**10.1 SIPES splenectomy**

Few centers worldwide are performing SIPES pediatric splenectomy (**Table 2**). On extensive review there were only 166 SILS splenectomy cases, out of them only 61 SIPES pediatric splenectomy published in English, German, Greek, French, Italian, or Spanish literatures in all age groups (0.6–90 years) [23–28]. No publications regarding the safety of SIPES splenectomy were performed by trainees. Laparoscopic splenectomy is a demanding technique which needs high level of skills and mainly performed by the most experienced trained surgeon. Our SIPES splenectomy series is the largest one. 49 SIPES splenectomies were performed by 15 trainees. 25 (51%) were male and 24 (49%) were female. Mean age was 6.9 years (2.5–14.8 years). Six cholecystectomies were done simultaneously. 45 patients were having sickle cell disease, two with thalassemia, one spherocytosis, and one Fanconi's anemia. MOT for splenectomy was 182 min (130–190) and 251 min for splenectomy with cholecystectomy (230–270) min depending on severity of adhesions and size of the spleen


**147**

**Figure 3.**

**Table 2.**

**Summary**

*KFAFH SIPES outcome.*

0 125 min

*Single-Incision Pediatric Endosurgery (SIPES) DOI: http://dx.doi.org/10.5772/intechopen.85305*

P value <0.001 (**Figures 4** and **5**). Two were converted to open due to bleeding and were in the beginning of the series. There is neither wound infection nor incisional hernia update. SIPES splenectomy is now the standard of care in our unit, and we

• This is the first series of SIPES splenectomy for hematological diseases done by trainees.

**Procedures Age OT (min) # Conversion** Splenectomy (six with cholecystectomy) 2.5–14.8 130–270 49 2

2 130–190 SIPES splenectomy 2.5–14.8 49 Raboei

**years**

(2.7–9.7)

SIPES splenectomy 6 months 1 Joshi et al.

2–17 20 SIPES

procedures 8 months

37 patients (20 with extra port)

0.6–90 81 Gkegkeset

**Number Authors**

Dutta [18]

Seims et al. [20]

al [23]

[24]

[25]

highly recommend it as excellent approach for splenectomy.

**Conversion Time/min Detail procedures Age** 

2 (excluded) 116 SIPES 7.1

2 combined splenectomy/ cholecystectomy

SILS and SIPES splenectomy

0 90–176 4 splenectomy

(range, 45–420 min)

*Comparison of SIPES splenectomy in pediatric age group.*

**Table 1.** *SIPES outcome at KFAFH.* *Single-Incision Pediatric Endosurgery (SIPES) DOI: http://dx.doi.org/10.5772/intechopen.85305*

#### **Figure 3.** *KFAFH SIPES outcome.*

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

2010 to 2016 is shown in (**Table 1** and **Figure 3**).

**Procedures Age OT** 

Splenectomy (6 with cholecystectomy) 2.5–14.8 130–270 49 2

Intussusception 10 months 90 I 0

SIPES nephrectomy 18 months 100 1 0 SIPES abdominal orchidectomy 18 months 20 1 0

Sleeve gastrectomy 13–18 years 40–120 3 0 Total 324

2 months–12 years

18 months–7 years

> 4 days–13 years

> > years

years

Cholecystectomy (one with inguinal hernia

Appendectomy (carcinoid, adhesion, 6 perforated, 4 appendix mass)

SIPES hernia repair percutaneous internal ring

Fundoplication (liver retract, Endo Stitch, 2

Assisted Mitrofanoff one with nephrectomy

Malrotation (Ladd's procedure) 16 and 17

Adhesiolysis 3 and 6

Morgagni hernia 3 and 5 years 90 and

Ovarian cystectomy (oophorectomy) (2

repair+ 1 with appendectomy)

suturing (PIRS)

hiatal hernia)

teratomas)

