OTA, the authors reply

We read with great interest the comment by Dr. W. T. Ng concernig our article regarding the one-trocar appendectomy (OTA) published on ‘‘Surgical Endoscopy’’. The aim of our article was to underline the interest of OTA and in particular to raise a question about its use also in adult patients and by reading your letter we have achieved this objective. Certainly, as you have underlined, this procedure is easy to adopt in pediatric patients [3, 6] thanks to the small dimension of the operative chamber and the possibility of easily extracting the appendix through the umbilical orifice. We think that the same technique of OTA can also be adopted safely in adults; the 84.6% success rate presented in our article compared to the 100% rate of previous published papers does not depend on the authors’ lack of experience, but only on the anatomic conditions and on the degree of inflammation of the appendix [1, 2]. Our current strategy with patients with suspect appendicitis (children or adults) is to start the operation with laparoscopic procedure by using operative optics; then, if the surgeon thinks that it is possible to complete the procedure by using only one trocar, he performs OTA. If the appendix it is fixed or in retrocecal position, we can insert one or two more ports and complete the procedure in laparoscopy. It is also possible to perform a mixed procedure if the surgeon prefers to complete the procedure in open surgery by using a McBurney incision [4–6]. The technique described by Dr. Ng, in which endoloops are used, seems a little bit complicated compared to the simple and linear one-trocar technique that we have reported. As Dr. Ng certainly knows, with only one trocar it is possible to dissect, to section, and to coagulate by using different instruments; for this reason also a fixed appendix can be mobilized [5, 6]. We believe that the OTA, as clearly appears from our paper and from other articles published in the international literature, presents several advantages compared to the three-trocar procedure, but the surgeon’s experience in performing this techniques is fundamental [3–6]. Several groups prefer to adopt the three-trocar procedure because they do not have the operative optics and related instruments and also because they lack the necessary experience with one-trocar procedures, and for this reason they strongly criticize these groups who routinely adopt OTA [5]. We think that one-trocar appendectomy is an easy technique to perform in children, but also in adults; the only problem which might occur at the beginning of the experience consists of the difficulty of simultaneously moving the optical aid and the surgical instrument. The authors belive that the one-trocar appendectomy is a good and feasible technique, and it represents a valid alternative to other laparoscopic procedures for performing appendectomy in pediatric and adult patients. We think that the only ‘‘more sense’’ of this discussion about OTA is that there exist several laparoscopic procedures to be adopted in case of appendicitis (including OTA), and the surgeon, through his own experience and knowledge, must choose the most suitable technique to adopt in each single case. No doubt Prof. Ng agrees about this point.