appendicitis is the most frequent indication for urgent surgery in children . since 1894 , when mc burney described the laparotomic technique for appendectomy
, the same operation has been the gold standard for acute appendicitis for over a century . in 1983 ,
semm   described for the first time the standard three ports laparoscopic appendectomy and since then the minimally invasive approach has gained wide acceptance among the pediatric surgeons .
different variations of the laparoscopic technique have been proposed , all aiming to better cosmetic results , reduction in costs , and charges for hospitals , while keeping the safety of the operation unchanged .
the umbilicus as the unique site to gain access to the abdomen and to the appendix has been widely reported in the literature , both as a port to exteriorize the appendix and perform an extracorporeal operation [ 2 , 3 ] and as the site to place all laparoscopic instruments and perform an intracorporeal appendectomy ( sils ; single - site laparoscopic surgery ) [ 4 , 5 ] .
the trans umbilical laparo - assisted technique ( tulaa ) merges together the advantages of both a good intraabdominal laparoscopic visualization and the safety and quickness of an extracorporeal traditional appendectomy .
a large series of pediatric patients operated on with this technique was presented in 1999 by valla et al . , but patients were selected for absence of complicated appendicitis . recently ,
ohno et al . presented a paper in which the tulaa procedure was used in 416 patients but without any perforated appendicitis or local abscesses in the series .  
we present the experience of our centre , in which the use of tulaa was firstly introduced in 2006 , in a team where only one surgeon had used the technique before , and it was decided to perform it with every kind of appendicitis , with or without the suspect of complicated appendicitis .
the charts of all patients admitted to our surgical department from january 2006 to december 2010 , with a diagnosis of appendicitis based on clinical ( migration of pain to right lower quadrant ( rlq ) , fever , and rebound tenderness in rlq ) , laboratory ( elevated wbc count , elevate c reactive protein ( crp ) ) , and ultrasound ( us ) findings were retrospectively reviewed for demographical data , surgical treatment , time for completing the operation , intraoperative finding , need for conversion , and surgical complications .   before 2006 ,
all suspected appendicitis , regardless of history and perforation status , were treated by open surgery , and antibiotic therapy was prescribed according to the preference of the surgeon . since 2006 , a new protocol for the treatment of complicated and uncomplicated appendicitis was introduced in our surgical department .
all patients with suspected nonperforated or perforated appendicitis but with a history of less than 72 hours and no ultrasound evidence of consolidated appendiceal mass are offered tulaa .
all patients undergoing surgery are administered a single dose of ampicillin  plus  sulbactam ( 50  mg / kg / dose ) as prophylaxis 30 before starting the operation . if there is no perforation , the therapy with the same antibiotic
is continued for 24 hours and then stopped ; whenever perforation is found , a regimen of ceftriaxone ( 100  mg / kg / die in one administration ) plus metronidazole ( 7.5  mg / kg / dose every 8  hrs ) is administered as long as the patient is afebrile for at least 24 hours , inflammatory markers are diminishing , and full oral diet is restored . in case of discharge before 7 days of intravenous antibiotics , patients are put on oral amoxicillin ( 50  mg / kg / dose every 12  hrs ) and metronidazole ( 7.5  mg / kg / dose every 8  hrs ) to complete a whole week of therapy .  
all appendiceal masses ( symptoms lasting for at least 72 hours before presentation and us confirming the presence of a consolidated appendiceal abscess ) are admitted to the ward and treated conservatively with an antibiotic regimen of ampicillin plus sulbactam ( 50  mg / kg / dose every 8  hrs ) , metronidazole ( 7.5  mg / kg / dose every 8  hrs ) , and tobramicina ( 5  mg / kg / die in one administration ) .
after 48 hours of antibiotics , the patients are evaluated clinically , and inflammatory markers ( crp and wbc ) are repeated : if laboratory and clinical improvements are observed , the antibiotic therapy is continued until the patients are afebrile for at least 48 hours , inflammatory markers are progressively diminishing , and oral diet is resumed . after 8 weeks , an interval tulaa is performed . if no improvements are seen after 48 hours of antibiotics , the patients are offered tulaa .
appendiceal abscesses with us evidence of a fecalith are treated with immediate tulaa since the fecalith is a known risk factor for abscess persistence .
patients are started on a liquid diet 12 hours after the operation and on semiliquid diet in the first postoperative day .
criteria for discharge are patient afebrile for at least 24 hours , restoration of full oral diet , and decreasing inflammatory markers . the patient is placed in the supine position under general anesthesia and mechanical ventilation .
