Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study

Early versus delayed appendicectomy for appendiceal phlegmon or abscess

BACKGROUND

This is an update of a Cochrane review first published in 2017. Acute appendicitis (inflammation of the appendix) can be simple or complicated. Appendiceal phlegmon and appendiceal abscess are examples of complicated appendicitis. Appendiceal phlegmon is a diffuse inflammation in the bottom right of the appendix, while appendiceal abscess is a discrete inflamed mass in the abdomen that contains pus. Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms (e.g. abdominal pain, loss of appetite, nausea, and vomiting) and avoid complications (e.g. peritonitis (infection of abdominal lining)). Surgery for people with appendiceal phlegmon or abscess may be early (immediately after hospital admission or within a few days of admission), or delayed (several weeks later in a subsequent hospital admission). The optimal timing of appendicectomy for appendiceal phlegmon or abscess is debated.

OBJECTIVES

To assess the effects of early appendicectomy compared to delayed appendicectomy on overall morbidity and mortality in people with appendiceal phlegmon or abscess.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 11 June 2023, together with reference checking to identify additional studies.

SELECTION CRITERIA

We included all individual and cluster-randomised controlled trials (RCTs), irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included eight RCTs that randomised 828 participants to early or delayed appendicectomy for appendiceal phlegmon (7 trials) or appendiceal abscess (1 trial). The studies were conducted in the USA, India, Nepal, and Pakistan. All RCTs were at high risk of bias because of lack of blinding and lack of published protocols. They were also unclear about methods of randomisation and length of follow-up. 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon We included seven trials involving 788 paediatric and adult participants with appendiceal phlegmon: 394 of the participants were randomised to the early appendicectomy group (open or laparoscopic appendicectomy as soon as the appendiceal mass resolved within the same admission), and 394 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed open or laparoscopic appendicectomy several weeks later). There was no mortality in either group. The evidence is very uncertain about the effect of early appendicectomy on overall morbidity (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.19 to 2.86; 3 trials, 146 participants; very low-certainty evidence), the proportion of participants who developed wound infections (RR 0.99, 95% CI 0.48 to 2.02; 7 trials, 788 participants), and the proportion of participants who developed faecal fistulas (RR 1.75, 95% CI 0.36 to 8.49; 5 trials, 388 participants). Early appendicectomy may reduce the abdominal abscess rate (RR 0.26, 95% CI 0.08 to 0.80; 4 trials, 626 participants; very low-certainty evidence), reduce the total length of hospital stay by about two days (mean difference (MD) -2.02 days, 95% CI -3.13 to -0.91; 5 trials, 680 participants), and increase the time away from normal activities by about five days (MD 5.00 days; 95% CI 1.52 to 8.48; 1 trial, 40 participants), but the evidence is very uncertain. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess We included one trial involving 40 paediatric participants with appendiceal abscess: 20 were randomised to the early appendicectomy group (emergent laparoscopic appendicectomy), and 20 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed laparoscopic appendicectomy 10 weeks later). There was no mortality in either group. The trial did not report on overall morbidity, various complications, or time away from normal activities. The evidence is very uncertain about the effect of early appendicectomy on the total length of hospital stay (MD -0.20 days, 95% CI -3.54 to 3.14; very low-certainty evidence).

AUTHORS' CONCLUSIONS

For the comparison of early versus delayed open or laparoscopic appendicectomy for paediatric and adult participants with appendiceal phlegmon, very low-certainty evidence suggests that early appendicectomy may reduce the abdominal abscess rate. The evidence is very uncertain whether early appendicectomy prevents overall morbidity or other complications. Early appendicectomy may reduce the total length of hospital stay and increase the time away from normal activities, but the evidence is very uncertain. For the comparison of early versus delayed laparoscopic appendicectomy for paediatric participants with appendiceal abscess, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy. Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery, and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities and length of hospital stay.

Management of early appendicular lump in children - laparoscopic technique versus open surgery: a comparative study in low-middle income country perspective

Background

In the pediatric population, appendectomy is one of the most common emergency operations. Laparoscopic appendectomy (LA) is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role of laparoscopy in appendicular lump is more controversial and remains undefined and is not well practiced in low-middle income countries. The aim of this study was to determine a better surgical treatment plan for early appendicular lump in children.

Methods

This prospective observational study was performed in Pediatric Surgery Department of Chittagong Medical College and Hospital for a period of 1 year from April 2018 to March 2019. Sixty children with appendicular lump selected consecutively as per eligibility criteria underwent either LA or open appendectomy (OA), that is, 30 children per group. They were followed up until hospital discharge to observe outcomes.

Results

There were no differences in terms of patient’s age, sex, clinical presentation and laboratory findings between the two groups. Postoperative pain severity was significantly less in the LA group than that in the OA group (p<0.01). The incidence of wound infection was significantly lower in the LA group than that in the OA group (6.7% in LA and 46.7% in OA; p<0.01). Children in the LA group had a shorter duration of hospital stay in comparison to the OA group [median (IQR) was 8 (5.75–11.25) days and 12 (7.75–18.00) days, respectively, in LA and OA groups; p=0.01].

Conclusion

The study findings suggest that LA is feasible and should replace OA in cases of early appendicular lump in children.

Study of management of appendicular abscess in children

AIM

To compare the outcomes in children who underwent emergency surgery and those who underwent percutaneous drainage for appendicular abscess.

