Prospective evaluation of a primary laparoscopic approach for children presenting with simple or complicated appendicitis

Minimally Invasive Treatment for Appendiceal Mass Formed After Acute Perforated Appendicitis

The optimal treatment for appendiceal mass formed after appendiceal rupture due to acute appendicitis is surrounded with controversy. The treatment strategy ranges from open surgery (emergency or interval appendectomy), laparoscopic appendectomy, and image-guided drainage, to conservative treatment with or without antibiotics. Nonsurgical treatment (including conservative and drainage treatment), followed by interval appendectomy to prevent recurrence, is the traditional management of these patients. The need for interval appendectomy after a successful conservative or/and image-guided drainage treatment, has recently been questioned as the risk of recurrence is relatively small. Several authors consider that even in cases involving only ambulatory follow-up observation, without interval surgery after conservative management, the recurrence rate and risks of missing underlying pathologies were not high. This article evaluates the minimally invasive treatment modalities in the management of appendiceal mass, risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Laparoscopic Appendectomy in Children: Preliminary Study in Pediatric Hospital Albert Royer, Dakar

Appendiceal pathology's management has benefited in recent years from the advent of laparoscopic surgery. This study is to make a preliminary assessment of laparoscopic management of acute and complicated appendicitis in children after a few months of practice at the University Hospital Albert Royer, Dakar. This is a retrospective study of 22 cases of patients, all operated on by the same surgeon. The parameters studied were age, sex, clinical data and laboratory features, radiological data, and results of surgical treatment. The mean age of patients was 9.5 years with a male predominance. The series includes 14 cases of acute appendicitis and 8 complicated cases. Appendectomy anterograde is practiced in 81% of cases. Appendectomy was associated with peritoneal wash in 17 patients including 9 cases of acute appendicitis. Drainage of Douglas pouch is performed in 2 patients with complicated appendicitis; the average production was 300 cc of turbid liquids and any complications were not founded. An abscess of Douglas pouch is noted in 2 patients with complicated appendicitis undrained. These Douglas abscesses were treated medically. No conversion of laparotomy was performed in the series. After an average of 8 months no other problems were noted.

Feasibility of a laparoscopic approach for generalized peritonitis from perforated appendicitis in children

PURPOSE

This study evaluated the feasibility of a laparoscopic approach in children with generalized peritonitis secondary to perforated appendicitis.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of patients who underwent laparoscopic appendectomy with drainage for generalized peritonitis secondary to perforated appendicitis at our hospital between September 2001 and April 2012. Laparoscopic outcomes were compared with outcomes of an open method for perforated appendicitis.

RESULTS

Ninety-nine patients underwent laparoscopic appendectomy (LA) for generalized peritonitis from perforated appendicitis, and 87 patients underwent open appendectomy (OA) for perforated appendicitis. Wound infection was more common in the OA group (12.6%) than in the LA group (4.0%; p=0.032). The incidence of intestinal obstruction during long-term follow-up was significantly higher in the OA group (4.6% vs. 0.0% in the LA group; p=0.046). LA was possible in most patients for whom LA was attempted, with a conversion rate of 10.8%. Conversion to OA was affected by the preoperative duration of symptoms and the occurrence of intraoperative complications.

CONCLUSION

LA is feasible for use in children with generalized peritonitis from perforated appendicitis, with reasonable open conversion and perioperative complication rates comparable to those of the OA group.

Percutaneous drainage of intra-abdominal abscess in children with perforated appendicitis

BACKGROUND

Because the surgical management of perforated appendicitis remains controversial, percutaneous catheter drainage (PCD) has gained favor for managing periappendiceal abscess in hemodynamically stable children.

OBJECTIVE

To determine the safety and effectiveness of PCD in children with perforated appendicitis and to identify any variables of prognostic value.

MATERIALS & METHODS

We retrospectively evaluated clinical data and imaging features for 33 children undergoing PCD for periappendiceal abscess from October 2006 to February 2010. Those with preprocedural CT studies were assigned to one of three risk categories based on imaging features.

RESULTS

Appendectomy was successfully postponed for all patients. Our technical success rate was 87.9%, with three recurrences (two requiring repeat drainage, one managed conservatively) and one possible complication (enterocutaneous fistula formation). Children with large and diffuse abscesses had a 50% rate of technical failure, which was significantly increased when compared to children with large but localized abscesses (P < 0.028). Extraluminal appendicolith, extraluminal gas, leukocytosis, ileus/obstruction and procedural variables were not reliable predictors of outcome.

CONCLUSION

PCD can be effective for managing perforated appendicitis in children. Children with large and ill-defined abscess might be at increased risk for complication or recurrence.

Single-port laparoscopic Heller myotomy and Dor fundoplication: initial experience with a new approach for the treatment of pediatric achalasia

PURPOSE

The aim of this report was to evaluate the safety and feasibility of single-port laparoscopic Heller myotomy and Dor fundoplication (SPLHD) as treatment of pediatric esophageal achalasia.

