Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice?

The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review

OBJECTIVE

Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769).

RESULTS

Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)).

CONCLUSION

Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing.

LEVEL OF EVIDENCE

Level II.

Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis

BACKGROUND

Laparoscopic appendectomy (LA) is the preferred approach in uncomplicated appendicitis. However, in patients with complicated appendicitis (CA), the best approach is still unclear though laparoscopy is being increasingly preferred over open appendicectomy (OA) nowadays.

AIM

To comprehensively review the current literature and compare the associations of LA and OA concerning various postoperative outcomes in order to determine the best approach for children with CA.

METHODS

The PRISMA guidelines were adhered to and an electronic database search was extensively performed. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Methodological and statistical heterogeneity, as well as publication bias of the included studies, were assessed.

RESULTS

Four randomized controlled trials (266 LA versus 354 OA) and thirty-six case-controlled trials (2580 LA versus 3043 OA) were included in the analysis. Compared to OA, LA has a shorter length of stay, a lower rate of surgical site infection as well as a significantly lower overall complication rate. The rates of intraabdominal abscess formation, post-operative fever, pneumonia and ileus are similar in the two groups. So are the rates of readmissions and reoperations. LA was also shown to have a shorter time taken to oral intake and a lesser requirement of analgesics as well as intravenous antibiotics. Operative time for OA was found to be significantly shorter than that for LA.

CONCLUSION

This meta-analysis objectively demonstrates that laparoscopy has a better overall complication profile compared to OA and should be the procedure of choice in children with complicated appendicitis.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Laparoscopic Versus Open Appendectomy for Acute Appendicitis in Children: a Nationwide Retrospective Study on Postoperative Outcomes

PURPOSE

Our aim was to compare postoperative outcomes of laparoscopic and open appendectomies for acute appendicitis in children under the circumstance of widespread use of laparoscopic surgery.

METHOD

This study included data on laparoscopic and open appendectomies in children with acute appendicitis from the National Clinical Database, which is a Japanese nationwide surgical database, in 2015. The occurrence rates of complications within 30 days after the surgery and postoperative hospital stay were compared by univariate and multivariate analyses. p < 0.05 was considered statistically significant.

RESULTS

This study included 4489 appendectomies, of which 3166 surgeries (70.5%) were performed laparoscopically. Appendectomy was performed for complicated and uncomplicated appendicitis in 1765 (39.3%) and 2724 cases (60.7%), respectively. Postoperative complications within 30 days were observed in 246 operations (5.5%). Organ-space surgical site infection (SSI), deep wound SSIs, and superficial wound SSIs were observed in 2.3%, 1.0%, and 2.4% of operations, respectively. On multivariate analysis, the incidence of postoperative complications (odds ratio 1.21, 95% CI 0.90-1.64, p = 0.207) and the length of hospital stay (median 4 days in both groups, p = 0.835) were not significantly different between patients who underwent laparoscopic or open appendectomy. Subgroup analysis in complicated and uncomplicated appendicitis cases also demonstrated no significant differences in the incidence of postoperative complications between those who underwent laparoscopic or open appendectomy.

CONCLUSION

This study suggested that the occurrence of postoperative complication and the length of hospital stay in pediatric patients who underwent laparoscopic appendectomy are similar with those in pediatric patients who underwent open appendectomy for acute appendicitis.

Adhesive small bowel obstruction after appendectomy in children - Laparoscopic versus open approach

BACKGROUND

The aims of this study were to compare the incidence of small bowel obstruction (SBO) requiring laparotomy after laparoscopic appendectomy (LA) and open appendectomy (OA) in children and to identify risk factors for SBO.

METHODS

Medical records of patients who underwent appendectomy from 2000 to 2014 at our department of Pediatric Surgery were reviewed. Risk factors were analyzed using Cox proportional hazard regression.

RESULTS

Totally 619 out of 840 patients were included. OA was performed in 474 (76.6%), LA in 130 patients (21%), and 15 (2.4%) were converted from LA to OA. Age, sex and proportion of perforated appendicitis were comparable in the LA and OA groups. Median follow-up time was 11.4 years (2.6-18.4). The incidence of SBO after LA was 1.5%, after OA 1.9% and in the converted group 6.7% (p = 0.3650). There were no significant differences in the incidence of postoperative intraabdominal abscess, wound infection or length of stay between LA and OA. Perforation and postoperative intra-abdominal abscess were identified as risk factors with 9.03 (p < 0.001) and 6.98 (p = 0.004) times higher risk of SBO, respectively.

CONCLUSIONS

The risk for SBO after appendectomy in children was significantly related to perforated appendicitis and postoperative intra-abdominal abscess and not to the surgical approach.

LEVEL OF EVIDENCE

Level III.

Pediatric appendectomy in developing countries: How does it differ from international experience?

Introduction

A review of the English literature indicates the faint superiority of laparoscopic (LA) over open appendectomy (OA) in the pediatric population; however, a developing-country's experience in the field is not available yet. This study presents our experience in LA versus OA over the last 7 years in one university hospital in Lebanon and compares our results to the international ones.

Method

A single center retrospective study was done including all patients aged less than 15 years who underwent appendectomy. A description of each operative technique is presented. Patients' characteristics, intraoperative finding, operative timing (OT), length of stay (LOS) and short term postoperative complications including surgical site infection (SSI) rate, intra-abdominal abscess formation (IAA) rate and reoperation rate were all studied. Statistical analysis was done using Chi-square or Fisher's exact test, as for continuous, Student's t test was used or one-way ANOVA in case of more than 2 categories.

