Surgical Science, 2013, 4, 426-428
http://dx.doi.org/10.4236/ss.2013.410083 Published Online October 2013 (http://www.scirp.org/journal/ss)
Outcomes of Single-Incision Laparoscopic Appendectomy
at a Single Center*
Takahiro Watanabe#, Hidetosi Wada, Masanori Sato, Yuichirou Miyaki, Junpei Tochikubo,
Norihiko Shiiya
Division of General Surgery and Endoscopic Surgery, Surgery I, Hamamatsu University School of Medicine, Hamamatsu, Japan
Received August 1, 2013; revised September 1, 2013; accepted September 9, 2013
Copyright © 2013 Takahiro Watanabe et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background and Objectives: Recently, single-incision laparoscopic surgery has been popular for minimally invasive
surgery and cosmetic improvement. We studied outcomes of single-incision laparoscopic appendectomy (SILA) in ac-
cordance with our strategy for acute appendicitis. Methods: Clinical outcomes were revealed in each of nine emergency
SILA (e-SILA) cases and eight interval SILA (i-SILA) cases performed for the treatment of acute appendicitis between
September 2010 and August 2012 at our hospital. Results: The male to female ratio was 6:3 for e-SILA and 5:3 for
i-SILA cases. Mean ages were 33.1 ± 17.8 years and 41 ± 21.6 years for e-SILA and i-SILA, respectively. The pre-
treatment white blood cell (WBC) count and C-reactive protein (CRP) levels were 14960 ± 4080/μL and 1.4 ± 2.3 mg/d,
respectively, for e-SILA and 12657 ± 4290/μL and 6.7 ± 8.3 mg/d, respectively, for i-SILA. The maximum transverse
diameter of appendix was 12.6 ± 3.5 mm for e-SILA and 11.6 ± 3.5 mm for i-SILA. Appendiceal abscesses were en-
countered in one (11%) e-SILA and three (38%) i-SILA cases. Perforation of the appendix at operation occurred in two
(22%) e-SILA cases and no i-SILA cases. Generalized peritonitis occurred in 4 (44%) e-SILA cases but in none of the
i-SILA cases. The postoperative hospital stay was 5.3 days for e-SILA, 2.7 days for i-SILA. Conversion to laparotomy
was not required in either group. One additional trocar was needed for an e-SILA case, and paralytic ileus occurred as a
postoperative complication in one e-SILA case. Conclusion: The outcomes of SILA performed under our strategy were
acceptable and useful without major postoperative complications.
Keywords: Laparoscopic Appendectomy; Single Access Laparoscopic Surgery; Minimally Invasive Surgery
1. Introduction
Since the initial report by Semm on laparoscopic appen-
dectomy in 1983 [1], the procedure has been widely per-
formed worldwide. Recently, single-incision laparo-
scopic appendectomy (SILA) has been increasingly per-
formed in many surgical centers. In Japan, the cases of
single-incision laparoscopic surgery have been increasing
since 2000; we have employed SILA for the treatment of
acute appendicitis since September 2010 in our hospital.
In this study, we aimed to reveal outcomes of SILA in
accordance with our strategy for acute appendicitis.
2. Materials and Methods
From September 2010 to August 2012, we performed 17
SILA procedures at Hamamatsu University School of
Medicine. These included nine emergency SILA (e-SILA)
and eight interval SILA (i-SILA) cases. We revealed the
clinical outcomes each of e-SILA and i-SILA.
Our treatment strategy for acute appendicitis is de-
picted in Figure 1. We performed e-SILA in cases of
generalized peritonitis and those with likely perforated
appendicitis such as a markedly swollen appendix, thin-
ning of the appendix wall and impacted appendiceal cal-
culi. Andi-SILA was adopted to avoid extended opera-
tions, such as ileocecal resections, and to decrease post-
*Disclosure of interest: We report no conflict of interest.
#Corresponding author. Figure 1. Our strategy of treatment for acute appendicitis.
C
opyright © 2013 SciRes. SS

T. WATANABE ET AL. 427
operative complications. We followed a conservative
treatment for cases of local peritonitis, appendiceal ab-
scesses, and spread of inflammation around the appen-
dix. In cases requiring an interval appendectomy in order
to avoid recurrent appendicitis following conservative
therapy, i-SILA was performed a few months later. Pa-
tients selected e-SILA or i-SILA if they had mild in-
flammatory appendicitis along with the absence of
aforementioned signs or symptoms.
Operation was performed using a 1.5 - 2.0 cm tran-
sumbilical vertical incision. Thereafter, the fascia and the
peritoneum were opened vertically, and three 5-mm tro-
cars were inserted into the abdomen for introduction of
endoscopic instruments. Carbon dioxide was used to in-
flate the abdomen at 8 - 10 mmHg pressure. The operator
used two 5-mm forceps, and the first assistant manned a
30˚ 5-mm laparoscope (KarlStorz, Tuttlingen, Germany).
The mesoappendix and appendicular vessel was dis-
sected using laparoscopic coagulating shears. Once the
cecum was mobilized to the umbilicus, the appendix was
excised and removed via the transumbilical incision in all
cases. A first or second generation cephalosporin antibi-
otic was administered only on the day of surgery in most
cases ofi-SILA cases. Conversely, antibiotics such as
second generation cephalosporin, tazobactam sodium/
piperacillin sodium and carbapenem were administered
for an average of 4.4 days in e-SILA cases at the sur-
geon’s discretion.
3. Results
The male to female ratio was 6:3 for e-SILA and 5:3 for
i-SILA cases. Mean ages were 33.1 ± 17.8 years and 41 ±
21.6 years for e-SILA and i-SILA, respectively. In addi-
tion, the pretreatment white blood cell (WBC) count and
C-reactive protein (CRP) levels were 14960 ± 4080/μL
and 1.4 ± 2.3 mg/d, respectively, for e-SILA and 12657 ±
4290/μL and 6.7 ± 8.3 mg/d, respectively, for i-SILA.