and orchidectomy

*SIPES outcome at KFAFH.*

**10.1 SIPES splenectomy**

**10. Outcomes of SIPES at King Fahad Armed Forces Hospital (KFAFH)**

The outcome of our retrospective study of all SIPES cases which was done from

Few centers worldwide are performing SIPES pediatric splenectomy (**Table 2**). On extensive review there were only 166 SILS splenectomy cases, out of them only 61 SIPES pediatric splenectomy published in English, German, Greek, French, Italian, or Spanish literatures in all age groups (0.6–90 years) [23–28]. No publications regarding the safety of SIPES splenectomy were performed by trainees. Laparoscopic splenectomy is a demanding technique which needs high level of skills and mainly performed by the most experienced trained surgeon. Our SIPES splenectomy series is the largest one. 49 SIPES splenectomies were performed by 15 trainees. 25 (51%) were male and 24 (49%) were female. Mean age was 6.9 years (2.5–14.8 years). Six cholecystectomies were done simultaneously. 45 patients were having sickle cell disease, two with thalassemia, one spherocytosis, and one Fanconi's anemia. MOT for splenectomy was 182 min (130–190) and 251 min for splenectomy with cholecystectomy (230–270) min depending on severity of adhesions and size of the spleen

**(min)**

90 and 120

120

80 and 100

1.5–13 years 90–180 10 0

7–16 85 ± 40 52 2 (extra

3–12 70–160 137 0

20–45 46 22 (extra

90–180 8 0

30–90 10 0

2 0

2 0

2 0

**# Conversion**

port)

port)

**146**

**Table 1.**


### **Table 2.**

*Comparison of SIPES splenectomy in pediatric age group.*

P value <0.001 (**Figures 4** and **5**). Two were converted to open due to bleeding and were in the beginning of the series. There is neither wound infection nor incisional hernia update. SIPES splenectomy is now the standard of care in our unit, and we highly recommend it as excellent approach for splenectomy.


**Figure 4.** *MOT SIPES splenectomy.*

**Figure 5.** *SIPES MOT over years.*

#### **10.2 SIPES appendectomy**

Most centers advocate laparoscopy for treating acute appendicitis in order to minimize the size and the number of skin incisions even with complicated ones [29]. SIPES pediatric appendectomy has gained significant popularity, as its main advantage is preferable cosmetic result. Previous studies have typically compared SIPES and CLA appendectomy in children and showed heterogeneous results. There was no difference in duration of hospital stay or postoperative complications. Longer MOT with SIPES appendectomy was the main concern [11, 30–41]. One study has shown that SIPES appendectomy in children is safe and feasible when performed by resident doctors and compare it when performed by fellows [42]. Chandler NM et al. studied SIPES versus conventional laparoscopic appendectomy CLA in children. 110 patients underwent appendectomy; 50 SIPES Group 1 and 14 were excluded (perforated) [30, 33]. They concluded that MOT and pain medication are the only significant values between SIPES and conventional. There was no increase in wound infection [43, 44].

**149**

**10.3 SIPES cholecystectomy**

Appendectomy (carcinoid, adhesion, six perforated, four appendix mass)

**Summary**

*Single-Incision Pediatric Endosurgery (SIPES) DOI: http://dx.doi.org/10.5772/intechopen.85305*

**Table 3.**

*Performing surgeon and MOT.*

We started SIPES appendectomy in 2011, and it became our standard approach for acute appendicitis. It is carried out routinely by trainees and specialist. We compared SIPES appendectomy with CLA between our center and another training center. We conducted retrospective study at two training military institutes, KFAFH and Prince Sultan Medical City PSMMC. A total of 322 patients were operated. 187 patients (58%) underwent CLA, and 137 patients (42%) underwent SIPES appendectomy. 120 patients (64%) of CLA and 87 (63%) patients of SIPES appendectomy were males. 67 patients (36%) of CLA and 42 (37%) patients of SIPES appendectomy were females. The mean age of the patients in CLA and SIPES appendectomy was 10 and 9.6 years, respectively. Diagnosis at time of operation was simple appendicitis in 166 patients who underwent CLA and 126 patients who underwent SIPES appendectomy, and complicated appendicitis was in 21 and 11 patients, respectively. 143 CLA (76%) were performed by specialist, and 44 cases (24%) were performed by trainees. 47 SIPES appendectomy (34%) were performed by specialist, and 90 cases (66%) were performed by trainees (**Table 3**) (P value <0.001). The MOT was 70 min for CLA and 86 min for SIPES appendectomy (P value <0.001). The mean length of hospital stay is 2.6 days for CLA and 2.8 days for SIPES appendectomy. Bilateral percutaneous internal ring suturing (PIRS) and right PIRS were performed on 2 patients who underwent SIPES appendectomy. Three cases developed intraabdominal collection (2.2%), one case had wound infection (0.7%), and two cases had adhesion (1.5%), treated conservatively in SIPES appendectomy. There were five cases of intra-abdominal collection (2.7%), two cases of wound infection (1.1%), and one case of adhesion (0.5%) in CLA. Negative appendectomy rate has been 10%.