Result

Appendectomy was performed in 84 patients. 52 patients underwent OA through a Rocky Davis incision, and 32 patients underwent a LA. We found an advantage of LA over OA in reducing SSI, otherwise both approaches were similar.

Conclusion

In accordance with international results, in our experience, LA is superior to OA only with regards to SSI.

Do Racial/Ethnic and Economic Factors Affect the Rate of Complicated Appendicitis in Children?

Introduction

Appendicitis continues to be one of the most common surgical conditions in the pediatric population. We set out to determine demographic and practice variations among children admitted with appendicitis and highlight the racial/ethnic and healthcare access role in relation to the rate of complicated appendicitis using the 2012 Kids' Inpatient Database (KID). Methodology. A retrospective cross-sectional database study was performed using the 2012 KID. All children (age 1 months to 20 years) with appendicitis were identified using the ICD-9 diagnosis codes. Children with a diagnosis of appendicitis were compared with all other discharges. Among children with appendicitis, demographic and practice variations and the rate of complicated appendicitis were evaluated. Univariate and multivariate analyses were done to analyze the data. Sample weighing was done to present national estimates.

Results

In 2012, a total of 89, 935 out of 2.7 million pediatric hospital discharges (3.3%) had a diagnosis of appendicitis. The incidence of appendicitis was higher in males (4.7%), 6–15-year age group (7.43%), Hispanics (5.2%), and in the Western region (5.2%) and was lower in infants (0.02%) and African American children (1.2%) (p < 0.0001). The proportion of children with peritonitis or abscess was higher in children's hospitals (48.2% vs. 29.0%; OR 2.3, 95% CI: 2.2–2.4). The risk of complicated appendicitis was inversely related to age, while racial and ethnic minority status, bottom quartile of the income group, and government insurance increased the risk. Laparoscopic appendectomy was performed more frequently at children's hospitals (84.8% vs. 74.3%; p < 0.0001).

Conclusions

Appendicitis is more common in Hispanics, males, older children, and in the Western region. Complicated appendicitis is more common in younger children, minority groups, low-income group, and children with government insurance. Children's hospitals manage more children with complicated appendicitis and are more likely to perform laparoscopic appendectomy.

Comparing the Cost and Outcomes of Laparoscopic versus Open Appendectomy for Perforated Appendicitis in Children

Although laparoscopic appendectomy (LA) is accepted treatment for perforated appendicitis (PA) in children, concerns remain whether it has equivalent outcomes with open appendectomy (OA) and increased cost. A retrospective review was conducted of patients younger than age 17 years treated for PA over a 12.5-year period at a tertiary medical center. Patient characteristics, pre-operative indices, and postoperative outcomes were analyzed for patients undergoing LA and OA. Of 289 patients meeting inclusion criteria, 86 had LA (29.8%) and 203 OA (70.2%), the two groups having equivalent patient demographics and preoperative indices. Inpatient costs were not significantly different between LA and OA. LA had a lower rate of wound infection (1.2 vs 8.9%, P = 0.017), total parenteral nutrition use (23.3 vs 50.7%, P < 0.0001), and length of stay (5.56 ± 2.38 days vs 7.25 ± 3.77 days, P = 0.0001). There was no significant difference in the rate of postoperative organ space abscess, surgical re-exploration, or rehospitalization. In children with PA, LA had fewer surgical site infections and shorter lengths of hospital stay compared with OA without an increase in inpatient costs.

Development in the surgical treatment of acute appendicitis: A single-center experience

PURPOSE

Laparoscopy has become the treatment of choice for acute appendicitis. The aim of the study was to compare open (OA) and laparoscopic (LA) approaches in all forms of acute appendicitis.

METHODOLOGY

Two hundred and ninety-two children underwent appendectomy (238 LA/54 OA). 3/238 patients required conversion. LA surgical technique has been modified by closing also the distal stump of appendix (DSC) before removing it.

RESULTS

Early experience: 130 appendectomy, 44 by OA (34%), and 86 by LA (66%). The mean operative time was similar for both techniques. Complicated appendicitis (CA) was observed in 14 patients (11%). 10 patients treated with OA (10/14 = 71%) and 4 with LA (4/14 = 29%). Complications occurred mainly in the LA group without statistical significance.

LATE EXPERIENCE

One hundred and sixty-two appendectomy, 10 OA (6.17%), and 152 LA (93.8%). Thirty-eight children (23.4%) had CA. The mean operative time was lower in LA group without reaching statistical significance. Total complication rate (CR) was 7.4%. CR in patients with DSC was null and significantly lower when compared to patients without DSC.

CONCLUSION

Our results demonstrated that nearly all cases of appendicitis may be managed by laparoscopy. Ligature of distal appendiceal stump is a trick that may significantly improve outcomes during LA appendectomy.

An Enhanced Recovery Protocol that Facilitates Same-day Discharge for Simple Laparoscopic Appendectomies

Acute appendicitis is the most common gastrointestinal condition requiring urgent operation in the pediatric population with laparoscopic appendectomy (LA) being the current surgical technique. We describe the implementation of a standardized protocol to reduce postoperative nausea and vomiting (PONV) and facilitate same-day discharge after LA.

Current practice patterns for postoperative activity restrictions in children

BACKGROUND

Postoperative activity restrictions are designed to prevent undue stress on a recent repair and minimize the risk of surgical complication, however, there is little evidence to support certain restrictions in clinical practice. For the pediatric population, there is a paucity of formal evaluations of postoperative activity restrictions, and little is known about current practice patterns among pediatric surgeons. This study aimed to describe national practice patterns of pediatric surgeons for postoperative activity recommendations following three common general surgical procedures.