METHODS

A 9-year-old boy with a significant history of achalasia underwent SPLHD. The single-port was inserted using an umbilical incision. The falciform ligament and left liver lobe were raised using an elevating suture, providing good visualization of the operative field at the cardia. The Heller myotomy was planned to be 4 cm long, extending 1 cm onto the gastric wall.

RESULTS

The SPLHD was successfully accomplished without the need for any skin incisions or additional ports. Oral intake was resumed on the first postoperative day, and the length of hospital stay was 8 days. The patient had complete resolution of dysphagia and regurgitation. No complications were noted, and the patient had an excellent cosmetic result.

CONCLUSIONS

The SPLHD is a safe and feasible procedure for symptomatic pediatric achalasia when performed by a surgeon experienced in laparoscopic and esophageal surgery.

Laparoscopic single port surgery in children using Triport: our early experience

Laparoscopy has become the gold standard technique for appendectomy and cholecystectomy. With the emergence of newer laparoscopic instruments which are roticulating and provide 7 degrees of freedom it is now possible to perform these operations through a single umbilical incision rather than the standard 3-4 incisions and thus lead to more desirable cosmetic results and less postoperative pain. The newer reticulating telescopes provide excellent exposure of the operating field and allow the operations to proceed routinely. Recently, ports [Triports (Olympus surgery)/SILS ports] especially designed for single incision laparoscopic surgery (SILS) have been developed. We herein describe our experience with laparoscopic single port appendectomies and cholecystectomies in children using the Triport. This is a retrospective cohort study of children who underwent single incision laparoscopic surgery between May 2009 and August 2010 at Texas Children's Hospital and Ben Taub General Hospital in Houston Texas by a single surgeon. Charts were reviewed for demographics, type of procedure, operative time, early or late complications, outcome and cosmetic results. Fifty-four patients underwent SILS. A total of 50 appendectomies (early or perforated) and 4 cholecystectomies were performed using this new minimally invasive approach. The average operative time for SILS/LESS appendectomy was 54 min with a range between 25 and 205 min, while operative time for SILS cholecystectomy was 156 min with a range of 75-196 min. Only small percentage (4%) of appendectomies (mostly complicated) were converted to standard laparoscopy, but none were converted to open procedure. All patients were followed up in the clinic after 3-4 weeks. No complications were noted and all patients had excellent cosmetic results. Parents were extremely satisfied with the cosmetic results. SILS/LESS is a safe, minimally invasive approach for appendectomy and cholecystectomy in children. This new approach is performed in an acceptable operative time with good outcomes and great cosmetic result.

Laparoscopic versus open appendicectomy for complicated appendicitis: A prospective study

AIMS

The purpose of this study was to compare open versus laparoscopic appendicectomy (LA) in complicated appendicitis.

MATERIALS AND METHODS

We prospectively analyzed all children over a 2-year period who underwent appendicectomy in a single institution and found 30 cases of complicated appendicitis diagnosed on the table and confirmed by histopathology. These children were allocated randomly into Group 1 if they had LA and Group 2 if they had open appendicectomy (OA), solely based on surgeon assessment. The parameters assessed were duration of symptoms before surgery, use of postoperative parenteral analgesia, timing of initiation of feeds after surgery, postoperative complications and duration of postoperative stay.

RESULTS

Of the 30 patients with complicated appendicitis, 12 patients in Group 1 underwent LA and 18 patients in Group 2 underwent OA. The two groups were comparable for age and sex. Children in Group 1 were found to need less parenteral analgesia (two out of 12 versus six out of 18). Postoperatively, feeds were started earlier in Group 1 than in Group 2 (2.5 days versus 3.7 days). The average postoperative hospital stay was 5 days in Group 1 and 7.5 days in Group 2. There were only minor wound infections in Group1 as against two major complications in Group 2. There was no mortality in either group.

CONCLUSIONS

In complicated appendicitis, laparoscopic approach carries definite advantages with less postoperative morbidity and hospital stay. It is a feasible and better alternative than the open approach in complicated appendicitis.

Severity of appendicitis correlates with the pediatric appendicitis score

PURPOSE

The pediatric appendicitis score (PAS) has been used as a diagnostic tool for the assessment of acute abdominal pain. Our institution has utilized this scoring system as part of a clinical pathway for acute appendicitis. We sought to discover if the PAS could also serve as a prognostic indicator.

METHODS

Patients treated within the clinical pathway were divided into three groups (A, B, and C) based on the PAS assigned on admission. Data pertaining to intraoperative findings and length of hospital stay were collected prospectively.

RESULTS

In 4 months, 112 patients were enrolled in the study (median age 10.5, range 1-18). 69 of these patients underwent early laparoscopic appendectomy. For group A, 75% had simple appendicitis and 5% were complex. For group B, 68.4% patients had simple appendicitis and 26.3% were complex. For group C, 27.3% were simple and 63.6% were complex. Mean length of hospital stay increased from 1.63 ± 0.34 for patients in group A to 5.9 ± 1.37 for patients in group C.

