Flexible-tip laparo-endoscopic surgery: A bridge to single port appendicectomy in children

Introduction: Single port surgery (SPS) has been demonstrated to have some advantages over conventional laparoscopy. However, currently available port sizes may limit the application in younger children or those with a small umbilicus. Moreover, the consultant learning curve required to master single port surgery may have a negative impact on surgical training. We report the first series of children who were treated with a reduced incision technique for appendicectomy using flexible-tip laparo-endoscopic surgery (FLES). Patients and Methods: FLES was set up using one 11-mm and 2×5-mm bladeless ports (Ethicon XCEL™) via umbilical and low left iliac fossa incisions. A 10-mm flexible-tip laparo-endoscope was utilized. Tip angulation ensured visibility while minimising instrument clashing. A database of children undergoing FLES was kept prospectively. Demographic and peri-operative information and complications were recorded. Data are presented as medians with ranges. Results: Between March and June 2010, 5 children (4 females) aged 9 (4-13) years underwent FLES for right iliac fossa pain. 2 procedures were performed by the admitting consultant, 3 by a supervised inexperienced laparoscopic trainee. 4 children had acute appendicitis including 1 with an inflammatory mass. Another had a haemorrhagic ovarian cyst. Appendicectomy was performed in all. The duration of surgery was 104 (93-130) min, and postoperative hospital stay was 2 (1-6) days. At 7 (5-8) months follow-up no complications have been recorded. At follow-up, the cosmetic results were judged to be excellent in all by the children, their parents and the reviewing surgeon. Conclusions: FLES is an alternative to standard laparoscopy and SPS in children, and be performed effectively and safely by junior trainees. Cosmetic results are excellent. It may represent a bridge technology, particularly for younger children, until single port products and techniques more suitable for appendicectomy in this age group are available. Finally, flexible-tip technology may play a useful role as SPS evolves.