METHODS

A 7-item survey was sent to all American Pediatric Surgical Association (APSA) members regarding surgeon practice of recommended activity restrictions for school attendance, participation in playground or gym, participation in contact sports, and heavy lifting in children following 3 procedures: exploratory laparotomy, laparoscopic appendectomy, and inguinal hernia repair. Information on type and duration of clinical practice was also collected for each surgeon. Descriptive and bivariate analyses were performed.

RESULTS

The survey was completed by 293 pediatric surgeons for a response rate of 28.9%. There was wide national variability in the recommended activity restrictions for children <12 years old among pediatric surgeons. Following laparoscopic appendectomy, 30.7%, 51.9% and 47.8% of surgeons recommends restriction of gym, contact sports, and heavy lifting for 2-3 weeks respectively, but 26.7%, 19.8%, and 22.2% do not recommend any restriction whatsoever of these three activities. Following inguinal hernia repair, 31.7%, 49.1% and 44.4% of surgeons recommend restriction of gym, contact sports, and heavy lifting for 2-3 weeks, but 30.8%, 30.8%, and 29.2% do not recommend any restriction of these three activities. Only 22% of surgeons change their activity restriction recommendations for children ≥12 years old, this decision was not associated with surgeon years in practice or type of practice.

CONCLUSIONS

There is considerable variability in surgeon recommendations for activity restrictions following three general surgery procedures in children. While activity restrictions are rooted in the physiology of wound healing, there is little evidence to support the benefit of these restrictions in clinical practice. In addition, activity restriction may have unintended deleterious effects on a child's psychosocial well-being and quality of life. Further investigation should be pursued to understand the utility of activity restrictions in children and their impact on clinical outcomes and patient quality of life.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level V, expert opinion.

Gangrenous appendicitis: No longer complicated

BACKGROUND

Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hypothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of stay (LOS) and antibiotic usage without increasing postoperative infections.

METHODS

In February 2016, we strictly defined complex appendicitis as a hole in the appendix, extraluminal fecalith, diffuse pus or a well-formed abscess. We switched gangrenous appendicitis to a simple pathway and reviewed all patients undergoing laparoscopic appendectomy for 12 months before (Group 1) and 12 months after (Group 2) the protocol change. Data collected included demographics, appendicitis classification, LOS, presence of a postoperative infection, and 30-day readmissions.

RESULTS

Patients in Group 1 and Group 2 were similar, but more cases of simple appendicitis occurred in Group 2. Average LOS for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (p < 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses.

CONCLUSIONS

Gangrenous appendicitis can be safely treated as simple appendicitis without increasing postoperative infections or readmissions.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II.

Perforated vs. nonperforated acute appendicitis: evaluation of short-term surgical outcomes in an elderly population

BACKGROUND

Acute appendicitis is a common acute surgical abdominal condition and despite the majority of cases are observed in children and young adults, its occurrence in the elderly seems to be increasing, with a higher risk of perforation. The aim of this study was to evaluate the surgical outcomes following appendectomy for acute appendicitis in the elderly, making a comparison between perforated and nonperforated groups regarding operative time, hospital stay and postoperative complications.

METHODS

The medical records of 48 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis from January 2011 to December 2016 were retrospectively reviewed. Patients were grouped into those with perforated and those with non-perforated appendicitis (NPA) and a comparison was made between both groups regarding demography, operative time, length of hospital stay and postoperative complications.

RESULTS

From 48 patients over 60 years diagnosed with acute appendicitis, a PA was removed from 10 patients (20.8%). The PA group consisted of 3 males and 7 females, and their mean age was 71.6 years (range 65-84). The NPA group included 22 males and 16 females, and their mean age was 76.5 years (range 63-96). The mean operative time was 58±18.7 minutes and 43.3±9.9 minutes in the perforated and nonperforated groups respectively, with statistically significant difference (P=0.0013). The mean length of hospital stay was similar in the PA group and in the NPA group, being 6.5±1.8 days and 5.4±1.8 days respectively, but these differences were not statistically significant (P=0.093). The frequency of postoperative complications was similar in both groups as they were observed in 3 patients (30%) of the PA group and 10 patients (26%) of the NPA group (P=0.2488). No postoperative intraabdominal abscess was observed in both groups and there was no death after the surgery.

CONCLUSIONS

PA, despite requiring a longer mean operative time, in our series is not producing a longer hospital stay or more postoperative complications compared to NPA. The non-operative management of uncomplicated appendicitis is a reasonable option in frail patients in order to avoid the burden of morbidity related to operation, nevertheless surgery remains the standard of care in all age groups.

Laparoscopic Appendectomy in Children With Perforated Appendicitis: A Meta-Analysis

BACKGROUND

The purpose of this meta-analysis was to compare the influence of different surgical procedures on perforated appendicitis in pediatric population.

MATERIALS AND METHODS

Studies were identified through a computerized literature search of Pubmed, Embase, Ovid, the Cochrane Colorectal Cancer Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials, the Cochrane Library database, and Web of Science. Two reviewers independently assessed the quality of each study and abstracted outcome data. Data were extracted comparing laparoscopic appendectomy (LA) and open appendectomy (OA) in pediatric population with regard to several postoperative variables. We synthesized published data using fixed-effect models, expressing results as relative risk (RR).

RESULTS

Nine eligible studies were included which came from various medical centers all over the world. Statistically significant differences between "LA" and "OA" groups were found for wound infection (RR=0.88), intra-abdominal abscess (RR=1.38), and bowel obstruction (RR=0.79).