CONCLUSION

Our observational data suggests that the PAS may be a prognostic tool for acute appendicitis. It thereby may impact on preoperative management and postoperative clinical pathways. A larger cohort is necessary to validate our findings.

Transumbilical laparoscopically assisted appendectomy: an alternative minimally invasive technique in pediatric patients

INTRODUCTION

Transumbilical laparoscopically assisted appendectomy (TULAA) has been reported in the literature as an alternative to traditional three-port laparoscopic appendectomy (LA). Our study compares outcomes between LA and the one-trocar transumbilical technique in a single institution over a concurrent time frame for all cases of pediatric appendicitis.

METHODS

An Institutional Review Board-approved retrospective chart review of all appendectomies from July 2007 through June 2009 was performed. All appendectomies were performed either laparoscopically or transumbilically. One surgeon predominantly used the TULAA method, whereas the other 2 surgeons used strictly the LA method. No cases were converted to open. Categorization of specimens as normal, acute, or ruptured was based on pathology reports. Outcomes analyzed for each group included surgical duration, cost, length of stay, fever (>101.5F), wound infection, ileus, and postoperative abdominal-pelvic abscess.

RESULTS

A total of 131 appendectomies were performed by 3 surgeons, 83 were LA and 48 were TULAA. For all stages of appendicitis, outcomes differed significantly only for operating room cost, with the TULAA being significantly less expensive. All other outcomes were similar between the two techniques.

CONCLUSION

Our study suggests that TULAA is a reasonable alternative to the standard minimally invasive technique for appendicitis in both acute and ruptured situations. All analyzed complications were similar between the groups, suggesting that TULAA is an acceptable surgical method in pediatric patients for all stages of appendicitis.

Single incision laparoscopic surgery for acute appendicitis: feasibility in pediatric patients

Background. Laparoscopic appendicectomy is accepted by many as the gold standard approach for the treatment of acute appendicitis. The use of Single Incision Laparoscopic Surgery (SILS) has the potential of further reducing postoperative port site complications as well as improving cosmesis and patient satisfaction. Method. In this paper we report our experience and assess the feasibility of SILS appendicectomy in the pediatric setting. Results. Five pediatric patients with uncomplicated appendicitis underwent SILS appendicectomy. There were no significant intraoperative or postoperative complications. All patients were discharged within 24 hours. Conclusions. The use of Single Incision Laparoscopic Surgery appears to be a feasible and safe technique for the treatment of uncomplicated appendicitis in the pediatric setting. Further studies are warranted to fully investigate the potential advantages of this new technique.

Laparoscopic appendectomy is recommended for the treatment of complicated appendicitis in children

Laparoscopic appendectomy in children is well accepted for the treatment of non complicated appendicitis. An increased risk of postoperative intraabdominal abcess formation has been reported in complicated appendicitis. The puropose of this study was to compare open (OA) versus laparoscopic appendectomies (LA) in complicated appendicitis in children and to assess the safety and feasibility of LA. The hospital records of 118 consecutive patients who underwent appendectomy for complicated appendicitis (perforated/gangrenous) from 2000 to 2006 were retrospectively analysed. Fifty-four patients had LA and 64 underwent OA. There were 74 males and 44 females. The length of hospital stay ranged from 4 to 12 days in the LA group and 4 to 17 days in the OA group. Five patients (9.2%) in the LA group had post operative complications; intraabdominal collections in 3 and wound infections in 2. Ten patients (15.6%) had postoperative complications in the OA group; intraabdominal collections in 5, wound infection in 3, pleural effusion in 1 and prolonged ileus in 1. In complicated appendicitis the complication rate is lower for LA as compared to OA. We recommend laparoscopic approach to all children presenting with complicated appendicitis.

Complicated appendicitis in children: a clear role for drainage and delayed appendectomy

INTRODUCTION

Children presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy.

METHODS

A retrospective review of all children undergoing appendectomy over a 5-year period was performed.

RESULTS

We identified 1,106 children: 360 had evidence of perforation and 92 had an intra-abdominal abscess or right lower quadrant phlegmon. Of these 92, 60 underwent primary appendectomy and 32 underwent drainage and/or antibiotic therapy with delayed appendectomy. Children undergoing delayed appendectomy had a longer prodrome of symptoms (6.9 vs 4.6 days, P = .002), slightly higher presenting white blood cell count (19.3 vs 16.6, P = .08), and had the same hospital length of stay, yet had a lower complication rate requiring readmission to the hospital (0% vs 10%) compared to those undergoing immediate appendectomy.

CONCLUSION

In children presenting with prolonged symptoms and a discrete appendiceal abscess or phlegmon, drainage and delayed appendectomy should be the treatment of choice.