Single-port Laparoscopic Appendectomy During Pregnancy :

Single-port transumbilical laparoscopy, also known as embryonic natural orifice transumbilical endoscopic surgery (E-NOTES), has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Within a short span, several clinical reports have emerged in the urologic literature. As this field is poised to move forward, a complete understanding of its evolution and current status is timely. To summarize and review the history of E-NOTES across surgical disciplines. This review emphasizes nomenclature, surgical technique, instrumentation, and perioperative outcomes. Specific urological and nonurological applications of single-port surgery to date are summarized. Using the National Library of Medicine database, the English-language literature was reviewed for the past 40 yr. Keyword searches included: scarless, scar free, single port/trocar/incision, intraumbilical, and transumbilical. Within the bibliography of selected references, additional sources were retrieved. The gynecologic and general surgical literature includes approximately 19 papers fulfilling the search criteria, encompassing extirpative procedures only. The urologic literature contains eight published reports of single-trocar transumbilical procedures. These reports are summarized in a chronological manner and grouped by subject. No prospective studies comparing outcomes to standard laparoscopy have been reported. Technical feasibility has been demonstrated for a broad range of extirpative and reconstructive procedures on the upper and lower urinary tracts, including simple and radical nephrectomy, donor nephrectomy, renal cryotherapy, pyeloplasty, ileal ureteral replacement, sacrocolpopexy, and varicocelectomy. E-NOTES has made its initial forays into laparoscopic surgery. Ongoing refinement in technique and instrumentation is likely to expand its future role.

To present our initial experience with single-port laparoscopic urologic surgery using the Uni-X Single Port Access Laparoscopic System, a single port, multichannel cannula, with specially designed curved laparoscopic instrumentation. We performed single-port laparoscopic surgery in 10 patients, including renal cryotherapy in 4, wedge kidney biopsy in 1, radical nephrectomy in 1, and abdominal sacrocolpopexy in 4. For the transperitoneal approach, the multichannel port was inserted transumbilically, and for retroperitoneoscopy, the port was inserted at the tip of the 12th rib. Data were collected prospectively into our institutional review board-approved data registry. Since September 25, 2007, a total of 10 patients have undergone single-port laparoscopic surgery for various upper abdominal and pelvic pathologic findings. All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time for the various kidney procedures was 2.5 hours (range 2 to 3.2) and was 2.5 hours (range 2 to 3) for sacrocolpopexy. The mean blood loss was 100 mL for the renal procedures and 90 mL for sacrocolpopexy. The hospital stay was 2.8 days (range 1 to 8) for the kidney procedures and 2 days for sacrocolpopexy. One complication occurred in a patient with baseline congestive heart failure who underwent cryoablation and required oxygen mask ventilation postoperatively that delayed her hospital discharge for 1 week. The same patient, who was anemic preoperatively, was transfused with 3 U of packed red blood cells, although the postoperative computed tomography scan revealed a small perinephric hematoma. Single-port laparoscopic renal cryotherapy, wedge kidney biopsy, radical nephrectomy, and abdominal sacrocolpopexy are safe and feasible. Additional experience and continued investigation are warranted.

Subsequent to a report from the authors' institution, the laparoscopic management of symptomatic cholelithiasis and appendicitis during pregnancy has become the standard of care at LDS Hospital using institutional guidelines. For comparison with previous outcomes described by the authors, 59 additional laparoscopic cases are reported. Medical records of all pregnant patients at LDS Hospital who underwent open or laparoscopic cholecystectomy or appendectomy between 1998 and 2002 were reviewed. The outcomes were compared with the authors' previous data. The laparoscopic management of symptomatic cholelithiasis and appendicitis during pregnancy increased from 54% to 97%. No significant differences in preterm delivery rates, birth weights, or 5-min Apgar scores were found between the two periods. No birth defects or uterine injuries occurred. With the use of the authors' guidelines, laparoscopy has become the standard of care for managing symptomatic cholelithiasis and appendicitis during pregnancy at LDS Hospital without significant increase in morbidity or mortality.