesalingam A,
5 Golub R, Siddiqui F, Pohl D. Laparoscopic versus open Kinross J, Evans J, Bloom I. Laparoscopic versus open ap-
appendectomy: a metaanalysis. J Am Coll Surg 1998; 186: pendicectomy in obese patients. Int J Surg 2011; 9: 451-455
545-553 [PMID: 9583695] [PMID: 21820087 DOI: 10.1016/j.ijsu.2011.06.005]
6 Suh YJ, Jeong SY, Park KJ, Park JG, Kang SB, Kim DW, Oh 22 Enochsson L, Hellberg A, Rudberg C, Fenyö G, Gudbjartson

WJG|www.wjgnet.com 8805 December 21, 2013|Volume 19|Issue 47|

 Ruffolo C et al . Acute appendicitis

T, Kullman E, Ringqvist I, Sörensen S, Wenner J. Laparo- N, Smyrniotis V. Conservative treatment of acute appen-
scopic vs open appendectomy in overweight patients. Surg dicitis: heresy or an effective and acceptable alternative to
Endosc 2001; 15: 387-392 [PMID: 11395821] surgery? Eur J Gastroenterol Hepatol 2011; 23: 121-127 [PMID:
23 Cantürk Z, Cantürk NZ, Cetinarslan B, Utkan NZ, Tarkun I. 21164348 DOI: 10.1097/MEG.0b013e32834233b6]
Nosocomial infections and obesity in surgical patients. Obes 39 Mariadason JG, Wang WN, Wallack MK, Belmonte A, Ma-
Res 2003; 11: 769-775 [PMID: 12805398] tari H. Negative appendicectomy rate as a quality metric in
24 Mason RJ, Moazzez A, Moroney JR, Katkhouda N. Laparo- the management of appendicitis: impact of computed to-
scopic vs open appendectomy in obese patients: outcomes mography, Alvarado score and the definition of negative ap-
using the American College of Surgeons National Surgical pendicectomy. Ann R Coll Surg Engl 2012; 94: 395-401 [PMID:
Quality Improvement Program database. J Am Coll Surg 22943328 DOI: 10.1308/003588412X13171221592131]
2012; 215: 88-99; discussion 99-100 [PMID: 22632913 DOI: 40 Navez B, Therasse A. Should every patient undergoing lapa-
10.1016/j.jamcollsurg.2012.03.012] roscopy for clinical diagnosis of appendicitis have an appen-
25 Flum DR, Steinberg SD, Sarkis AY, Wallack MK. Appendici- dicectomy? Acta Chir Belg 2003; 103: 87-89 [PMID: 12658883]
tis in patients with acquired immunodeficiency syndrome. J 41 Jaunoo SS, Hale AL, Masters JP, Jaunoo SR. An international
Am Coll Surg 1997; 184: 481-486 [PMID: 9145068] survey of opinion regarding investigation of possible appen-
26 Masoomi H, Mills SD, Dolich MO, Dang P, Carmichael JC, dicitis and laparoscopic management of a macroscopically
Nguyen NT, Stamos MJ. Outcomes of laparoscopic and normal appendix. Ann R Coll Surg Engl 2012; 94: 476-480
open appendectomy for acute appendicitis in patients with [PMID: 23031764 DOI: 10.1308/003588412X13373405385377]
acquired immunodeficiency syndrome. Am Surg 2011; 77: 42 Van Vlodrop V, Pattyn P, Ceelen W. Management of the
