Is having three trocar (port) incision sites in the right lower abdomen, above the umbilicus, and right upper quadrant appropriate for an appendectomy?

Three-Trocar Laparoscopic Appendectomy Port Placement

Yes, the described trocar placement (right lower abdomen, above the umbilicus, and right upper quadrant) is appropriate and represents the standard conventional three-port technique for laparoscopic appendectomy. This configuration is explicitly recognized as the established approach in current guidelines and is associated with superior outcomes compared to single-incision techniques 1.

Standard Three-Port Technique Configuration

The conventional three-trocar laparoscopic appendectomy (CLA) typically uses:

• Umbilical or supraumbilical port: Usually 10-12mm for the camera and specimen extraction 1
• Right lower quadrant port: Working port for instrumentation 1
• Right upper quadrant or suprapubic port: Additional working port for retraction and manipulation 1

This configuration provides optimal triangulation for visualization and manipulation of the appendix, particularly when dealing with retrocecal or pelvic positions 1.

Evidence Supporting Three-Port Over Single-Incision Technique

The 2020 World Society of Emergency Surgery (WSES) Jerusalem Guidelines provide level 1a evidence that conventional three-port laparoscopic appendectomy is superior to single-incision approaches 1:

Operative Efficiency

• Shorter operative time: CLA demonstrates significantly reduced operative time compared to single-incision laparoscopic appendectomy (SILA), with a mean difference of 5.81 minutes (P = 0.003) 1
• Lower conversion rates: Three-port technique has significantly lower conversion rates (OR 4.14) compared to SILA 1

Safety Profile

• Lower surgical site infection rates: Meta-analyses show SILA is associated with higher incidence of SSI compared to three-port technique 1
• Less surgical trauma: In pediatric patients, three-port technique produces less severe surgical trauma as measured by CRP and IL-6 levels 1

Clinical Outcomes

• Equivalent complication rates: No significant differences in total postoperative complications, intra-abdominal abscess, ileus, or wound hematoma between techniques 1
• Similar hospital stay: Length of hospital stay and analgesic requirements are comparable 1

Port-Specific Technical Considerations

Trocar Size and Closure Requirements

Fascial closure is recommended for all trocar sites ≥10mm 1:

• The umbilical/supraumbilical port (typically 10-12mm) requires fascial closure to prevent trocar-site hernias 1
• Trocar-site hernia rates increase significantly with ports ≥10mm, particularly at midline locations 1
• Non-bladed trocars may reduce hernia risk when available 1

Off-Midline Placement Advantage

The right lower quadrant and right upper quadrant ports are appropriately positioned off-midline, which reduces trocar-site hernia risk 1:

• Midline trocar placement increases hernia rates compared to off-midline locations 1
• The described configuration optimally balances surgical access with hernia prevention 1

Clinical Context and Guideline Recommendations

The WSES guidelines provide a strong recommendation (1B) for laparoscopic appendectomy as the preferred approach over open appendectomy for both adults and children with acute appendicitis 1:

• Lower postoperative pain 1
• Lower incidence of surgical site infections 1
• Higher quality of life scores 1
• Shorter hospital stay despite longer operative time 1

Common Pitfalls to Avoid

Do not confuse the standard three-port technique with reduced-port or single-incision approaches 1:

• While single-incision techniques are feasible, they require longer operative times and have higher conversion rates 1
• The three-port technique remains the gold standard with the most favorable risk-benefit profile 1

Ensure proper fascial closure of the umbilical/supraumbilical port 1:

• Failure to close fascial defects ≥10mm significantly increases trocar-site hernia risk 1
• This is particularly important at midline locations 1