**4. Special patient categories**

#### **4.1 Fertile females**

Especially in the subgroup of fertile females authors report a negative laparotomy rate between 22-40% and a negative laparoscopy rate between 4-17% and (Sauerland et al., 2004). Females predominated among those readmitted (76%). Fertile females benefit from the laparoscopic approach at a level Ia evidence and there was no inconsistency between studies (Sauerland, 2010; Vettoretto & Agresta, 2010; Gaitan, 2011).

Laparoscopic Appendectomy 127

unnecessary procedures without missing pathologic conditions. Walsh et al. report that the negative appendectomy rate in their series was 27%, which is higher than in the nonpregnant population. Regarding the diagnostic tools it has been reported that the sensitivity of ultrasound is inversely correlated to the gestational age, while CT scan retains a high sensitivity and specificity throughout pregnancy. It seems reasonable to perform an ultrasound first, in order to exclude an obstetric pathology, and to proceed with a CT if

Pediatric patients seem to benefit from the laparoscopic approach for suspected appendicitis in the same ways adults do, and intraabdominal abscesses are not more frequent than with the open approach. However, more RCTs are needed in order to come to final conclusions. Especially in extremely obese children laparoscopy is considered to be the procedure of choice both in complicated, and not complicated cases. The operative time is reported to be shorter, there are less overall complications, and reduced analgesia requirements (Kutasy et

Single-port-laparoscopy for acute appendicitis is reported to be safe and effective in children (Tam et al., 2010) and adults, and may have advantages in terms of cosmetic results and patient satisfaction (Barbaros et al.; 2010; Lee YS, 2009; Raakow et al.;Tsai & Selzer, 2010). We tried this approach on two patients but could not really see the benefits. On the contrary, we believe that the single port technique is much more appropriate and ergonomic in robotic surgery. More comparative studies between the conventional technique and the single port approach are needed in order to determine its role in laparoscopic appendectomy, especially regarding long term morbidity (i.e. hernias) at the entrance site.

Needlescopic appendectomy can be safe and effective according to a recent review and is supposed to reduce pain compared to conventional laparoscopy (Sajid et al., 2009; Sauerland et al., 2010). Nevertheless it is associated with a longer operating time and a higher conversion rate. Multicenter, randomized controlled trials are recommended before it can be

Incidental appendectomy is considered to eventually be necessary in women with ovarian endometrioma and chronic pelvic pain, as the majority of the appendices are found to have histopathologically confirmed pathology although being macroscopically normal (Wie et al., 2008). Incidental robotic appendectomy is reported to be safe and effective in women undergoing gynaecologic surgery, in women with chronic pelvic pain, and women with ovarian malignancy (Akl et al., 2008). In the latter group three out of seven patients were found to have appendicular metastasis. Our experience with the DaVinci (TM, Intuitive Surgical Inc.) Robotic System started in 2006, and is today the everyday routine of the

**5. Novel techniques and future research implications** 

necessary (Butala, 2010).

**4.6 Pediatric patients** 

**5.1 Novel techniques** 

used routinely.

**5.1.1 Single port appendectomy** 

**5.1.2 Needlescopic appendectomy** 

**5.1.3 Robotic appendectomy** 

al., 2011).
