However, this kind of approach results in longer operating times than standard multiport laparoscopic appendectomy because of the clashing of instruments Seliciclib [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.

A routine antibiotic prophylaxis is also a recommended procedure before performing an appendectomy [14]. 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 [15], therefore, confirming that the extracorporeal operation does not endanger the umbilical scar. Petnehazy et al. [16] 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. 5.

Conclusions 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. We, therefore, recommend its wide use Drug_discovery in the pediatric surgical settings.
The study took place from December, 2011 to December, 2012 in the Tertiary Care Unit of Rajavithi Hospital. All operations were performed by a colorectal surgeon. The inclusion criteria were (1) patients who had been diagnosed with cancer at the middle or low rectum or the anal canal and (2) patients who had rejected neoadjuvant chemotherapy. The exclusion criteria were (1) patients who were unfit for surgery; (2) patients who did not attend for followup; (3) patients for whom anesthesia was contraindicated; and (4) patients with asymptomatic stage IV disease.