MATERIALS AND METHODS

In this prospective study, 45 children of appendicular abscess detected on ultrasonogram (USG) were included in the study. The following characteristics were registered: age, gender, the time from onset of symptoms to seeking care, pain, vomiting, fever and general peritonitis; white blood cell count. The size, location of the abscess was noted on USG. After the diagnosis, we divided the patients into two groups based on the type of management. Patients who underwent emergency surgery and appendectomy (Group 1) which composed of twenty patients (14 males and six females) with their ages ranged from 3 to 18 years, and patients treated with ultrasound-guided percutaneous drainage and interval appendectomy (Group 2) which composed of 25 patients, (15 males and ten females) with their ages ranged from 2 to 18 years.

RESULTS

Group 1 included twenty patients and Group 2 included 25 patients. In Group 1, on USG the average size of the abscess was 7.2 ± 2.5 cm. After the surgery regained their functional recovery during a mean period of 3.2 ± 1 days. In Group 2, on USG average abscess size was 6.8 ± 2.4 cm. After the procedure regained their functional recovery on the second day. No major complications were noted in Group 2. On the contrary, 12 patients (60%) of Group 1 show complications in the form of wound infection in eight children and wound dehiscence in four children.

CONCLUSIONS

USG-guided percutaneous drainage was safe and effective way of management of appendicular abscess.

Evolution of minimally invasive distal pancreatectomies at a single institution

Introduction

This study aims to study the changing trends and outcomes associated with the adoption of minimally invasive distal pancreatectomy (MIDP) at a single centre.

Materials and Methods

Retrospective review of sixty consecutive patients who underwent MIDP from September 2006 to November 2016 at a single institution. To study the evolution of MIDP, the study population was divided into three groups consisting of twenty patients (Group I, Group II and Group III).

Results

Sixty patients underwent MIDP with 11 (18.3%) requiring open conversions. The median operation time was 305 (range: 85-775) min and the median post-operative stay was 6 (range: 3-73) days. Fifteen procedures were spleen-saving pancreatectomies. Major post-operative morbidity (>Grade 2) occurred in 12 (20.0%) patients and there was no mortality or reoperations. There were 33 (55.0%) pancreatic fistulas, of which 15 (25.0%) were Grade B fistulas of which 12 (20.0%) required percutaneous drainage. Comparison between the three groups demonstrated a statistically significant increase in the frequency of procedures performed, increase in robotic-assisted procedures and proportion of asymptomatic tumours resected. There also tended to be non-significant decrease in open conversion rates from 25% to 5% between the three groups and increase in tumour size resected from 24 to 40 mm.

Conclusion

Comparison between the three groups demonstrated that MIDP was performed with increased frequency. There was a statistically significant increase in the frequency of resections performed for asymptomatic tumours and resections performed through robotic assistance. There was also a non-significant trend towards a decrease in open conversions and increase in the size of tumours resected.

Early experience with robot-assisted laparoscopic hepatobiliary and pancreatic surgery in Singapore: single-institution experience with 20 consecutive patients

INTRODUCTION

Experience with robot-assisted laparoscopic (RAL) hepatobiliary and pancreatic (HPB) surgery remains limited worldwide. In this study, we report our early experience with RAL HPB surgery in Singapore.

METHODS

A retrospective review of the first 20 consecutive patients who underwent RAL HPB surgery at a single institution over a 34-month period from February 2013 to November 2015 was conducted. The 20 cases were performed by three principal surgeons, of which 17 (85.0%) were performed by a single surgeon.

RESULTS

The median age of patients was 56 (range 22-75) years and median tumour size was 4.0 (range 1.2-7.5) cm. The surgeries performed included left-sided pancreatectomies (n = 10), hepatectomies (n = 7), triple bypass with bile duct exploration for obstructing pancreatic head cancer with choledocholithiasis (n = 1), cholecystectomy for Mirizzi's syndrome (n = 1) and gastric resection for gastrointestinal stromal tumour (n = 1). The median operation time was 445 (range 80-825) minutes and median blood loss was 350 (range 0-1,200) mL. There was only 1 (5%) open conversion. There were 2 (10.0%) major morbidities (> Grade II on the Clavien-Dindo classification) and no 30-day/in-hospital mortalities. There was no reoperation for postoperative complications. The median postoperative stay was 5.5 (range 3-22) days.

CONCLUSION

Our initial experience confirms the feasibility and safety of RAL HPB surgery.

Management of Pediatric Perforated Appendicitis: Comparing Outcomes Using Early Appendectomy Versus Solely Medical Management

BACKGROUND

There is controversy regarding whether children with perforated appendicitis should receive early appendectomy (EA) versus medical management (MM) with antibiotics and delayed interval appendectomy. The objective of this study was to compare outcomes of children with perforated appendicitis who receive EA versus MM.

METHODS

Case review of consecutive children <18 years of age with perforated appendicitis who received either EA or MM during an 8-year period. Criteria for hospital discharge included patient being afebrile for at least 24 hours, pain-free and able to tolerate oral intake.