**Operation Performing surgeon MOT NO.** SIPES appendectomy Specialist 70.723 47

CLA Specialist 64.681 141

Trainee 95.289 90 Total 86.861 137

Trainee 88.457 46 Total 70.529 187

Minimally invasive techniques have revolutionized surgical treatment. Few centers worldwide have advanced SIPES for pediatric age group. Many papers that were published in English literatures proved the safety and efficacy of SIPES cholecystectomy [44–48]. Up to our knowledge, there is no study regarding MOT of SIPES

**Procedures Age OT (min) # Conversion**

3–12 70–160 137 0

• SIPES appendectomy is the commonest procedure done in our center by our trainees.

*Single-Incision Pediatric Endosurgery (SIPES) DOI: http://dx.doi.org/10.5772/intechopen.85305*


**Table 3.**

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

**148**

**10.2 SIPES appendectomy**

**Figure 4.**

**Figure 5.**

*SIPES MOT over years.*

*MOT SIPES splenectomy.*

Most centers advocate laparoscopy for treating acute appendicitis in order to minimize the size and the number of skin incisions even with complicated ones [29]. SIPES pediatric appendectomy has gained significant popularity, as its main advantage is preferable cosmetic result. Previous studies have typically compared SIPES and CLA appendectomy in children and showed heterogeneous results. There was no difference in duration of hospital stay or postoperative complications. Longer MOT with SIPES appendectomy was the main concern [11, 30–41]. One study has shown that SIPES appendectomy in children is safe and feasible when performed by resident doctors and compare it when performed by fellows [42]. Chandler NM et al. studied SIPES versus conventional laparoscopic appendectomy CLA in children. 110 patients underwent appendectomy; 50 SIPES Group 1 and 14 were excluded (perforated) [30, 33]. They concluded that MOT and pain medication are the only significant values between SIPES and conventional. There was no increase in wound infection [43, 44].

*Performing surgeon and MOT.*

We started SIPES appendectomy in 2011, and it became our standard approach for acute appendicitis. It is carried out routinely by trainees and specialist. We compared SIPES appendectomy with CLA between our center and another training center. We conducted retrospective study at two training military institutes, KFAFH and Prince Sultan Medical City PSMMC. A total of 322 patients were operated. 187 patients (58%) underwent CLA, and 137 patients (42%) underwent SIPES appendectomy. 120 patients (64%) of CLA and 87 (63%) patients of SIPES appendectomy were males. 67 patients (36%) of CLA and 42 (37%) patients of SIPES appendectomy were females. The mean age of the patients in CLA and SIPES appendectomy was 10 and 9.6 years, respectively. Diagnosis at time of operation was simple appendicitis in 166 patients who underwent CLA and 126 patients who underwent SIPES appendectomy, and complicated appendicitis was in 21 and 11 patients, respectively. 143 CLA (76%) were performed by specialist, and 44 cases (24%) were performed by trainees. 47 SIPES appendectomy (34%) were performed by specialist, and 90 cases (66%) were performed by trainees (**Table 3**) (P value <0.001). The MOT was 70 min for CLA and 86 min for SIPES appendectomy (P value <0.001). The mean length of hospital stay is 2.6 days for CLA and 2.8 days for SIPES appendectomy. Bilateral percutaneous internal ring suturing (PIRS) and right PIRS were performed on 2 patients who underwent SIPES appendectomy. Three cases developed intraabdominal collection (2.2%), one case had wound infection (0.7%), and two cases had adhesion (1.5%), treated conservatively in SIPES appendectomy. There were five cases of intra-abdominal collection (2.7%), two cases of wound infection (1.1%), and one case of adhesion (0.5%) in CLA. Negative appendectomy rate has been 10%.

**Summary**

• SIPES appendectomy is the commonest procedure done in our center by our trainees.