CONCLUSIONS

Our meta-analysis found that LA is associated with lower incidence of wound infections and bowel obstruction, but the rate of intra-abdominal abscess was higher than OA.

Appendectomy Skin Closure Technique, Randomized Controlled Trial: Changing Paradigms (ASC)

BACKGROUND

Appendectomy is the most frequent and urgent gastrointestinal surgery. Overtime, the surgical techniques have been improved upon, in order to reduce complications, get better cosmetic results, and limit the discomfort associated with this procedure, by its high impact in the surgery departments. The traditional skin closure is associated with a poor cosmetic result and it requires stitches removal, alongside the pain associated with this procedure, and no benefits were demonstrated in the literature regarding separated stitches over intradermic stitch. This is a randomized controlled trial, and our objective is to compare two different skin closure techniques in open appendectomy.

METHODS

A prospective randomized trial method was used, with a total number of 208 patients participating in the study, after acute appendicitis diagnosis in the emergency department. They were randomized into two groups: patients who would receive skin closure with a unique absorbable intradermic stitch (Group A) and another group that would receive the traditional closure technique, consistent in non-absorbable separated stitches (Group B). General characteristics like gender, age, Body Mass Index (BMI), comorbidities, and allergies were registered. Days of Evolution (DOE) until surgery, previous use of antibiotics, complicated or uncomplicated appendicitis, surgical time, and wound complications like skin infection, dehiscence, seroma or abscess were also registered in each case.

RESULTS

8 patients were excluded due to negative appendicitis during surgery and lack of follow-up. Two groups, each containing 100 patients, were formed. General characteristics and parity were compared, and no statistically significant differences were observed. Difference in the surgical time (Group A: 47.35 min vs Group B: 54.13 min, p < .001) and cases with complicated appendicitis (Group A: 58 and Group B:38, p = .005) were found to be statistically significant. Four wound complications were reported, and the incidence of seroma (Group A:0 and Group B:5, p = .02) and abscess (Group A:2 and Group B:8, p = .05) were found to have some statistical significant difference. In a multivariate analysis, a relationship was observed between BMI > 25 kg/m² and seroma (p = .006), BMI > 25 kg/m² and abscess (p = .02), surgical time >50 min and seroma (p < .001), >2 DOE and abscess (p = .001), and complicated appendicitis with seroma development (p = .03).

CONCLUSION

Open appendectomy skin closure with a unique absorbable intradermic stitch is safe, with a reduced seroma and abscess incidence, compared to traditional closure, and an equivalent dehiscence and superficial infection incidence, allowing a lower hospital attention cost and length of hospital stay for treatment of complications. The relative risk of complications with traditional skin closure is 2.91 higher, compared to this new technique.

Predicting Postoperative Complications After Pediatric Perforated Appendicitis

PURPOSE

Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA.

MATERIAL AND METHODS

The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions.

RESULTS

Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001).

CONCLUSIONS

Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.

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.

Pediatric laparoscopic appendectomy: a population-based study of trends, associations, and outcomes

PURPOSE

We performed a population-based study to analyze the trends, associations, and outcomes of laparoscopic appendectomy (LA) in the Canadian universal health care setting.

METHODS

Children younger than 18years coded for urgent appendectomy in the discharge abstract database of the Canadian Institute of Health Information during 2004-2010 were analyzed. The Cochran-Armitage test, logistic regression, and quintile regression were used to perform the necessary analyses.

RESULTS

41,405 children were studied. LA incidence steadily increased from 28.8% to 66.4%, p<.0001. Conversion rates significantly decreased, while LA for perforated appendicitis significantly increased. LA occurred significantly less in younger patients [OR 0.24 (<5years), OR 0.45 (6-11 years)], males [OR 0.79], and operations by a general surgeon [OR 0.33]. Rural domicile, socioeconomic status, and hospital type had no effect. LA decreased hospital stay for simple appendicitis by one day beginning in 2006, and by variable durations for perforated appendicitis throughout the study period.

CONCLUSIONS

The incidence of LA in Canada has more than doubled. Older children, females, and patients treated by pediatric surgeons are more likely to receive LA, while domicile, socioeconomic status, and hospital type have no effect. LA reduced hospital stay for both simple and perforated appendicitis.

Laparoscopic appendectomy in the elderly: our experience

BACKGROUND

Laparoscopic appendectomy for acute appendicitis is one of the most common surgical procedures performed in the world. We aimed to compare laparoscopic and open appendectomy in the elderly in our experience.

METHODS

We performed a retrospective review of elderly patients who underwent appendectomy for acute appendicitis from 1st of January 2006 to the 31st of July 2012. We analyzed 39 appendectomies in elderly patients: 20 procedures were performed using open technique (Group O) and 19 using laparoscopic technique (Group L).

RESULTS

In the analysis of intraoperative variables there was no statistically significant difference. In this study there was no statistically significant difference also in peri-operative variables.

CONCLUSION

Laparoscopic appendectomy is a safe and feasible technique in acute appendicitis also in the elderly.

Short term and long term results after open vs. laparoscopic appendectomy in childhood and adolescence: a subgroup analysis

Background

A comparative study was performed to compare quality of life after laparoscopic and open appendectomy in children and adolescents in a German General Hospital. The same study population was re-evaluated regarding their quality of life several years after operation.

Methods

Children and adolescents (n = 158) who underwent appendectomy for acute appendicitis between 1999 and 2001 were retrospectively analysed. Seven years after surgery those patients were interviewed applying a SF-36 questionnaire regarding their quality of life.