1372-1376 [PMID: 22127092] ‘normal’ appendix during surgery for right fossa syndrome:
27 Watters JM, Blakslee JM, March RJ, Redmond ML. The influ- proposed clinical algorithm. Acta Chir Belg 2007; 107: 8-11
ence of age on the severity of peritonitis. Can J Surg 1996; 39: [PMID: 17405592]
142-146 [PMID: 8769925] 43 Sakpal SV, Bindra SS, Chamberlain RS. Laparoscopic ap-
28 Kanona H, Al Samaraee A, Nice C, Bhattacharya V. Stump pendectomy conversion rates two decades later: an analysis
appendicitis: a review. Int J Surg 2012; 10: 425-428 [PMID: of surgeon and patient-specific factors resulting in open
22846617 DOI: 10.1016/j.ijsu.2012.07.007] conversion. J Surg Res 2012; 176: 42-49 [PMID: 21962732 DOI:
29 Daniels ED, Pettifor JM, Schnitzler CM, Russell SW, Patel 10.1016/j.jss.2011.07.019]
DN. Ethnic differences in bone density in female South 44 Leister I, Becker H. [Relaparoscopy as an alternative to lapa-
African nurses. J Bone Miner Res 1995; 10: 359-367 [PMID: rotomy for laparoscopic complications]. Chirurg 2006; 77:
7785456] 986-997 [PMID: 17036247]
30 Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Appendi- 45 Sporn E, Petroski GF, Mancini GJ, Astudillo JA, Miedema
ceal stump abscess as an early complication of laparoscopic BW, Thaler K. Laparoscopic appendectomy--is it worth the
appendectomy: report of a case. Surg Today 2002; 32: 919-921 cost? Trend analysis in the US from 2000 to 2005. J Am Coll
[PMID: 12376795] Surg 2009; 208: 179-85.e2 [PMID: 19228528 DOI: 10.1016/
31 Gomes CA, Nunes TA, Soares C, Gomes CC. The ap- j.jamcollsurg.2008.10.026]
pendiceal stump closure during laparoscopy: historical, 46 Cothren CC, Moore EE, Johnson JL, Moore JB, Ciesla DJ,
surgical, and future perspectives. Surg Laparosc Endosc Burch JM. Can we afford to do laparoscopic appendectomy
Percutan Tech 2012; 22: 1-4 [PMID: 22318050 DOI: 10.1097/ in an academic hospital? Am J Surg 2005; 190: 950-954 [PMID:
SLE.0b013e31823fbf15] 16307952]
32 Roberts KE, Starker LF, Duffy AJ, Bell RL, Bokhari J. Stump 47 Haas L, Stargardt T, Schreyoegg J. Cost-effectiveness of open
appendicitis: a surgeon’s dilemma. JSLS 2011; 15: 373-378 versus laparoscopic appendectomy: a multilevel approach
[PMID: 21985727 DOI: 10.4293/108680811X13125733356954] with propensity score matching. Eur J Health Econ 2012; 13:
33 Watkins BP, Kothari SN, Landercasper J. Stump appendi- 549-560 [PMID: 21984223 DOI: 10.1007/s10198-011-0355-6]
citis: case report and review. Surg Laparosc Endosc Percutan 48 Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY,
Tech 2004; 14: 167-171 [PMID: 15471026] Esposito TJ. Comparison of outcomes after laparoscopic ver-