no bladder catheterization is used since all patients are asked to void before entering the operatory theatre .
a single - infraumbilical incision is performed , and an 11  mm balloon trocar is inserted under direct visualization .
capnoperitoneum is maintained within a range of 8 to12  mmhg according to the bodyweight of the patient with insufflation of co2 at a rate of 1.5  l / min .
a single - operative laparoscope ( karl storz endoskope , hopkins optical devices ) with a side - arm viewing is inserted through a single , transumbilical port ( figure 1 ) , and a grasper is used to identify the appendix and to dissect retroperitoneal adhesions : when the tip of the appendix is freed , it is exteriorized through the umbilicus .
an extracorporeal appendectomy is performed by dividing and ligating the mesoappendix , suture ligation , and inversion with purse string of the appendiceal base . no endomechanical
, one or two further additional 5  mm trocars for additional graspers or cautery hook might be introduced .   at the end of the procedure ,
intraperitoneal local anesthetic drugs such as naropine 0.2% at a dose of 0.5  ml / kg are instilled in the peritoneal cavity through one of the trocars .
postoperative analgesia is administered via an elastomeric intravenous pump with tramadol 28  mcg / kg / min for 24 hours plus repeated doses of paracetamol 10  mg / kg every 8 hours .
nausea is controlled by ondansetron 0.15  mg / kg every 8 hours , and rescue analgesic therapy consists of ketoprofene 1  mg / kg every 8 hours .
when the appendectomy is considered impossible to be safely completed with any laparoscopic technique , it is converted to an open access .  
a primary open access is chosen only when the performing surgeons are not trained in laparoscopy or abdominal distension is prominent .
an expert tula surgeon is defined as a surgeon who has performed at least 30 procedures as first operator or is trained in laparoscopy .
from january 2006 until december 2010 , 203 patients ( 79 female and 124 male ) with an average age of 10 years ( range 317 ) were admitted to our surgical ward with a diagnosis of appendicitis .
seven ( 3.4% ) out of 203 patients presented with an appendiceal mass and were treated conservatively according to the protocol : none required urgent surgery , and they all underwent interval tulaa 8 weeks later .
the remaining 196 patients ( 96.5% ) underwent urgent surgery . in 15 out of 196 cases , a primary open access
was chosen : in 3 cases for marked abdominal distension , in one case because the surgical team was not sufficiently trained in laparoscopy , and in 11 cases because of palpation of a mass at the induction of anesthesia , and neither surgeons was an expert operator .
sixty - six percent of the primary open accesses were performed in the first two years of the study .
the intraoperative tulaa finding ( figure 2 ) was uninflamed appendicitis in 18 cases ( 10% ) , uncomplicated acute appendicitis ( catarrhal / phlegmonous without signs of perforation ) in 109 ( 60% ) cases , 49 ( 27% ) cases were either gangrenous or perforated appendicitis with local peritonitis , and 5 ( 3% ) were diffuse peritonitis .
the 7 elective cases operated on after antibiotic treatment showed an appendix with adhesions but no acute inflammation .
none of these was converted , one required an additional trocar , and no complications were recorded .
the mean operatory time for the elective procedure was 43.   of all 181 urgent tulaa , 12 ( 6.6% ) were converted : in 3 cases the intraoperative finding was nonperforated appendicitis with retrocaecal position , in 8 cases there was a perforation with local peritonitis , and one was a diffuse peritonitis .
nine operations were converted by a team of nonexpert surgeons , and 3 by a team in which at least one surgeon was considered expert .
of the 169 nonconverted tulaa procedures , 151 were carried out through the single umbilical port , 16 ( 9.4% ) required a second trocar , and 2 ( 1.2% ) required a third trocar .
the mean operative time for single- port tulaa was 52 ( 47 when the first operator was an expert , 55 when the first was a nonexpert ) . among the 181 urgent operations ,
there were 5 wound infections ( 3.8% ) , of which one required a surgical revision , and 5 patients ( 3.8% ) were diagnosed as having postoperative intraperitoneal abscess which were all managed conservatively with intravenous antibiotics .
the tulaa technique was first reported in a large pediatric series by valla et al . in 1999 .
it was described as umbilical one - puncture laparoscopic - assisted appendectomy ( uoplaa ) , and performed in 200 of preoperatively selected children , that showed no signs of advanced appendicitis or diffuse peritonitis .