Results

For short term outcomes there was a trend towards reduced specific postoperative complications in the laparoscopically operated group (9.3 vs. 10.7%). Significantly more patients in the laparoscopic group would recommend the operation procedure to family members or friends than in the open group. Among the evaluated patients there was a significantly higher satisfaction concerning size and appearance of their scars in the laparoscopic group. The results of the evaluation in the eight categories of the SF-36 showed similar results in both groups.

Conclusions

More patients with laparoscopic appendectomy appeared to be satisfied with their operation method as becomes evident by a higher recommendation rate and a higher satisfaction concerning their scars.

Open versus laparoscopic appendectomy in the pediatric population: a literature review and analysis of complications

BACKGROUND

This study aims to compare the results of laparoscopic and open appendectomy (LA and OA, respectively) in a pediatric population with particular attention to complications analysis.

SUBJECTS AND METHODS

A literature search was performed using Medline, Cochrane, Embase, Sci Search, Lilacs, and PubMed databases on all studies published during the 14-year interval of 1997-2010. Comparative studies of LA versus OA in the pediatric population were included in these studies. Data concerning operative time, length of hospital stay, postoperative complications, postoperative pain, and surgical trauma were recorded.

RESULTS

We recorded 52 studies, but 26 of these were excluded from our analysis because they were neither relevant nor related to the adolescent population. The 26 studies analyzed showed a population of 123,628 children and adolescents (ages 0-18 years) who underwent appendectomy by laparoscopic (LA, 42,213 [34.1%]) and open (OA, 81,415 [65.9%]) techniques. Our analysis showed that patients undergoing LA presented a lower incidence of surgical wound infection, lower incidence of postoperative ileus, a lower use of analgesics in the postoperative period, an earlier resumption of normal diet, a shorter hospitalization, and a more rapid recovery to resume normal activities compared with patients undergoing OA. This study, comparing LA versus OA in children, failed to identify any major difference between the two techniques in terms of formation of intra-abdominal abscesses. As for operative time, our analysis showed globally a significant reduced operative time in OA versus LA in complicated appendicitis, but in simple appendicitis the operative time seems to be the same.

CONCLUSIONS

Our analysis of the literature showed that the LA technique presents several advantages compared with the OA technique. For this reason, if a child is hospitalized today for appendicitis treatment in a pediatric center where the laparoscopic approach is unavailable, he or she should be placed on antibiotics and transferred to a center that offers the laparoscopic approach.

Laparoscopic appendectomy for perforated appendicitis in children has complication rates comparable with those of open appendectomy

PURPOSE

To evaluate the outcome of laparoscopic (LA) vs. open appendectomy (OA) in children with perforated appendicitis (PA).

METHODS

We reviewed the medical files of 221 children who underwent LA (n=75), OA (n=122), and conversion (CO) (n=24), comparing duration of operation, re-admissions, re-operations, intra-abdominal abscesses (IAA), and wound infections.

RESULTS

Compared to OA, LA resulted in fewer re-admissions (1.3% vs. 12.3%; P=.006), fewer re-operations (4% vs. 17.2%; P=.006), and fewer wound infections (0% vs. 11.5%; P=.001). No differences in the duration of operation (72.9 ± 23.0 min vs. 77.7 ± 48.0 min; P=.392) or IAA (4% vs. 11.5%; P=.114) were observed. Compared to LA, CO had more complications.

CONCLUSIONS

We report that LA is superior to OA with regard to incidence of re-admission, re-operation, and wound infection.

Laparoscopic versus open appendectomy in the management of all stages of acute appendicitis in children: a retrospective study

BACKGROUND

We conducted this study in order to evaluate whether laparoscopic appendectomy was an alternative therapeutic tool to open appendectomy for all stages of pediatric appendicitis.

MATERIALS AND METHODS

Between January 2000 and November 2004, the charts of 177 children who underwent appendectomy by a single surgeon were reviewed. The patients were divided into open and laparoscopic appendectomy groups. Each group was subdivided into three stages: simple appendicitis, perforated appendicitis, and appendicitis with abscess. The age, gender, white blood cell count, absolute neutrophil count, C-reactive protein, operating time, duration of postoperative hospital stay, minor and major complications, and use of intravenous analgesia were recorded. Fisher's exact and Student's t-test were used for statistical analysis.

RESULTS

There were fewer minor complications (9/32 vs. 0/20, p = 0.009) in perforated appendicitis stage and fewer major complications (9/26 vs. 1/24, p = 0.011) in appendicitis with abscess stage between open and laparoscopic appendectomy group. But surgery for each laparoscopic appendectomy group took longer to perform than for the corresponding open appendectomy group in each stage (p < 0.05). There was no significant difference in other data between corresponding groups in each stage.

CONCLUSION

Laparoscopic appendectomy may be considered a better alternative to open appendectomy for children with perforated appendicitis and appendicitis with abscess.

Cost-effectiveness of open versus laparoscopic appendectomy: a multilevel approach with propensity score matching

OBJECTIVE

To compare postoperative complications and cost of treatment of laparoscopic (LA) versus open appendectomy (OA) and to identify the most cost-effective treatment method.

METHODS

Patients treated for appendectomy in US veterans health administration (VHA) hospitals in 2005 were included into our study. Direct medical cost and postoperative complications during hospitalization were used as outcomes. Propensity score matching was employed to adjust for baseline imbalances between treatment groups. It was adjusted for the severity of appendicitis, comorbidities according to Charlson Comorbidity Index, and demographic variables. 1:1 optimal matching with replacement was performed. Based on the matched samples, we estimated generalized linear mixed regression models for costs (gamma model) and postoperative complications (logit model). Besides patients' covariates, predictors of hospital resource use and quality of care at the hospital level were considered as explanatory variables.