RESULTS

Of 203 patients diagnosed with perforated appendicitis, 122 received EA and 81 received MM. All received parenteral antibiotic therapy initiated in the emergency department and continued during hospitalization. There were no significant differences between groups in mean patient age, mean complete blood count total white blood cells count, gender distribution, rates of emergency department fever or rates of intra-abdominal infection (abscess or phlegmon) identified on admission. Compared with patients receiving MM, those receiving EA experienced significantly fewer (1) days of hospitalization, parenteral antibiotic therapy and in-hospital fever; (2) radiographic studies, percutaneous drainage procedures and placement of central venous catheters performed; (3) post admission intra-abdominal complications and (4) unscheduled repeat hospitalizations after hospital discharge. Only 1 EA-managed patient developed a postoperative wound infection.

CONCLUSIONS

Children with perforated appendicitis who receive EA experience significantly less morbidity and complications versus those receiving MM. The theoretical concern for enhanced morbidity associated with EA management of perforated appendicitis is not supported by our analysis.

Early versus delayed appendicectomy for appendiceal phlegmon or abscess

BACKGROUND

Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial.

OBJECTIVES

To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials.

SELECTION CRITERIA

We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmonForty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscessForty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD -0.20 days; 95% CI -3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities.

AUTHORS' CONCLUSIONS

It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy.Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay.

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.

Impact of high-grade obstruction on outcomes in patients with appendiceal inflammatory masses managed by nonoperative treatment

Purpose

To retrospectively assess the impact of high-grade obstructions identified on initial CT on outcomes of patients with appendiceal inflammatory masses managed by nonoperative treatment.

Methods

Institutional Review Boards approved this retrospective study and informed consent was waived. Included were 52 consecutive patients diagnosed with appendiceal inflammatory masses by CT scan and managed by nonoperative treatment. The main outcome measure was treatment failure and secondary outcomes were complications and initial and total hospital stay. Patient demographics, inflammatory markers, and CT findings for presence of an appendiceal inflammatory mass and high-grade obstruction were assessed. Patients with and without high-grade obstruction were compared for patient characteristics and outcomes using Fisher exact test and Student t-test.

Results

Among 52 patients, 14 (27%) had high-grade obstruction on CT examination at presentation. No significant differences were observed in patient characteristics (P > 0.05), treatment failure (P = 0.33), complications (P = 0.29), or initial (P = 0.73) or total (P = 0.72) hospitalization between patients with and without high-grade obstruction.

Conclusion

For patients who were managed by nonoperative treatment for appendiceal inflammatory masses, the presence of high-grade obstruction identified on initial CT scan did not significantly affect outcomes of treatment failure, complications, and initial and total hospitalization.

Early experience with totally laparoscopic major hepatectomies: single institution experience with 31 consecutive cases

BACKGROUND

Totally laparoscopic major hepatectomy (LMH) is a technically challenging procedure with limited studies mainly from high-volume expert centers reported. In this study, we report our initial experience with totally LMH.

METHODS

A retrospective review of a prospective database of 340 consecutive patients who underwent laparoscopic liver resection at a single institution was conducted. Thirty-one consecutive patients who underwent attempted totally LMH between March 2011 to December 2016 were identified. Major hepatectomies were defined as resection of ≥3 contiguous segments which included only right/left hepatectomies, extended hepatectomies or central hepatectomies.

RESULTS

The procedures included 11 right hepatectomies, one extended right hepatectomy, nine left hepatectomies (two including middle hepatic vein), two extended left hepatectomies, two left hepatectomies with caudate lobe and six central hepatectomies. The median tumor size was 40 (range, 12-100) mm and the median operation time was 435 (range, 245-585) min. Median blood loss was 500 (range, 100-1900) mls and 10 (32.3%) patients required blood transfusion. There were three (9.7%) open conversions of which two occurred during the first five cases. There was one (3.2%) major (>grade 2) morbidity and there were no 30-day/in-hospital mortalities or reoperations. The median postoperative stay was 5 (range, 3-14) days.

CONCLUSION

Our initial experience confirms the feasibility and safety of LMH. There was an increase in the number and proportion of LMH performed at our institution over time.

Evolution of laparoscopic liver resection at Singapore General Hospital: a nine-year experience of 195 consecutive resections

INTRODUCTION

We aimed to analyse the changing trends, safety and outcomes associated with the adoption of laparoscopic liver resection (LLR) at a single centre.

METHODS

A retrospective review of patients who underwent LLR from 2006 to 2014 at our institution was performed. To explore the evolution of LLR, the study was divided into three equal consecutive time periods (Period 1: 2006-2008, Period 2: 2009-2011, and Period 3: 2012-2014).

RESULTS

Among 195 patients who underwent LLR, 24 (12.3%) required open conversions, 68 (34.9%) had resection of tumours in the difficult posterosuperior segments and 12 (6.2%) underwent major (≥ 3 segments) hepatectomies. Median operation time was 210 (range 40-620) minutes and median postoperative stay was 4 (range 1-26) days. Major postoperative morbidity (> Grade II) occurred in 11 (5.6%) patients and 90-day/in-hospital mortality was 1 (0.5%). During the study, the number of LLRs performed showed an increasing trend (Period 1: n = 22; Period 2: n = 19; Period 3: n = 154). Other statistically significant trends were: (a) increase in malignant neoplasms resected; (b) increase in resections of difficult posterosuperior segments; (c) longer median operation time; and (d) decrease in open conversion rates.