34 Tugnoli G, Giorgini E, Biscardi A, Villani S, Clemente N, sus open appendectomy for acute appendicitis at 222 ACS
Senatore G, Filicori F, Antonacci N, Baldoni F, De Werra C, NSQIP hospitals. Surgery 2010; 148: 625-35; discussion 635-7
Di Saverio S. The NOTA study: non-operative treatment for [PMID: 20797745 DOI: 10.1016/j.surg.2010.07.025]
acute appendicitis: prospective study on the efficacy and 49 Kapischke M, Friedrich F, Hedderich J, Schulz T, Caliebe
safety of antibiotic treatment (amoxicillin and clavulanic A. Laparoscopic versus open appendectomy--quality of life
acid) in patients with right sided lower abdominal pain. BMJ 7 years after surgery. Langenbecks Arch Surg 2011; 396: 69-75
Open 2011; 1: e000006 [PMID: 22021722 DOI: 10.1136/bmjo- [PMID: 20927534 DOI: 10.1007/s00423-010-0715-1]
pen-2010-000006] 50 Vettoretto N, Agresta F. A brief review of laparoscopic
35 Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appen- appendectomy: the issues and the evidence. Tech Co-
dectomy versus antibiotic treatment for acute appendicitis. loproctol 2011; 15: 1-6 [PMID: 21086013 DOI: 10.1007/
Cochrane Database Syst Rev 2011; (11): CD008359 [PMID: s10151-010-0656-2]
22071846 DOI: 10.1002/14651858.CD008359.pub2] 51 McKinlay R, Mastrangelo MJ. Current status of laparoscopic
36 Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A me- appendectomy. Curr Surg 2003; 60: 506-512 [PMID: 14972215]
ta-analysis comparing conservative treatment versus acute 52 Vettoretto N, Gobbi S, Corradi A, Belli F, Piccolo D, Per-
appendectomy for complicated appendicitis (abscess or nazza G, Mannino L. Consensus conference on laparoscopic
phlegmon). Surgery 2010; 147: 818-829 [PMID: 20149402 DOI: appendectomy: development of guidelines. Colorectal
10.1016/j.surg.2009.11.013] Dis 2011; 13: 748-754 [PMID: 21651696 DOI: 10.1111/
37 Paajanen H, Grönroos JM, Rautio T, Nordström P, Aarnio j.1463-1318.2011.02557.x]
M, Rantanen T, Hurme S, Dean K, Jartti A, Mecklin JP, Sand 53 Roberts KE. True single-port appendectomy: first experi-
J, Salminen P. A prospective randomized controlled mul- ence with the “puppeteer technique”. Surg Endosc 2009; 23:
ticenter trial comparing antibiotic therapy with appendec- 1825-1830 [PMID: 19169749 DOI: 10.1007/s00464-008-0270-9]
tomy in the treatment of uncomplicated acute appendicitis 54 Lin YY, Shabbir A, So JB. Laparoscopic appendectomy by
(APPAC trial). BMC Surg 2013; 13: 3 [PMID: 23394263 DOI: residents: evaluating outcomes and learning curve. Surg
10.1186/1471-2482-13-3] Endosc 2010; 24: 125-130 [PMID: 19760332 DOI: 10.1007/
38 Sakorafas GH, Mastoraki A, Lappas C, Sampanis D, Danias s00464-009-0691-0]

