title: Extracorporeal and intracorporeal approaches of single-incision laparoscopic appendectomy in children: is one superior to another?
abstract: BACKGROUND
  Single-incision laparoscopic surgery has been widely popularized for pediatric appendicitis. Various techniques have been proposed with two main approaches: extracorporeal and intracorporeal. The purpose of this study is to compare the result of different approaches in single-incision laparoscopic appendectomy (SILA) in children.
  
  
  METHODS
  With IRB approval, patients less than 18years of age who underwent SILA were enrolled from July 2012 to December 2015. The patients were divided into three groups based on surgical approach: extracorporeal (Extra), mixed (Mix), and intracorporeal (Intra) approaches. Parameters were retrospectively reviewed, including age, gender, white blood cell (WBC), operation time, operative findings, time to diet, length of hospital stay (LOS), and complications. Statistical analysis was performed separately for simple and complicated appendicitis.
  
  
  RESULTS
  There were 32, 32, and 24 patients with simple appendicitis in Extra, Mix, and Intra respectively. There were 27, 15, and 31 patients with complicated appendicitis in the three groups, respectively. No significant difference was noted in the mean age, gender distribution, or WBCs between the different groups. A higher percentage of patients with complicated appendicitis received intracorporeal approach than those with simple appendicitis (42.5% vs. 27.3%, p=0.044). In simple appendicitis, the LOS was significantly longer in Extra as compared to Mix (p=0.043). Otherwise, the mean LOS, time to diet, and complications were not significantly different. The mean operation time was similar between groups of simple appendicitis (56.5±19.5, 63.6±23.5, and 70.1±23.1 min, p=0.08), whereas it was significantly shorter in Extra of complicated appendicitis (67.6±16.4, 86.6±19.0, and 89.9±23.4 min, p<0.001). Multivariate analysis showed that intracorporeal approach is an independent factor for prolonged operation time in both simple and complicated appendicitis.
  
  
  CONCLUSIONS
  Different approaches of SILA in children have similar outcomes for both simple and complicated appendicitis. Extracorporeal is the most time efficient; however, intracorporeal can be helpful to deal with complex situations.
  
  
  METHODS
  III.
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan.
authors.forename: Yao-Jen
authors.initials: YJ
authors.lastname: Hsu
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medical College, New Taipei City, Taiwan.
authors.forename: Paul Chia-Yu
authors.initials: PC
authors.lastname: Chang
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medical College, New Taipei City, Taiwan. Electronic address: chinhungwei@yahoo.com.tw.
authors.forename: Chin-Hung
authors.initials: CH
authors.lastname: Wei
authors.affiliation: Department of Pediatric Surgery, Changhua Christian Hospital, Changhua, Taiwan.
authors.forename: Fu-Yu
authors.initials: FY
authors.lastname: Wei
authors.affiliation: Department of Pediatric Surgery, Mackay Memorial Hospital, Hsinchu, Taiwan.
authors.forename: Yih-Cherng
authors.initials: YC
authors.lastname: Duh
mesh_terms: D000293:Adolescent; D001062:Appendectomy / Q000379:methods*; D001064:Appendicitis / Q000601:surgery*; D002648:Child; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D015999:Multivariate Analysis; D061646:Operative Time; D012189:Retrospective Studies; D000072836:Surgical Wound / Q000453:epidemiology; D016896:Treatment Outcome
keywords: Children; Complicated appendicitis; Extracorporeal; Intracorporeal; Laparoscopic appendectomy; Single incision