CONCLUSION

Over the study period, the number of LLRs increased rapidly. LLR was increasingly performed for malignant neoplasms and lesions located in the difficult posterosuperior segments, resulting in longer operation times. However, open conversion rates decreased, and there was no change in postoperative morbidity and other perioperative outcomes.

Laparoscopic Liver Resection for Tumors in the Left Lateral Liver Section

Background:

The laparoscopic approach is increasingly adopted for liver resections today especially for lesions located in the left lateral liver section. This study was conducted to determine the impact of the introduction of laparoscopic liver resection (LLR) as a surgical option for suspected small- to medium-sized (<8 cm) tumors located in the left lateral section (LLS).

Methods:

This is a retrospective review of 156 consecutive patients who underwent LLR or open liver resection (OLR) of tumors located in the LLS. The study was divided into 2 consecutive periods (period 1, January 2003 through September 2006, and period 2, October 2006 through April 2014); LLR was available as a surgical option only in the latter period. Comparisons made were LLR versus OLR, LLR versus OLR (in period 2 only), and resections performed in period 1 versus period 2.

Results:

Forty-two patients underwent LLR with 4 conversions. LLR was significantly associated with a longer median operative time [167.5 minutes (range, 60–525) vs 105 minutes (range, 40–235); P < .001], decreased need for the Pringle maneuver [n = 1 (2%) vs 22 (19%); P = .008], and shorter postoperative stay [n = 4 (range, 1–10) days vs 5 days (range, 2–47); P < .001] compared with open resection. Comparison of the 42 patients who underwent LLR with the 64 contemporaneous patients who underwent OLR demonstrated similar outcomes. Again, LLR was associated with a significantly longer operation, decreased need for the Pringle maneuver, and shorter hospital stay.

Conclusions:

LLR can be safely adopted to treat lesions in the LLS. The procedure is associated with a shorter postoperative stay and a decreased need for the Pringle maneuver, but longer operative time compared with that required for OLR.

Operative management of appendicitis

Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.

Pre-operative CT predictors associated with 30-day adverse events in patients with appendiceal inflammatory masses who underwent immediate appendectomies

PURPOSE

To retrospectively evaluate pre-operative CT predictors that are associated with 30-day adverse events in patients who underwent immediate appendectomies for appendiceal inflammatory masses.

METHODS

This retrospective study was approved by our institutional review board, and the requirement for informed consent was waived. One hundred forty-four consecutive patients who underwent immediate appendectomies and were diagnosed with appendiceal inflammatory masses by pre-operative CT from January 2005 to December 2013 at a tertiary hospital were included. The main outcome measure was 30-day adverse events. Patient demographics and data for inflammatory markers including leukocyte counts, segmented neutrophils, and C-reactive protein levels were collected by a single radiologist. Pre- and post-operative CT findings were evaluated for features of appendiceal inflammatory masses, associated findings, and post-operative adverse events by two radiologists in a blinded fashion with consensus to assess surgical and pathologic results, post-operative outcomes, and original CT interpretations. Appendiceal inflammatory masses were defined as complicated appendicitis with a phlegmon or an abscess that was identified on pre-operative CT exam. Factors associated with 30-day adverse events were assessed using logistic regression analysis.

RESULTS

A total of 22 (15%) of the 144 patients (mean age [±SD] 44.6 ± 22.0 years, range 3-97 years) experienced 30-day adverse events: ten intra-abdominal abscesses, three wound infections, two cases of peritonitis, two small bowel obstructions, two intra-abdominal abscesses with peritonitis, one intra-abdominal abscess with wound infection, one intra-abdominal abscess with small bowel obstruction, and one case of peritonitis with small bowel obstruction. In univariate analysis, the presence of appendicolith (odds ratio [OR] 2.49, p = 0.048) and high-grade obstruction (OR 3.79; p = 0.01) were associated with adverse events. High-grade obstruction (adjusted OR 3.05; p = 0.04) was the only independent pre-operative predictor associated with 30-day adverse events in patients with appendiceal inflammatory masses.

CONCLUSIONS

High-grade obstruction was an independent pre-operative CT predictor associated with 30-day adverse events in patients who underwent immediate appendectomies for appendiceal inflammatory masses.

Early laparoscopic management of appendicular mass in children: Still a taboo, or time for a change in surgical philosophy?

INTRODUCTION:

Early appendicectomy has been found to be a safe and better alternative for management of appendicular mass in various studies in adults, while very few studies report such advantages in the paediatric population. We conducted this study to assess the safety, efficacy and need of early laparoscopic appendicectomy (ELA) in child patients with appendicular mass.

MATERIALS AND METHODS:

All patients with appendicular mass who underwent ELA at our institute between September 2011 and August 2014 were retrospectively reviewed. Appendicular mass was defined as a right iliac fossa mass in a case of acute appendicitis, diagnosed by clinical, laboratory and radiological evaluation, and palpation under anaesthesia, the patient being subjected to laparoscopic treatment.

RESULTS:

Forty-eight (48) patients were confirmed to have appendicular mass intraoperatively and were included in the analysis. There were 30 males and 18 females, with ages ranging 7-13 years (mean 9 years). In the present study, appendicular complications included appendicular abscess (62.5%), gangrenous appendicitis (25%), sloughed-out appendix (8.33%) and appendicular perforation (4.16%). The average operative time was 72 min (range 45-93 min). One case (1.92%) required conversion to open procedure due to failure of identification of the appendicular base of a sloughed-out appendix. Post-operative complications were found in 4 (7.69%) patients, of whom 3 (5.76%) had minor wound infection at the umbilical port site and 1 (1.92%) had post-operative pelvic abscess, which was managed with percutaneous aspiration.