our choice of offering tulaa as the first choice operation to the whole spectrum of appendicitis ( except local consolidated abscess without fecaliths ) was dictated by the fact that this technique can be easily switched to a standard three - port laparoscopic appendectomy , which is widely reported in the literature to be feasible also in advanced form of appendicitis . in our series , only 10% of cases ( 16 urgent and one elective procedure ) required an additional port , and only 2 cases ( one perforated appendicitis with local peritonitis and one gangrenous retrocecal appendicitis ) required the positioning of 2 additional trocars . the possibility to insert a second or
a third trocar in a position that suites the intraoperative findings and the anatomy of the patient , rather than using the standard positions for the traditional laparoscopic procedure , can be of great help during the division of adherences and omentum especially in advanced cases .
similar results in the number of additional ports were reported by stylianos et al .   with 9.8% of 359 cases which required one or two additional ports , by valla et al .
in 2006 reported a lower use of additional trocars in only 2 of 111 patients ( 2% ) .
the latter report has also a lower rate of conversions ( 2% ) than in our experience and this could be explained by the fact that when tulaa was first introduced in our hospital , the equipment was not well trained in laparoscopy : 75% of our conversions were made by nonexpert members of the staff , and 66% of cases were converted in the first two years of the protocol .
this confirms the need of a period of learning curve and the possibility of using this operation as a starting training to acquire laparoscopic abilities .
our operating time ( 52 minutes ) seems longer than other reports : stylianos et al .
24 minutes , visnjic 33 minutes : these series , however , exclude perforated appendicitis while we include all stages of appendicitis .
the only complication we exclude was us confirmed appendiceal abscess with a symptom duration longer than 72 hours , where a conservative management was carried on , according to the current literature .  
recently , numerous reports appeared in the literature describing the so - called sils ( single - incision laparoscopic surgery ) technique where a single umbilical trocar is used to introduce three or four instruments or , as an alternative , at the umbilical site a subcutaneous pocket is created and the natural umbilical fascial defect plus one or two other stab incisions are used to place cannulas ( or only instruments ) to perform an endocorporeal laparoscopic appendectomy [ 4 , 5 , 12 ] . however , this kind of approach results in longer operating times than standard multiport laparoscopic appendectomy because of the clashing of instruments [ 12 , 13 ] , and it does not have the remarkable reduction in costs that the single trocar operative scope have , compared to standard laparoscopic technique [ 9 , 10 ] . in our series , 30% of cases were advanced stages of appendicitis but we feel that this is not a condition that should stop from starting the operation with a tulaa approach : the only real contraindication to tulaa is the intestinal loops ' huge distension that may exist in some diffuse peritonitis . the concern for umbilical infections due to exteriorization of a suppurative or ruptured appendix can be controlled if adequate skin gauze protection is secured around the umbilical opening when bringing the appendix out .
our rate of wound infections ( 3.8% ) matches perfectly the one calculated for standard three - port laparoscopic appendectomy in a recent meta - analysis comparing open and laparoscopic appendectomy , therefore , confirming that the extracorporeal operation does not endanger the umbilical scar .
petnehazy et al .   suggest that tulaa can be a simpler approach for appendectomy in obese children , and even if we did not stratify our population by weight in the present study , a single incision has proved to be a quick and effective approach for this kind of patients also in our hands .
according to our experience , tulaa is a safe , minimally invasive approach to patients suffering for acute appendicitis , regardless of the perforation status .
it is also a suitable operation for training laparoscopic abilities , and it has low instrumentation requirements .
 the paper reports the results of a retrospective review of the medical charts of 203 patients admitted to a pediatric surgical unit with a diagnosis of acute appendicitis between january 2006 and december 2010 when a transumbilical laparoscopic - assisted appendectomy ( tulaa ) was introduced as a new surgical technique . among 203 admitted patients , 
 7 ( 3.5% ) had a localized appendiceal abscess and were treated with antibiotics . 
 all of them responded to antibiotics and underwent tulaa interval appendectomy 8 weeks later . 
 196 patients ( 96.5% ) underwent immediate surgery . in 12/181 ( 6.6% ) urgent cases , conversion to laparotomy was necessary , in 3 patients because of bowel distension and in 9 for retrocecal position of appendix . in all 181 tulaa completed procedures , one trocar was used in 151 cases ( 89.4% ) , two trocars in 16 ( 9.4% ) , and three trocars in 2 ( 1.2% ) . the mean operative time for single port tulaa was 52 complications included 5 wound infections and 5 intra - abdominal abscesses , all managed conservatively . in conclusion , tulaa is a safe , minimally invasive approach with acute appendicitis , regardless of the perforation status , and can be recommended in the pediatric urgical settings . 
1. Introduction
2. Materials and Methods
3. Results
4. Discussion
5. Conclusions