RESULTS

The total study population comprised of 1,128 patients (370 LA, 758 OA) from 95 VHA hospitals. Type of appendectomy had a significant influence on total costs (P=0.005), with predicted costs for LA being 17.1% lower in comparison to OA (OA: 10,851 US$ [95%CI: 9,707 US$; 12,131 US$] vs. LA: 8,995 US$ [95%CI: 8,073 US$; 10,022 US$]). Differences in the predicted overall postoperative complication were not significant between LA and OA (P=0.6311). Severity of appendicitis had a significant impact on costs and postoperative complications.

CONCLUSION

Predicted costs for LA were 1,856 US$ lower than for OA while the postoperative complication rate did not differ significantly. Thus, LA is the treatment of choice from a provider's perspective.

Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children

BACKGROUND

Appendectomy is one of the most common emergency operations performed in the pediatric population. The aim of this pooled analysis is to compare the outcome from complicated appendicitis (CA) and uncomplicated appendicitis (UA) following laparoscopic appendectomy (LA) and open appendectomy (OA) in children.

METHODS

A systematic literature search was performed. Primary outcome measures were incidence of complications, intra-abdominal abscess, and wound infection. Secondary outcomes were length of operation, length of hospital stay, incidence of bowel obstruction, and readmission.

RESULTS

Seventy-three thousand one hundred fifty appendectomies for UA and 34,474 appendectomies for CA were included. For UA, the only significant difference between the groups was a reduced length of hospital stay following LA. LA in CA was associated with reduced complications (pooled odds ratio [POR] = 0.53; P < 0.05), wound infections (POR = 0.42; P < 0.05), length of hospital stay (WMD = -0.67; P < 0.05), and bowel obstruction episodes (POR = 0.8; P < 0.05), but an increased incidence of intra-abdominal abscess and length of operation.

CONCLUSION

Pooled analysis demonstrates that, in children with uncomplicated acute appendicitis, LA is associated with a reduced hospital stay but broad equivalence in postoperative morbidity when compared with the conventional approach. Although overall morbidity is reduced when the laparoscopic approach is utilized, in cases of CA, the risk of intra-abdominal abscess is increased.

Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum

Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.

Comparison of outcomes of laparoscopic versus open appendectomy in children: data from the Nationwide Inpatient Sample (NIS), 2006-2008

BACKGROUND

The benefits of laparoscopic appendectomy (LA) remain undefined as compared to open appendectomy (OA) in children, particularly in cases of perforated appendicitis. The purpose of the present study was to evaluate the outcomes of LA versus OA in perforated and nonperforated appendicitis in children.

METHODS

Using the Nationwide Inpatient Sample database, we evaluated the clinical data of children (<18 years old) who underwent LA and OA from 2006 to 2008. Incidental and elective appendectomies were excluded.

RESULTS

A total of 212,958 children underwent urgent appendectomy in the United States during these years. The overall rate of perforated appendicitis was 27.7, and 56.9% of all cases were performed laparoscopically. In nonperforated cases, LA was associated with comparable overall complication rate (LA: 2.56 vs. OA: 2.66%; p = 0.26), shorter length of hospital stay (LOS, LA: 1.6 vs. OA: 2.0 days; p < 0.01), comparable mortality (LA: 0.01 vs. OA: 0.02%; p = 0.25); and higher hospital charges (LA: $20,328 vs. OA: $16,830; p < 0.01) compared to OA. In perforated cases, LA had a lower overall complication rate (LA: 16.03 vs. OA: 18.07%; p < 0.01), shorter LOS (LA: 5.1 vs. OA: 5.8 days; p < 0.01), lower mortality (LA: 0.0% versus OA: 0.06%; p < 0.01), and similar hospital charges (LA: $33,361 versus OA: $33, 662; p = 0.71) compared to OA.

CONCLUSIONS

LA is safe in children with acute perforated and nonperforated appendicitis, and is associated with shorter hospital stay than OA. The laparoscopic approach is associated with lower morbidity and mortality in perforated cases. However, in nonperforated cases, these benefits are modest and are associated with higher hospital charges.

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 versus open appendectomy for appendicitis in elderly patients

Purpose

The appendectomy is the most common emergent surgical procedure in elderly patients. The increasing number of elderly persons has been accompanied by an increase in the number of cases of acute appendicitis in the elderly. In order to understand the clinical significance of a laparoscopic appendectomy for elderly patients with appendicitis, we investigated the results of a laparoscopic appendectomy for treating patients over 60 years of age with appendicitis and compared them with the results for an open technique.

Methods

We studied retrospectively patients over 60 years of age who underwent an appendectomy with either a laparoscopic (LA) or open (OA) technique for appendicitis between July 2007 and December 2009. There were 30 patients in the LA group and 47 patients in the OA group. The demographic data, operative time, length of the hospital stay, bowel movement, pain control, cost, complications and pre-existing disease were assessed.

Results

There were no significant differences between the LA and the OA groups with respect to pre-existing diseases, gender, age, American Society of Anesthesiologists (ASA) score and the number of cases of complicated appendicitis, operative time, length of hospital stay, and times of analgesics use. However, the proportion of early gas out (within POD #2) was significantly greater in the LA group (80% vs. 57%, P < 0.05), and postoperative complications were significantly lower in the LA group (7% vs. 32%, P < 0.01). The costs for the two groups were not significantly different.

Conclusion

A laparoscopic appendectomy is a safe and effective procedure in elderly patients and is not associated with any increase in morbidity. It can be recommended for routine use in treating elderly patients with appendicitis.

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.

