In classical LA care should be taken in order to place the trocar incisions parallel to Langers’ lines of wound healing [22]; moreover 10/12 operative trocar (if used) should be put preferably in the supra-pubic area (instead of left or right flank). Whenever possible 5 mm trocars should be preferred, at least in those cases in which the appendix can be

NCT-501 research buy extracted from the optical trocar. Alternative supra-pubic positions have been described in order to improve cosmetics [23]. The use of miniports (minilaparoscopic appendectomy) has been shown to carry similar results with less analgesic requirement and rate of conversion in non-complicated cases [24]. These tricks might render the difference between single trocar and classic laparoscopy not influential in terms of visible scars. Another claimed advantage regards incisional

hernias. This problem increases in the lower abdomen, where the intra-abdominal pressure learn more is higher in the upstanding position. The rationale for larger incisions of the fascia, required for single trocar access, is that the “”open”" technique is mandatory, and so is the closure suture (under direct vision): this should lower the incisional hernias. This isn’t anyway proved by trials in the literature, where different trocar entries are never studied in association tuclazepam with postoperative observation of port-site hernias. If this hypothesis should be ever demonstrated “”open access”" (using Hasson technique) should be find more routinely performed for the induction of pneumoperitoneum also in conventional laparoscopy. Conclusions In conclusion, single port appendectomy is technically feasible for most cases of appendicitis. Anyway, the possible advantages, advocated for single access

surgery in other diseases, should be carefully considered in relation to the advantages of laparoscopic appendectomy over the open appendectomy, which are not so evident even after more than twenty years from the first operation by Hans de Kok [25]. Therefore, on the basis of the published results of this technique, we recommend its application only to restricted groups of patients: notably pre-menopausal women in which, after explorative laparoscopy (10 mm trocar passed through an intra-umbilical incision), the level of inflammation of the appendix is not so high and absolutely not complicated by generalized peritonitis, abscess, gangrene or perforation; if these conditions are satisfied, the 10 mm trocar can be substituted with a multi-port single trocar which should guarantee a complete wound protection during the extraction of the organ.