DISCUSSION:

ELA avoids misdiagnosis, treats complicated appendicitis at its outset, and avoids complications and/or failure of non-operative treatment of a potentially lethal, diseased appendix. This approach is associated with minimal complications in experienced hands and is a safe and feasible option in children with appendicular mass.

Robotic hepatectomy: initial experience of a single institution in Singapore

INTRODUCTION

In this study, we report our initial experience with robotic hepatectomy.

METHODS

Consecutive patients who underwent robotic hepatectomy at Singapore General Hospital, Singapore, from February 2013 to February 2015 were enrolled in this study. The difficulty level of operations was graded using a novel scoring system for laparoscopic hepatectomies.

RESULTS

During the two-year period, five consecutive robotic hepatectomies were performed (one left lateral sectionectomy, one non-anatomical segment II/III resection, one anatomical segment V resection with cholecystectomy, one extended right posterior sectionectomy and one non-anatomical segment V/VI resection). Two hepatectomies were performed for suspected hepatocellular carcinoma, two for solitary liver metastases and one for a large symptomatic haemangioma. The median age of the patients was 53 (range 38-66) years and the median tumour size was 2.5 (range 2.1-7.3) cm. The median total operation time was 340 (range 155-825) minutes and the median volume of blood loss was 300 (range 50-1,200) mL. There were no open conversions and no mortalities or major morbidities (> Clavien-Dindo Grade II). The difficulty level of the operations was graded as low in one case (Score 2), intermediate in three cases (Score 5, 6 and 6) and high in one case (Score 10). There was one minor morbidity, where the patient experienced Grade A bile leakage, which resolved spontaneously. The median length of postoperative hospital stay was 5 (range 4-7) days.

CONCLUSION

Our initial experience confirmed the feasibility and safety of robotic hepatectomy.

First experience with robotic spleen-saving, vessel-preserving distal pancreatectomy in Singapore: a report of three consecutive cases

INTRODUCTION

The use of laparoscopic distal pancreatectomy (LDP) has increased worldwide due to the reported advantages associated with this minimally invasive procedure. However, widespread adoption is hindered by its technical complexity. Robotic distal pancreatectomy (RDP) was introduced to overcome this limitation, but worldwide experience with RDP is still lacking. There is presently evidence that RDP is associated with decreased conversion rate and increased splenic preservation as compared to LDP.

METHODS

We conducted a prospective study on our initial experience with robotic spleen-saving, vessel-preserving distal pancreatectomy (SSVP-DP) between July 2013 and April 2014.

RESULTS

Three consecutive patients underwent attempted robotic SSVP-DP. The indications were a 2.1-cm indeterminate cystic neoplasm, 4.5-cm solid pseudopapillary neoplasm and 1.2-cm pancreatic neuroendocrine tumour. For all three patients, the procedure was completed without conversion, and the spleen, with its main vessels, was successfully conserved. The median total operation time, blood loss and postoperative stay were 350 (range 300-540) minutes, 200 (range 50-300) mL and 7 (range 6-14) days, respectively. Two patients had minor Clavien-Dindo Grade I complications (one Grade A pancreatic fistula and one postoperative ileus). One patient had a Clavien-Dindo Grade IIIa complication (Grade B pancreatic fistula requiring percutaneous drainage). All patients were well at the time of reporting after at least six months of follow-up.

CONCLUSION

Our preliminary experience with robotic SSVP-DP confirmed the feasibility of the procedure.

Abscess due to perforated appendicitis: factors associated with successful percutaneous drainage

BACKGROUND

Percutaneous drainage is the standard treatment for perforated appendicitis with abscess. We studied factors associated with complete resolution (CR) with percutaneous drainage alone.

METHODS

Ninety-eight patients underwent percutaneous drainage for acute appendicitis complicated by abscess (October 1990 to September 2010). CR was defined as clinical recovery, resolution of the abscess on imaging, and drain removal without recurrence. Patients achieving CR were compared with patients not achieving CR.

RESULTS

The rate of CR was 78.6% (n = 77). Abscess grade was the only radiological factor associated with CR (P = .007). The CR rate was higher with transgluteal drainage (90.9% vs 79.2%) than with other anatomic approaches (P = .018) and higher with computed tomography-guided drainage than with ultrasound-guided drainage (82.7% vs 64.3%, P = .046).

CONCLUSION

CR was more likely to be achieved in patients with lower abscess grade, computed tomography-guided drainage, and a transgluteal approach.

Factors associated with and outcomes of open conversion after laparoscopic minor hepatectomy: initial experience at a single institution

BACKGROUND

Laparoscopic liver resection has been increasingly adopted worldwide as a result of the rapid advancement in surgical techniques and equipment. This study aims to determine the factors associated with and outcomes of open conversion after laparoscopic minor hepatectomy (LMH) based on a single center multi-surgeon experience.

METHODS

This is a retrospective review of the first 147 consecutive LMH performed between 2006 and April 2014 at a single institution. Data on patient demographics, pathology results, perioperative outcomes, and operative results were collected. Factors associated with open conversion were analyzed via univariate analysis and a P value <.05 was considered statistically significant.