Early discharge following laparoscopic appendectomy in children utilizing an evidence-based clinical pathway

BACKGROUND

The utility of laparoscopic appendectomy (LA) in children remains controversial. The determination of the efficacy of LA in children is complicated by variable postoperative management, duration of antibiotics,and criteria for discharge. The aim of this study was to examine the results of a commitment to LA and the concurrent implementation of an evidence-based clinical pathway (CP) for management appendicitis in a children's hospital.

METHODS

With institutional review board approval, all children presenting with appendicitis (n = 72; age =10.6 +/- 0.1 years) were offered LA and management directed by CP. Data were accrued prospectively for 12 consecutive months (May 2006 to April 2007) and analysis performed at 15 months. Data are reported as the mean +/- standard error of the mean.

RESULTS

Children were stratified based on the operative findings: group one - acute 41; group two-suppurative=11; and group 3-gangrenous or perforated 20. Duration of hospital stay differed between the groups:group one= 26 +/- 0.3 hours; group 2 =48 +/- 3 hours; group 3= 127 +/- 6 hours (P <0.05). No patients in groups one or two suffered a complication or were readmitted following discharge. Two patients in group 3 (10%)were readmitted and treated with antibiotic therapy alone. Overall, 66% of the children with acute appendicitis(27/41) and 27% with suppurative appendicitis (3/11) were discharged within 24 hours of admission. Discharge by 24 hours in groups 1 and 2 was not influenced by age, gender, or time of operation (before or after 7 PM).

CONCLUSIONS

The commitment to LA and use of CP resulted in discharge within 24 hours in 2 of 3 of children with acute appendicitis without readmission or complications being observed. Early discharge was not influenced by age, gender, or time of admission. For advanced appendicitis, length of hospital stay, determined by clinical parameters, resulted in a low rate of complication or readmission.

Laparoscopic appendectomy for complicated appendicitis: a comparison with open appendectomy

BACKGROUND

Although laparoscopic appendectomy (LA) is widely performed in many countries, LA for complicated appendicitis, which includes perforated or gangrenous appendicitis with or without localized or disseminated peritonitis, has not become a common practice yet.

METHODS

We retrospectively analyzed the clinical records of 230 patients who had undergone appendectomy for complicated appendicitis: 141 had undergone LA, 84 had conventional open appendectomy (OA), and 5 patients had conversion to the open procedure after laparoscopy. The LA group (total LA) was subdivided into "early experience (early LA: cases 1-56)" and "late experience (late LA: case 57 and higher)." We defined the early LA group as the comparison group to minimize selection bias.

RESULTS

Patient demographics were similar in the early LA and OA groups (P > 0.05). Wound infection was significantly more frequent in the OA group (P < 0.05). Intra-abdominal infection was equally common in these two groups. The overall rate of postoperative complications was significantly higher in the OA group (32.1%) than in the early LA group (18%; P < 0.05). This incidence was 12.8% in the total LA group. Hospital stay was significantly shorter in the early LA group (10.6 +/- 3.9 days; P < 0.05), and 8.9 +/- 3.7 days in the total LA group.

CONCLUSIONS

Our findings indicate that LA is safe and useful even for the treatment of complicated appendicitis if performed by an experienced surgeon.

Early discharge following laparoscopic appendectomy in children utilizing an evidence-based clinical pathway

BACKGROUND

The utility of laparoscopic appendectomy (LA) in children remains controversial. The determination of the efficacy of LA in children is complicated by variable postoperative management, duration of antibiotics,and criteria for discharge. The aim of this study was to examine the results of a commitment to LA and the concurrent implementation of an evidence-based clinical pathway (CP) for management appendicitis in a children's hospital.

METHODS

With institutional review board approval, all children presenting with appendicitis (n = 72; age =10.6 +/- 0.1 years) were offered LA and management directed by CP. Data were accrued prospectively for 12 consecutive months (May 2006 to April 2007) and analysis performed at 15 months. Data are reported as the mean +/- standard error of the mean.

RESULTS

Children were stratified based on the operative findings: group one - acute 41; group two-suppurative=11; and group 3-gangrenous or perforated 20. Duration of hospital stay differed between the groups:group one= 26 +/- 0.3 hours; group 2 =48 +/- 3 hours; group 3= 127 +/- 6 hours (P <0.05). No patients in groups one or two suffered a complication or were readmitted following discharge. Two patients in group 3 (10%)were readmitted and treated with antibiotic therapy alone. Overall, 66% of the children with acute appendicitis(27/41) and 27% with suppurative appendicitis (3/11) were discharged within 24 hours of admission. Discharge by 24 hours in groups 1 and 2 was not influenced by age, gender, or time of operation (before or after 7 PM).

CONCLUSIONS

The commitment to LA and use of CP resulted in discharge within 24 hours in 2 of 3 of children with acute appendicitis without readmission or complications being observed. Early discharge was not influenced by age, gender, or time of admission. For advanced appendicitis, length of hospital stay, determined by clinical parameters, resulted in a low rate of complication or readmission.

Outcome of laparoscopic appendectomy for perforated appendicitis in children

BACKGROUND

The aim of this study was to evaluate the outcome of laparoscopic (LA) vs open appendectomy (OA) in patients with perforated appendicitis in our center.

METHODS

Retrospective review from July 2002 to April 2007 (institutional review board-approved), evaluating 281 patients with perforated appendicitis based on surgical approach. We compared demographics, mean operative time, length of stay (LOS), infectious complications, and follow-up in patients with OA (n = 213) and LA (n = 68).

