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The next step towards ‘scar-less’ surgery utilises a modified single-port inserted through the umbilicus achieving excellent cosmetic results. This modification of laparoscopic surgery is currently being adopted in various elective general surgical procedures.1,2 Appendicectomy is one of the most commonly performed emergency laparoscopic procedures and provides an excellent training opportunity. In our institution, 26 appendicectomies (17 females) have been performed over a 6-month period.
The patient is placed in the Trendelenburg position with gentle downwards left tilt, with assistant and surgeon on patient's left and scrub nurse on the right. We use a tri-channel flexible port (2 mm × 5 mm, 1 mm × 10 mm) for the procedure (Fig. 1). Incision should be intra-umbilical so that postoperative scar is well hidden (Fig. 2). Due to a single entry point, the left- and right-hand instruments cross at the point of entry to the peritoneal cavity; therefore, the surgeon must remember that their left hand is operating the instrument on the right side of the screen. Roticulating instruments are commercially available but re-useable straight hook diathermy and graspers are suitable in most cases hence reducing cost. Conventional endoloops are used to ligate the appendix base (Fig. 3). The inflamed appendix is removed inside the port minimising the chance of wound contamination. Additional 5-mm ports can be added in case of difficulty; however, this has not been necessary so far in our experience. The 12-mm transumbilical incision is closed under vision with 1–2 PDS sutures.
The potential advantages of this technique are improved cosmesis (Fig. 4), reduced pain and port-related complications. Appendicectomy provides the ideal initial training operation for single-port surgery and appears to have a short learning curve. Our early results have not shown any potential disadvantages over the traditional laparoscopic technique.