RESULTS

LMH was performed for malignancy in 114 (77.6%) patients of which hepatocellular carcinoma (n = 82) and colorectal metastases (n = 16) were the most common pathologies. Forty-one (27.9%) patients had cirrhotic livers and 18 (15.7%) had fibrotic livers. Fifty patients (44%) had concomitant surgery in addition to LMH. Twenty (13.6%) procedures required open conversion and the most common reason was for bleeding (n = 12). Twenty-five patients (17%) experienced postoperative complications. Univariate analyses demonstrated that only individual surgeon volume (n ≤ 10 cases) [15 (24.2%) vs 5 (5.9%), P = .001] and institution volume (n ≤ 25 cases) [8 (32%) vs 12 (9.8%), P = .003] were factors associated with open conversion. Open conversion was significantly associated with increased intra-operative blood loss, increased intra-operative blood transfusion, increased postoperative morbidity, and longer postoperative stay.

CONCLUSIONS

Individual surgeon and institution volumes were important factors associated with open conversion after LMH. Open conversion after LMH resulted in poorer outcomes compared to procedures that were successfully completed laparoscopically.

Drainage of periappendiceal abscess and removal of free fecalith--extraperitoneal approach

Treatment of complicated acute appendicitis is controversial. The dilemma is further complicated by presence of free fecalith in a well-circumscribed abscess, which has been repeatedly demonstrated to be a major predicting factor of treatment failure of nonoperative treatment of acute appendicitis complicated with appendiceal abscess. If left behind after drainage of the abscess, further operations for removal of retained fecalith or recurrence of abscess might be required. However, little had been stressed over the significance of removal of the free fecalith when it was first encountered. We report our experience of drainage of appendiceal abscess and removal of free fecalith by taking an extraperitoneal approach. Both of our cases made a smooth recovery without any complication or recurrence after a 2-year follow-up. Treatment with this approach avoids many of the complications associated with formal laparotomy. Unlike image-guided drainage or laparoscopic drainage, this procedure is relatively simple and straightforward and can be performed in any level of hospital, including private practitioners and in less well-developed areas and countries. With proper case selection, we recommend this approach as one of the alternatives in the treatment of late-presenting appendiceal abscess with free fecalith.

Effectiveness of Interval Appendectomy After Conservative Treatment of Pediatric Ruptured Appendicitis with Abscess

The management of patients with acute perforated appendicitis with abscess is controversial. The aim of the present study was to assess the outcomes of treatment in patients with this condition. We retrospectively analyzed 31 patients (16 men and 15 women with a mean age of 8.4 years) with appendicitis presenting with abscess. Patients were divided into two groups (emergency operation group and interval operation group), and clinical characteristics and outcomes of treatment were investigated. On presentation, no differences in gender, age, body weight, duration of symptoms, temperature, white blood cell count, C-reactive protein level, or maximum size of the abscess in the axial view were detected between the two groups. Fifteen patients (48.4 %) underwent emergency surgery. The remaining 16 patients (51.6 %) were initially treated conservatively with antibiotics. All 16 patients underwent planned operations after receiving conservative treatment, and two (12.5 %) of these patients underwent appendectomy before the planned operation day because of recurrent appendicitis without abscess. There were no differences in the length of hospital stay. In the emergency operation group, six (40 %) patients presented with wound infection and four (26.7 %) developed a postoperative intra-abdominal abscess. No infective complications were reported in the interval operation group. Interval appendectomy after conservative treatment of pediatric ruptured appendicitis with abscess significantly reduced postoperative infection rates.

Singapore's anatomical future: quo vadis?

The disciplines of anatomy and surgery are not dichotomous since one is dependent on the other. Traditionally, surgeons predominantly taught gross and clinical anatomy. In this review, we examine the context of how human anatomy is taught nowadays. In essence, we discovered that there are certain discernable trends consistently observable between the American and British systems. In Singapore, the British Russell Group first influenced its education landscape but now more so by the American Ivy League. Singapore now has three medical schools all offering differing anatomy curricula, which serves as an opportune time for it to consider if there is a best approach given that the practice of surgery is also evolving in parallel. This review discusses the various pedagogies and issues involved, and will serve as a forum and stimulus for discussion. By tweaking the curriculum correctly and the lessons learnt, future doctors and surgeons in training will receive a better anatomical education, not just in Singapore but the world in general. Key recommendations include the use of body painting, clay, plasticine to facilitate the learning of anatomy, and the implementation of a body donation program. Furthermore, strategic mergers with key stakeholders will also ensure the survival of the discipline.

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.

Caecal tumour masquerading as an appendicular mass

Appropriate management of appendix mass is based on an accurate diagnosis of the underlying pathology. This is a report of a complex patient presenting with an appendix mass, whose surgery was deferred due to severe co-morbidities and who later died from severe metastatic disease. A 65-year-old lady presented with right iliac fossa pain and a mass. She was treated for an appendix mass initially and when the mass failed to resolve after four weeks, she was thoroughly investigated for the possibility of a tumour. Severe co-morbities had a significant impact on her management as definitive surgery was delayed. She represented 10 months after the initial admission with small bowel obstruction and died of metastatic caecal cancer. Management of appendix mass must entail a careful approach to investigating and treatment with emphasis on early intervention if the mass does not resolve promptly. This will avoid delayed diagnosis, treatment and a detrimental impact on prognosis.