RESULTS

Laparoscopic appendectomy patients were significantly older (12 vs 9.4 years), heavier (51.8 vs 36.6 kg) and more frequently girls (47.8% vs 34.3%). Mean operative time was longer in LA (72.6 vs 50.2 minutes). Median LOS was 5 days in LA and 6 days in OA. Few patients in each group required a drainage procedure for a persistent abscess (LA 4.4%, OA 4.7%; P = 1.000). Laparoscopic appendectomy patients had fewer wound infections (1.5% vs 9.5%; P = .034), and less follow-up visits were needed (>2 clinic visits 4.5% vs 16.4%; P = .013).

CONCLUSION

Laparoscopic appendectomy has a shorter median LOS, a trend toward less postoperative infectious complications, and fewer clinic visits than OA, which makes it a safe and effective procedure for patients with perforated appendicitis.

Laparoscopic appendectomy for simple and complicated appendicitis in children--safe or risky procedure

OBJECTIVES

The aim of the study was to present our experience and to assess the advantages of laparoscopic appendectomy, particularly in children with perforated appendicitis.

MATERIALS AND METHODS

Between 1999 and 2005, 505 laparoscopic appendectomies were performed. In children aged between 2 and 18 years, number, sex, age, histologic type of appendicitis, additional surgical procedures, number and type of complications, time of procedure, and hospitalization were analyzed.

RESULTS

There was no need for conversion even in perforated appendicitis and in technically difficult cases. In 21 (4.16%) children in postoperative period minor complications occurred. Average operating time was 43 minutes. Average hospital stay was 2.4 days.

CONCLUSIONS

Laparoscopic appendectomy is good alternative for classic appendectomy, irrespective of the degree of inflammation. Accurate cleaning and rinsing of the abdominal cavity essentially decreases the quantity of complications even in cases with perforated appendicitis. This suggests the expansion of indications toward laparoscopic appendectomy in case of all children with acute appendicitis.

Laparoscopic versus open appendectomy in children: a retrospective comparative study of 2,332 cases

AIM

The laparoscopic treatment of paediatric appendicitis remains controversial, especially in the presence of complications. This study evaluated the outcomes of open appendectomy (OA) and laparoscopic appendectomy (LA) by analysing the data from a multicentre study.

METHODS

The authors retrospectively reviewed a series of 2,332 appendectomies (1,506 LA and 826 OA) performed in children and adolescents (median age 8 years) in 9 different centres of paediatric surgery. For the patients operated using laparoscopy, an IN procedure was employed in 921 (61.2%), an OUT procedure in 571 (37.9%) and a MIXED procedure in 14 (0.9%). In the open surgery, a McBurney incision was adopted in 795 patients (96.4%).

RESULTS

Median duration of surgery was 40 minutes for LA and 45 minutes for OA. Median hospital stay was 3 days (LA) and 4.3 days (OA) in case of simple appendicitis and 5.2 days (LA) and 8.3 days (OA) in case of peritonitis. Complications were recorded in 124 LA cases (8.2%) and 65 OA cases (7.9%). The conversion rate in laparoscopy was only 1.6% (25 cases). The statistical analysis was performed using the Mann-Whitney test, and the main significant difference that emerged was the length of hospital stay, which was in favour of laparoscopy compared with open surgery (P < 0.0001).

CONCLUSIONS

We conclude that in clinical settings where laparoscopic surgical expertise and equipment are available and affordable, LA seems to be an effective and safe alternative to OA. Three out 9 centres participating in our survey perform LA in all patients with a suspicion of appendicitis. Our study shows that laparoscopy significantly reduces hospital stay in case of appendicitis and peritonitis and presents an extremely low conversion rate (1.6%) to open surgery. Laparoscopic transumbilical appendectomy (37.9%) in our series seems to be a simple option, even for less-skilled laparoscopic surgeons.

An Individualized Approach to Appendectomy in Children Based on Anatomico-Laparoscopic Findings

Whether an appendectomy should be performed “open” or laparoscopically is the subject of considerable debate. This study in children was undertaken to test the hypothesis that an individualized approach, based on disease stage, body habitus, and laparoscopic findings should dictate the removal technique. Data on 108 consecutive pediatric appendectomies were prospectively recorded. Except in complex cases, a 5 mm laparoscope was inserted umbilically, the findings were evaluated, and the best removal approach was selected. Depending on the degree of inflammation and mobility, the appendix was fully delivered and resected, either through the initial umbilical trocar site or, more commonly, through a second right lower quadrant (RLQ) trocar site. The second RLQ trocar incision was enlarged for limited or full conversion to an open approach, if needed. In overweight children, three trocars and a stapler were used. Children (63 boys, 45 girls) ranged in age from 3 to 18 years (mean, 11 years). A single umbilical port was used in 16 patients with low-grade appendiceal inflammation. A two trocar, laparoscopically-assisted appendectomy was used in 63 cases. Of these 63, a limited extension of the RLQ trocar incision was necessary in 4 patients and conversion to an open incision was needed in 4 children. The three trocar technique was used 21 times. Twelve of these were cases involving obese patients. A stapler was used 13 times. Four trocars were needed once. Seven patients with complex appendicitis did not undergo laparoscopy. Twenty-nine appendices were perforated, and there were 3 complications: 2 intra-abdominal abscesses and one trocar site wound infection. Because appendiceal disease is a spectrum, and children encompass a wide range of ages and sizes, an individualized approach, based on the anatomical parameters and the clinical and laparoscopic findings, allows for an efficient, patient-specific appendectomy: single trocar for minimally inflamed appendices, two trocars for the most common types, three trocars plus a stapler for overweight children, and an “open” procedure for complex cases.

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

Current management of appendicitis

Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.