WJG|www.wjgnet.com 8806 December 21, 2013|Volume 19|Issue 47|

 Ruffolo C et al . Acute appendicitis

55 Gagner M, Garcia-Ruiz A. Technical aspects of minimally [PMID: 22874680 DOI: 10.1097/SLE.0b013e31824f2cf8]

invasive abdominal surgery performed with needlescopic 65 Perez EA, Piper H, Burkhalter LS, Fischer AC. Single-inci-
instruments. Surg Laparosc Endosc 1998; 8: 171-179 [PMID: sion laparoscopic surgery in children: a randomized control
9649038] trial of acute appendicitis. Surg Endosc 2013; 27: 1367-1371
56 Matthews BD, Mostafa G, Harold KL, Kercher KW, Reardon [PMID: 23239295 DOI: 10.1007/s00464-012-2617-5]
PR, Heniford BT. Minilaparoscopic appendectomy. Surg Lap- 66 Moazzez A, Mason RJ, Katkhouda N. Laparoscopic ap-
arosc Endosc Percutan Tech 2001; 11: 351-355 [PMID: 11822857] pendectomy: new concepts. World J Surg 2011; 35: 1515-1518
57 Sajid MS, Khan MA, Cheek E, Baig MK. Needlescopic ver- [PMID: 21437747 DOI: 10.1007/s00268-011-1032-8]
sus laparoscopic appendectomy: a systematic review. Can J 67 Colon MJ, Telem D, Divino CM, Chin EH. Laparoendo-
Surg 2009; 52: 129-134 [PMID: 19399208] scopic single site surgery can be performed completely
58 Chock A, Seslar S, Stoopen E, Tristan A, Hashish H, Gon- with standard equipment. Surg Laparosc Endosc Percutan
zalez JJ, Franklin ME. Needlescopic appendectomy. Surg Tech 2011; 21: 292-294 [PMID: 21857483 DOI: 10.1097/
Endosc 2003; 17: 1451-1453 [PMID: 12811662] SLE.0b013e31822474a4]
59 Pelosi MA, Pelosi MA. Laparoscopic appendectomy using 68 Ahmed K, Wang TT, Patel VM, Nagpal K, Clark J, Ali M,
a single umbilical puncture (minilaparoscopy). J Reprod Med Deeba S, Ashrafian H, Darzi A, Athanasiou T, Paraskeva P.
1992; 37: 588-594 [PMID: 1387906] The role of single-incision laparoscopic surgery in abdominal
60 Romanelli JR, Earle DB. Single-port laparoscopic surgery: an and pelvic surgery: a systematic review. Surg Endosc 2011; 25:
overview. Surg Endosc 2009; 23: 1419-1427 [PMID: 19347400 378-396 [PMID: 20623239 DOI: 10.1007/s00464-010-1208-6]
DOI: 10.1007/s00464-009-0463-x] 69 Rehman H, Rao AM, Ahmed I. Single incision versus con-
61 Greaves N, Nicholson J. Single incision laparoscopic surgery ventional multi-incision appendicectomy for suspected ap-
in general surgery: a review. Ann R Coll Surg Engl 2011; 93: pendicitis. Cochrane Database Syst Rev 2011; (7): CD009022
437-440 [PMID: 21929912 DOI: 10.1308/003588411X590358] [PMID: 21735437 DOI: 10.1002/14651858.CD009022.pub2]]
62 Teoh AY, Chiu PW, Wong TC, Poon MC, Wong SK, Leong 70 Rao GV, Reddy DN, Banerjee R. NOTES: human experience.
HT, Lai PB, Ng EK. A double-blinded randomized controlled Gastrointest Endosc Clin N Am 2008; 18: 361-370; x [PMID:
trial of laparoendoscopic single-site access versus conven- 18381176 DOI: 10.1016/j.giec.2008.01.007]
tional 3-port appendectomy. Ann Surg 2012; 256: 909-914 71 Huang C, Huang RX, Qiu ZJ. Natural orifice transluminal
[PMID: 23154391 DOI: 10.1097/SLA.0b013e3182765fcf] endoscopic surgery: new minimally invasive surgery come
63 Rehman H, Ahmed I. Technical approaches to single port/ of age. World J Gastroenterol 2011; 17: 4382-4388 [PMID:
incision laparoscopic appendicectomy: a literature review. 22110263 DOI: 10.3748/wjg.v17.i39.4382]
Ann R Coll Surg Engl 2011; 93: 508-513 [PMID: 22004632 DOI: 72 Roberts KE, Solomon D, Mirensky T, Silasi DA, Duffy AJ,
10.1308/147870811X13137608455091] Rutherford T, Longo WE, Bell RL. Pure transvaginal ap-
64 Gill RS, Shi X, Al-Adra DP, Birch DW, Karmali S. Single- pendectomy versus traditional laparoscopic appendectomy
incision appendectomy is comparable to conventional lapa- for acute appendicitis: a prospective cohort study. Ann
roscopic appendectomy: a systematic review and pooled Surg 2012; 255: 266-269 [PMID: 22167005 DOI: 10.1097/
analysis. Surg Laparosc Endosc Percutan Tech 2012; 22: 319-327 SLA.0b013e31823b2748]

P- Reviewers: Amin AI, Okumura K, Vettoretto N

S- Editor: Zhai HH L- Editor: A E- Editor: Zhang DN

WJG|www.wjgnet.com 8807 December 21, 2013|Volume 19|Issue 47|

 Published by Baishideng Publishing Group Co., Limited
Flat C, 23/F., Lucky Plaza,
315-321 Lockhart Road, Wan Chai, Hong Kong, China
Fax: +852-65557188
Telephone: +852-31779906
E-mail: bpgoffice@wjgnet.com
http://www.wjgnet.com

I S S N  1 0  0 7  -   9  3 2  7

4   7

9   7 7 1 0  0 7   9 3 2 0 45

© 2013 Baishideng Publishing Group Co., Limited. All rights reserved.

View publication stats