Laparoscopic appendicectomy is a favorable alternative for complicated appendicitis in children

Aim:

To evaluate the role of laparoscopy in complicated appendicitis in children.

Materials and Methods:

A total of 119 children were operated for appendicitis between October 2005 and May 2008 at SRMC, Chennai. Forty-one patients underwent open appendicectomy (OA), and 71 patients underwent laparoscopic appendicectomy (LA). Twenty-six cases among the LA group and 16 among the OA group had complicated appendicitis. Twenty-six cases were completed laparoscopically, and 2 needed conversion to OA.

Results:

Out of 26 patients in the LA group, 23 made an uneventful recovery without any complications. One had minor port site infection, and 2 had prolonged loose stools. Out of 16 in the OA group, 7 had complications. Three had wound infection, 2 had loose stools, 1 had fecal fistula and another required subsequent surgeries. Operative duration in LA was 86.7 min (range: 75 to 120 min) and 90.3 min (range: 70 to 150 min) in OA. Oral feed resumption in LA was done at average of 2.7 days and in OA at 4.3 days. IV antibiotics were administered for an average of 3.6 days in LA and 4.8 days in OA, parenteral analgesic for 2.7 days in LA and 4.2 days in OA. The length of hospital stay was 5.4 days in LA and 7.3 days in OA.

Conclusion:

LA is a favorable alternative in children with complicated appendicitis in view of less postoperative pain, fewer postoperative complications and quicker return to normal activity.

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.

The laparoscopic approach for perforated appendicitis, including cases complicated by abscess formation

BACKGROUND

Although the laparoscopic approach for perforated appendicitis is commonly performed, there is some controversy over its use because of postoperative complications. These may be associated with various types of disease entities, from gangrenous change to diffuse peritonitis with abscess formation. The aim of the present study was to evaluate the safety and benefits of the laparoscopic approach for perforated appendicitis, including cases complicated by abscess, compared to open.

MATERIALS AND METHODS

A total of 1747 patients underwent treatment for appendicitis over a period of 3 years. The diagnosis of perforated appendicitis was made by radiology, operative finding, and pathology. Of our five attending surgeons, three performed open surgery for perforated appendicitis, while two performed laparoscopy.

RESULTS

There were 474 patients (27%) with perforated appendicitis without abscess (156 underwent laparoscopy, 318 underwent open) and 113 patients (6.4%) with perforated appendicitis and abscess (44 underwent laparoscopy, 69 underwent open). The duration for resumption of diet and hospital stay was shorter in the laparoscopy group than in the open group. There were no significant differences in postoperative complications between patients who had no abscess with laparoscopy and those with open: 5 intra-abdominal abscesses and 10 wound infections versus 11 intra-abdominal abscesses and 25 wound infections (P = 0.88, 0.12), and between patients who had abscesses with laparoscopy and those with open: 4 intra-abdominal abscesses and 3 wound infections versus 6 intra-abdominal abscesses and 6 wound infections (P = 0.94, 0.72).

CONCLUSIONS

The laparoscopic approach may be a safe, effective treatment for perforated appendicitis, even in the presence of an abscess.

Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome

OBJECTIVE

The purposes of this study were to retrospectively investigate the effectiveness and safety of CT-guided percutaneous drainage in the treatment of patients with acute appendicitis complicated by perforation and to identify CT findings and procedure-related factors predictive of clinical and procedure outcome.

MATERIALS AND METHODS

From March 2005 through December 2008, 41 consecutively registered patients (24 men, 17 women; age range, 18-75 years) underwent CT-guided percutaneous drainage for the management of acute appendicitis complicated by perforation and abscess. Three board-certified radiologists independently reviewed preprocedure CT images. Patients were assigned to one of three risk categories on the basis of the CT findings. Success and failure of percutaneous drainage were defined on a per-patient (i.e., clinical outcome) and per-procedure (i.e., technical outcome) basis. Immediate, periprocedure, and delayed complications were recorded. The association between candidate predictive variables, including demographic characteristics, preprocedure CT findings, and procedure-related factors and clinical or technical outcome was assessed with logistic regression models.

RESULTS

Fifty-two CT-guided procedures were performed on 41 patients. Percutaneous drainage had clinical and technical success rates of 90% (37 of 41 patients, 47 of 52 procedures) with no procedure-related complications. In seven patients (19%) clinical success required repeated drainage procedures. A large, poorly defined periappendiceal abscess and an extraluminal appendicolith on preprocedure CT images were independent predictors of clinical failure of percutaneous drainage.

CONCLUSION

CT-guided percutaneous drainage is both effective and safe in the treatment of patients with acute appendicitis complicated by perforation and abscess. The clinical and technical success rates are high.

Management of appendiceal mass: controversial issues revisited

PURPOSE

Although appendix mass occurs in 10% of patients with acute appendicitis, its surgical management is surrounded with controversy. This article reviews some of the controversial issues in the management of appendix mass.

METHODS

A search of the English literature was conducted for "appendiceal mass," "interval appendicectomy," and "laparoscopic appendicectomy" and manual cross-referencing.

