Thursday, December 1, 2011

Single incision laparoscopic surgery for appendicitis may not be better


I don’t usually like to review papers that have only been published in abstract form or orally presented because complete data are not available for analysis. But I’m going to make an exception here because a recent paper presented at the American College of Surgeons annual meeting in October and featured on page 1 of Surgery News supports one of my many biases.

Researchers at the Chinese University of Hong Kong performed a trial involving 200 patients undergoing laparoscopic appendectomy randomized into two groups, conventional 3-port [3P] and laparoscopic single-site access [LESS]. The 3P approach uses 3 small incisions to insert the scope/camera and instruments while the LESS uses a single incision at the umbilicus with the scope/camera and instruments all inserted via the one incision.

Guess what? LESS was not only harder to perform [due to the inability to triangulate the instruments which are too close to each other] but it also caused significantly more postoperative pain.

Although LESS theoretically might result in a better cosmetic result because the only incision is in the umbilicus, the 3P procedure results in one scar in the umbilicus and two 5 mm scars in the lower abdomen. The two 5 mm scars are often invisible several months after surgery.

This study is one of the few large randomized trials on any type of single incision surgery and may be the first to show that LESS is inferior to the current standard. Because of their findings, lead author Dr. Anthony Y. B. Teoh said that his group “reverted to the three-port procedure” for patients presenting with appendicitis.

I previously blogged about a small study extolling the virtues of single-port robotic cholecystectomy, which purported to show [but did not] that it was better than the standard laparoscopic method.

Will there be more disillusionment with single-port surgery as larger and better designed studies emerge?

9 comments:

Anonymous said...

A surgeon I know calls all things in this general category "stupid human tricks". I totally get what he means.

-SCRN

busysynch mac said...

I really never saw the point of LESS since, as you point out, the smaller incisions basically disappear in months. Ditto for endoscopic cholecystectomy, though I tried to keep an open mind for the first few I saw, not wanting to appear to much the geezer.
I am reminded of the old joke about the trans-anal tonsillectomy performed in the Soviet Union because you were required to keep your mouth shut.

Skeptical Scalpel said...

Thanks for the comments.

The trans-anal tonsillectomy might not be a joke. People are now removing gallbladders through the vagina.

Anonymous said...

This is but one more example of anything new being much more exciting than anything old, no matter how good the old is, and how unproven the new is.

Skeptical Scalpel said...

Agree. It happens all the time in medicine.

Anonymous said...

Change is always hard and subject to critical review. It was not too long ago when all appys and choles were done open, and the surgical community came down hard. Now look at us.
SILS may not be the answer, but I appreciate those surgeons who push the boundaries for the sake of improving and advancing the science of surgery.
ESK

Skeptical Scalpel said...

I agree with you up to a point. I think we are now in the "because we CAN do it this way, we should" phase of the evolution of minimally invasive surgery. Perhaps you will remember that a few years ago, surgeons were doing laparoscopic Whipple procedures because they could. It doesn't seem to have caught on.

hospital in mumbai said...

i read your article , you have shared nice experience on Laparoscopy

Is Laparoscopic surgery better than a traditional for femoral hernia?

Skeptical Scalpel said...

As far as I know, that has not been studied. The incidence of femoral hernia is low. It would be hard to accrue enough patients to compare laparoscopic vs. traditional.

A study just published in Archives of Surgery (http://is.gd/LOkWuL) claims that minimally invasive repairs are better for inguinal hernia with the caveat that the minimally invasive surgeon must be experienced.

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