Single-Incision Laparoscopic Appendectomy with a Low-Cost Technique and Surgical- Glove Port: “How To Do It” with Comparison of the Outcomes and Costs in a Consecutive Single-Operator Series of 45 Cases  Salomone Di Saverio, MD, FACS, FRCS, Matteo Mandrioli, MD, Arianna Birindelli, MD, Andrea Biscardi, MD, Luca Di Donato, MD, Carlos Augusto Gomes, MD, PhD, TCBC, Alice Piccinini, MD, Nereo Vettoretto, MD, Ferdinando Agresta, MD, Gregorio Tugnoli, MD, PhD, Elio Jovine, MD, PhD  Journal of the American College of Surgeons  Volume 222, Issue 3, Pages e15-e30 (March 2016) DOI: 10.1016/j.jamcollsurg.2015.11.019 Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 1 The simple and inexpensive equipment needed for establishment of a surgical-glove port: a wound protector sized small or extra small, a surgical sterile glove, and the usual traditional equipment for open Hasson technique for umbilical access. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 2 A transumbilical mid-line incision is made with extension ranging from 1.5 cm to maximum 2 cm after navel eversion with Kelly clamps. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 3 A safe open access to the abdominal cavity is therefore obtained under direct vision, after incision of the peritoneal layer. The incision can be enlarged up to 2.5 cm, underneath by cutting the fascia. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 4 The umbilical hole is the only working channel in this single-incision laparoscopic surgery technique and is the fulcrum for the movements of the laparoscopic instruments entering the abdominal cavity. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 5 (A) The wound protector is able to provide safe and convenient access for the laparoscopic straight instruments into the abdomen through the umbilical incision, and (B) guarantee the protected retrieval of the appendix specimen, avoiding contamination of the surgical site. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 6 The edges of the incision on the fingertip can be gently grasped and stretched to facilitate the introduction of the cannula inside the finger. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 7 Three cannulas are inserted within each finger of the glove and the CO2 tube is connected to the valve of any cannula (preferably, for CO2 connection, it should be used with the cannula toward the head of the patient to avoid twisting or conflicting the CO2 tube with the other trocars or with the inflated glove itself). Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 8 When the CO2 insufflation is started gradually and slowly, the glove is inflated, resembling the human hand, with the trocars inserted in each finger. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 9 (A) The scope is introduced first in the external space, within the surgical glove and the umbilical hole stretched by the wound protector is identified. (B) Then the scope can be carefully advanced under direct vision through the umbilicus inside the abdominal cavity. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 10 (A, B) By using the umbilical edges as a fulcrum, the 30-degree scope is able to explore the entire abdominal cavity, with achievement of appropriate 360-degree rotation in its major axis around the umbilicus, as well as using the rotation of the scope itself on its own circular axis, for reaching the best lateral views. Note from this picture, the elasticity and pliability of the surgical-glove port, which make it much easier to allow a wide range of movements for the instruments and to achieve enough triangulation than is usually allowed by traditional commercial single-port devices. (Figures provided courtesy of the artist, Dr Serena Galli.) Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 11 The pliability of the surgical-glove port allows a great flexibility for the laparoscope as well as for any other surgical instruments, and extreme angles of maneuverability can be reached by the scope and the 2 other surgical instruments. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 12 After the scope has been introduced inside the abdomen, the other instruments are usually introduced more easily under direct vision of the scope, which can be slightly retracted outside the abdominal cavity and within the surgical-glove port camera and is therefore able to (A) guide the entrance of the surgical instruments (eg, Maryland dissector, scissors), as well as (B) prevent accidental injuries on the abdominal wall, umbilical edges, or even tearing of the wound protector or glove itself. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 13 When the appendix is stuck by surrounding dense and thick inflammatory adhesions, the blunt use of suction device can be an extremely useful and effective method to get a plane for a safe dissection and mobilization from the surrounding inflamed viscera and tissues. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 14 (A, B) The movements in single-incision laparoscopic surgery are restricted and the triangulation is extremely limited or completely impossible to achieve due to coaxiality. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 15 (A, B, C, D) Triangulation and the movements for dissecting, cauterizing, cutting, and tying can be achieved more easily on the vertical axis, with one instrument grasping and pulling the tip of the appendix upward and the second instrument moving downward for dissecting the planes, cauterizing the mesentery, peeling and gently pulling the mesenteric tissues downward. (E) Once the appendix is fully mobilized and its base on the cecum is identified, the dissection and coagulation of the mesentery is carefully performed, paying attention to the limited triangulation. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 16 (A, B) The maximal rotation of the grip and of the fiberoptic cable of the 30-degree scope, can be used to change the angle of the view and be therefore able to “see” the operative field and the instruments with a “lateral eye,” to finally avoid or minimize the instruments conflict and collisions. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 17 (A, B, C) The camera enters the abdomen immediately after the grasper and the Endoloop, or the grasper can be pushed inside the loop inside the external space of the surgical glove, under direct scope vision. (D, E) The instruments (grasper usually in the left hand, grasping and pulling the appendix upward and the Endoloop is handled by the right hand) should be moved on the vertical axis and then the loop can slide down until the base of the appendix, with the aid of small rotational movements. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 18 (A, B) After knotting the appendiceal stump both proximally and distally, the lower Endoloop is purposely left long and pulled to get an effective retraction; the scissors are then carefully introduced for cutting the appendix between the 2 ties. The coaxiality requires a careful handling of the scissors. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 19 The larger umbilical incision, typically required for a single-incision laparoscopic surgery access, is often useful and large enough even for the extraction of the most bulky specimens. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 20 (A) The appendix is introduced into the finger and stored inside; (B) the glove finger containing the specimen can be closed from outside by knotting its base and the specimen can be left fully enclosed within the glove finger, avoiding any contamination or spillage. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions

Figure 21 Final steps of the procedure are the extraction of the instruments and camera, termination of the pneumoperitoneum with disconnection of the glove from the external ring of wound protector and careful extraction of the entire wound protector. Journal of the American College of Surgeons 2016 222, e15-e30DOI: (10.1016/j.jamcollsurg.2015.11.019) Copyright © 2016 American College of Surgeons Terms and Conditions