RESULTS AND CONCLUSION

The majority of the studies were small and retrospective. Emergency appendicectomy for appendix mass is emerging as an alternative to conventional conservative treatment. It is feasible, safe, and cost-effective, allowing early diagnosis and treatment of unexpected pathology. However, the appropriate timing for emergency surgery is not clear. After successful conservative management, interval appendicectomy is not necessary and can safely be omitted, except in patients with recurrent symptoms. In patients over 40 years of age, other pathological causes of right iliac mass must be excluded by further investigations (colonoscopy and computerized tomography scan), and a close follow-up is needed. Laparoscopic appendicectomy whether in emergency or interval settings is feasible and safe and should replace the conventional open method. Large prospective, randomized controlled trials are lacking, and therefore, such trials are needed to scientifically compare emergency surgery vs conservative management without interval appendicectomy.

Laparoscopic appendectomy after conservative management of appendix mass

The purpose of this study was to demonstrate the safety and efficacy of laparoscopic appendicectomy following non-operative management of appendix mass in children. Medical records of 103 consecutive patients (61 males, 42 females) who underwent non-operative treatment of appendix mass followed by laparoscopic elective appendicectomy were examined. Their ages ranged from 2 years 5 months to 15 years (mean 8.3 years). All patients were treated conservatively by close observation, antibiotics and intravenous fluids. Once the child was fit for discharge laparoscopic elective appendicectomy was booked for 4-6 weeks later. Ninety-three children responded to the initial conservative treatment and were discharged after a mean hospital stay of 5.6 days (range 3-10 days). Ten (9.7%) did not respond to initial treatment and developed appendix abscess requiring drainage. Average hospital stay in the 97 patients who had laparoscopic elective appendicectomy was 2.5 days (range 1-5 days). Three patients developed complications after elective appendicectomy, a stitch abscess in one, paralytic ileus in one and wound infection in one. Histological examination revealed fibrosed or resolving appendicitis in 52, acute or subacute appendicitis in 24, carcinoid tumour in two and normal appendix in 19. Laparoscopic elective appendicectomy is a safe and effective method of treatment following conservative treatment of appendix mass. Not only does it make the dissection and resection of the appendix easier but it also has the added advantage of performing adhesiolysis.

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.

Antibiotic Therapy and Interval Appendectomy for Perforated Appendicitis in Children: A Selective Approach

The role of initial nonoperative treatment in pediatric perforated appendicitis remains controversial. We examined our outcomes after using this approach in a selective manner. Children with perforated appendicitis treated during a 28-month period were retrospectively reviewed. Antibiotics and delayed appendectomy were used if there were more than 3 days of symptoms, absence of bowel obstruction, absence of diffuse peritonitis, and an appendiceal mass. Of 221 patients with perforated appendicitis, 32 (14%) were treated with this approach. Average age was 7.4 ± 4.2 years. Twenty-eight patients (88%) were successfully managed and 26 (81%) underwent appendectomy 8.6 ± 4.2 weeks after first presentation. Two patients did not respond completely, and underwent appendectomy during the same admission. Two patients initially responded, but had recurrent symptoms necessitating earlier appendectomy. There were no complications. Average total hospital stay was 7.2 ± 3.0 days. Initial nonoperative treatment is highly successful in selected children who meet specific criteria. Failure is not associated with increased morbidity.

Perforated Appendicitis in Children: Benefits of Early Laparoscopic Surgery

Introduction: The aim of this study was to analyse the feasibility, safety and benefits of laparoscopic appendicectomy (LA) in comparison with open appendicectomy (OA) for perforated appendicitis (PA) in children. Materials and Methods: A retrospective analysis of all consecutive cases of PA who underwent OA or LA between July 2001 and April 2004 was done. The patient demographics, duration of symptoms and operative findings were noted and the feasibility, safety and benefits of LA were analysed with respect to postoperative recovery and complications. Results: One hundred and thirty-seven consecutive patients with PA underwent either OA (n =46) or LA (n = 91). Both groups were comparable with respect to patient demographics, duration of symptoms and operative findings. The mean operative time was 106.5 min (95% CI, 100.2 - 112.8) in the LA group and 92.8 min (95% CI, 82.9-102.7) in the OA group (P = 0.02). The return to afebrile status after surgery was significantly faster in the LA group [mean, 45.4 hours (95% CI, 36.8-54)] than the OA group [mean, 77 hours (95% CI 56.7-97.3)] (P = 0.007). The mean duration for postoperative opioid analgesia was 2.5 days (95% CI, 2.2-2.7) for LA and 3.2 days (95% CI, 2.9- 3.6) for OA (P = 0.001). The resumption of oral feeds after surgery was at 3.1 days (95% CI, 2.8-3.3) for LA and 3.7 days (3.4-4.1) for OA (P = 0.005). The length of the hospital stay was shorter in the LA group [mean, 6.5 days (95% CI, 6.1-6.8)] as compared to that of the OA group [mean, 8.2 days (95% CI, 7.1-9.3)] (P = 0.006). Postoperative complications included wound infection, adhesive intestinal obstruction and pelvic abscess formation. The incidence of these complications was 5.6% in the LA group and 19.6% in the OA group (P = 0.01). Nine patients (9.8%) needed conversion to open surgery in the LA group. None of the LA patients had wound infection. Conclusion: LA is feasible, safe and beneficial in children with PA. Key words: Appendicitis, Complications, Treatment