One, given the two dimensional aspect to today's instrumentation, there is a high premium on the concept of "triangulation" of your ports. In other words, being able to approach a target from angled positions on the abdominal wall augments the efficiency and usefulness of right and left handed instrument control. Approaching a target with instruments originating from a zero degree position is awkward at best, and hemorrhagic stroke inducing at worst. Ultimately, in perhaps the most stinging rebuke, it lacks elegance. Any surgeon worth a darn, from a technical perspective, will always seek the Way of Elegance when performing an operation. (As an aside, relative absence of elegance is directly correlated with overall OR mood and surgeon/ancillary staff relationships.) Until the instrumentation improves (i.e. articulating capabilities, curved shafts, ect) then any and all attempts at zero degree single port laparoscopy will be efforts in frustration.
Two, in order to insert a port that allows three instruments, one has to necessarily make a larger fascial incision. Larger fascial incisions ineluctably lead to higher hernia rates. Ergo, single port surgery will lead to higher long term incisional hernia rates. It's very simple and intuitive. No degrees in quantum mechanics required for general surgery.
A recent RCT from Annals demonstrates entirely expected findings. Outcomes (short term) were noted to be similar whether one used single port surgery or conventional three port techniques. Interestingly, the outcome most cited by single port enthusiasts as a reason for their strategy (better cosmesis) was no better in conventional vs single port in the study.
So a surgeon is faced with a pseudo dilemma. Should he learn a new technique that offers no improvement on post operative pain, no better wound infection rate, lacks the element of elegance and comfort, is more expensive and likely leads to significantly higher rates of incisional hernia in the long run?
Answer seems obvious to me.
Objective: To compare surgical outcomes and quality of life between single-port laparoscopic appendectomy (SPLA) and conventional laparoscopic appendectomy (CLA) in patients with acute appendicitis.
Background: A prospective randomized single center study was performed to compare the outcome of SPLA and CLA in patients with acute appendicitis.
Methods: A total of 248 patients were randomized, but because of 18 withdrawals, the outcome of 224 is analyzed, 116 in CLA and 114 in SPLA.
Results: There was no significant difference in the overall complication rate (P = 0.470). There were no significant differences in infectious complications between the SPLA group and the CLA group (10.2% and 12.4%, respectively). The wound complication rate between the 2 groups was not significant (5.1% and 10.6%, respectively; P = 0.207). Cosmetic satisfaction score, 36-item short-form health survey, and postoperative pain scores were not significantly different between 2 groups.
Conclusions: SPLA failed to show any advantages over CLA relative to pain and cosmesis. However, SPLA is as safe as CLA