Moreover, the maximum transverse diameter of appendix
as measured by computed tomography was 12.6 ± 3.5
mm for e-SILA and 11.6 ± 3.5 mm for i-SILA. Appen-
diceal abscesses were encountered in one (11%) e-SILA
and three (38%) i-SILA cases. Perforation of the appen-
dix at operation occurred in two (22%) e-SILA cases and
no i-SILA cases. Generalized peritonitis occurred in 4
(44%) e-SILA cases but none of the i-SILA cases. The
number of cases with appendiceal calculi totaled 7 (78%)
for e-SILA and 2 (25%) for i-SILA (Table 1).
One additional trocar was used in a case of e-SILA
with severe inflammation; however, no additional trocars
were required in any of the i-SILA cases, and none of the
cases in either group were converted to laparotomy. The
operation times were 97 ± 38 min for e-SILA and 78 ±
32 min for i-SILA. Average blood loss was 5 ± 8 ml for
e-SILA and 2 ± 4 ml for i-SILA. The postoperative com-
plication of paralytic ileus developed in only one e-SILA
case, and the patient recovered with conservative man-
agement. No other postoperative complications, includ-
ing wound infections, were encountered. The postopera-
tive length of hospital stay was 2.7 ± 1.0 days (range, 2 -
5 days) for patients undergoing i-SILA and 5.3 ± 3.1
days (range, 2 - 12 days) for patients undergoing e-SILA
(Table 2).
4. Discussion
Since the first laparoscopic appendectomy was reported,
the procedure has been extensively performed worldwide.
Compared with open appendectomy, laparoscopic ap-
pendectomy has the benefits of a small incision size, less
postoperative pain, decreased postoperative complica-
tions, shorter hospital stay, and improved cosmesis [2-4].
In Japan, single-incision laparoscopic surgery was re-
ported for the first time in 2000, and the number of cases
undergoing this procedure has continued to increase since
Table 1. Characteristics of patients.
e-SILA i-SILA
Number of case 9 8
Male:Female 6:3 5:3
Age (years) 33.1 ± 17.8 41 ± 21.6
Original WBC (/μL) 14960 ± 4080 12657 ± 4290
Original CRP (mg/d) 1.4 ± 2.3 6.7 ± 8.3
Size of the appendix* (mm)12.6 ± 3.5 11.6 ± 3.5
Appendiceal calculi** 7 (78%) 2 (25%)
Appendiceal abscess 1 (11%) 3 (38%)
Perforation of the appendix2 (22%) 0
Generalized peritonitis 4 (44%) 0
WBC: White blood cell; CRP: C-reactive protein; SILA: single-incision
laparoscopic appendectomy; e-: emergency; i-: interval; *Measuring the
diameter of the appendix on the CT examination; **Appendiceal calculi that
can be identified on the CT examination.
Table 2. Outcomes of e-SILA and i-SILA.
e-SILA i-SILA
Additional ports 1 (11%) 0
Conversion to laparotomy 0 0
Operation time (min) 97 ± 38 78 ± 3
Blood loss (ml) 5 ± 8 2 ± 4
Postoperative complication1 (paralytic ileus) 0
Postoperative length of stay5.3 ± 3.1 2.7 ± 1.0
SILA: single-incision laparoscopic appendectomy.

T. WATANABE ET AL. 428
2008. The purpose of this research was to reveal out-
comes of SILA in accordance with the specific strategy
used at our hospital. Then, our result was acceptable
without major postoperative complications.
There are differences in strategies for acute appendici-
tis in each hospital. Surgical site infection (SSI) is the
most common complication after appendectomy. Mar-
genthaler et al. [5] reported the incidence of SSI after
appendectomy to be approximately 8%. It is essential to
reduce the incidence of SSI for improving the outcome
following appendicitis. In previous reports [6-8], a
wound infection rate of about 5% for single-incision ap-
pendectomies has been described, which was higher than
conventional laparoscopic appendectomy. In our study,
however, wound infection was not encountered. Appro-
priate surgical practices such as gentle manipulation and
adequate wound protection are essential to prevent SSI.
Our operation time for SILA was longer than that re-
ported in previous studies [9,10]. One reason for this
discrepancy may be our surgical technique. We per-
formed extracorporeal appendectomies through a single
umbilical incision after the cecum was mobilized to the
umbilicus, if necessary. The merit of this method is that
when appendiceal calculi are impacted at the appendiceal
base, we can easily manage this situation under direct
vision. However, Kang et al. [10] reported the impor-
tance of selecting intra- or extracorporeal appendectomy
whether the cecum is mobile or not in order to avoid un-
necessary manipulation and reduce operation time.
A total of 20 cases underwent conservative treatment
for acute appendicitis at our hospital from September
2010 to August 2012. Two cases (10%) were converted
to e-SILA because of severe inflammation, 8 cases (40%)
underwent i-SILA, and 10 cases (50%) did not undergo
any operation. At the discretion of the attending physi-
cian, antibiotics such as second generation cephalosporin,
tazobactam sodium/piperacillin sodium, and carbapenem
were administered for an average of 5.4 days as our con-
servative treatment. The hospital stay during conserva-
tive treatment averaged 7.3 days (range, 4 - 20), and the
outcomes were acceptable. As i-SILA was performed
after the inflammation subsided, under our treatment
regimen, patients in this group were able to be dis-
charged considerably earlier compared with those in the
e-SILA group.
5. Conclusion
In conclusion, the outcomes of SILA performed under
our strategy were acceptable and useful without major
postoperative complications.
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