SURGEON AT WORK Single-Incision Laparoscopic Appendectomy with a Low-Cost Technique and Surgical-Glove Port: “How To Do It” with Comparison of the Outcomes and Costs in a Consecutive Single-Operator Series of 45 Cases Salomone Di Saverio, MD, FACS, FRCS, Matteo Mandrioli, MD, Arianna Birindelli, MD, Andrea Biscardi, MD, Luca Di Donato, MD, Carlos Augusto Gomes, MD, PhD, TCBC, Alice Piccinini, MD, Nereo Vettoretto, MD, Ferdinando Agresta, MD, Gregorio Tugnoli, MD, PhD, Elio Jovine, MD, PhD During the last decade, an innovative but technically demanding technique, single-incision laparoscopic sur- gery (SILS), has been implemented with the intent to improve the impact of minimally invasive surgery on cosmesis, postoperative pain, and return to normal activ- ity. 1,2 Several studies and randomized controlled trials (RCTs) have compared SILS with laparoscopic appen- dectomy (LA) and have reported similar postoperative results. 3,4 However, the increased costs for SILS compared with the already costly LA, especially when performed using expensive equipment, is still a consider- able disadvantage that limits use of this technique. 5,6 In addition, use of curved instruments and the loss of trian- gulation among the instruments due to coaxiality makes SILS a much more difficult and challenging procedure to learn as it requires advanced laparoscopic skills. This can lead to longer operative times and a possible increased rate of iatrogenic injuries and postoperative complications. 6 More recently, however, a few authors have described a novel, self-made, and inexpensive single-port laparoendo- scopic single-site surgical method. 7-10 Using a surgical glove, this simple, single-port laparoscopic technique has several advantages: it is associated with substantially decreased costs compared with commercial single-port equipment and requires just the use of common laparo- scopic standard straight instruments with reduced coaxiality, without need for laparoscopic instruments with curved architecture, which are more expensive and less widely available to the community hospital. This means more working space and wider feasibility for this modified single-incision laparoscopic technique. Surgical-glove port has been adopted for several mini- mally procedures, including cholecystectomies 11 and appendectomies. 12 The encouraging early results reported for surgical- glove port laparoscopy, 13 and the absence in the contem- porary scientific literature of a detailed description of a standardized technique for SILS using a surgical-glove port, led us to explore this original technique for minimally invasive abdominal surgery through a single umbilical incision. We have improved our experience with technical refinement and standardization of the surgical-glove port technique, adding a well- documented, step-by-step, description with educational tips. Based on our consecutive and prospectively collected series of SILS appendectomies and as, to the best of our knowledge, the largest ever published series on the tech- nique of surgical-glove port in the literature, we aimed to investigate the feasibility, safety, and efficacy with particular focus on the cost-effectiveness of surgical- glove port, single-incision laparoscopic appendectomy (SGP-SILA) for acute appendicitis performed by a single surgeon with specific training in advanced laparoscopic surgery. We also aimed to assess the results of this proce- dures and the cost-effectiveness in comparison with a con- trol group of classic SILA performed in the same institution by another surgeon using a commercial device Disclosure Information: Nothing to disclose. Received October 20, 2015; Revised November 15, 2015; Accepted November 16, 2015. From the Department of Emergency and General Surgery and Trauma Sur- gery Unit, C A Pizzardi Maggiore Hospital Trauma Center, Bologna (Di Saverio, Mandrioli, Birindelli, Biscardi, Di Donato, Piccinini, Tugnoli, Jovine), Laparoscopic Surgery Unit, Department of Surgery, M Mellini Hospital, Chiari (Vettoretto), Department of Surgery, Adria Hospital, Adria, Rovigo (Agresta), Italy, and Department of Surgery, Hospital There- zinha de Jesus, Faculdade de Cie ˆncias Me ´dicas e da Sau ´de Juiz de Fora (SUPREMA), Juiz de Fora, Brazil (Gomes). Correspondence address: Salomone Di Saverio, MD, FACS, FRCS, Department of Emergency and General Surgery, C A Pizzardi Maggiore Hospital Trauma Center, AUSL Bologna, Largo B Nigrisoli 2, 40133 Bologna, Italy. email: salo75@inwind.it; salomone.disaverio@gmail.com e15 ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jamcollsurg.2015.11.019 ISSN 1072-7515/15