Outcomes of Transumbilical Laparoscopic-Assisted Appendectomy and Conventional Laparoscopic Appendectomy for Acute Pediatric Appendicitis in a Single Institution

Comparison of Transumbilical Laparoscopy-Assisted Appendectomy with Conventional Three-Port Laparoscopic Appendectomy Performed by Pediatric Surgeons in Training for Appendicitis in Children

Background: Transumbilical laparoscopy-assisted appendectomy (TULAA) is the technique of choice for all types of appendicitis. However, the technique is challenging for trainees to learn in comparison with performing conventional three-port laparoscopic appendectomy (CTPLA) in children. We aimed to compare the surgical outcomes of children with appendicitis treated by TULAA versus CTPLA performed by pediatric surgeons in training (PSITs). Materials and Methods: This retrospective study analyzed pediatric patients with acute appendicitis treated with CTPLA or TULAA between April 2016 and December 2022. Operative time (OT: minutes), pneumoperitoneum time (PT: minutes), blood loss (milliliter), length of hospital stay (days), and surgical site infection rate were compared between the two groups. Operative outcomes were also analyzed according to type of appendicitis such as uncomplicated and complicated cases. Results: Two hundred twenty-five laparoscopic appendectomies were performed by CTPLA (n = 94) or TULAA (n = 131). All cases were performed by PSITs and there was no open conversion cases. TULAA had a shorter OT (67.0 ± 28.4 versus 78.3 ± 21.7; P < .01) and PT (26.1 ± 17.4 versus 52.5 ± 22.1 min; P < .01). The surgical site infection rate was slightly higher in the TULAA group, but the difference was not statistically significant. In uncomplicated appendicitis (n = 164), significant differences between the CTPLA and TULAA groups were observed in OT (CTPLA versus TULAA: 70.7 ± 14.9 versus 59.1 ± 21.6, P < .01) and PT (CTPLA versus TULAA: 43.6 ± 13.1 versus 20.4 ± 13.6, P < .01). With regard to postoperative complications, only surgical site infection was significantly different between the CTPLA and TULAA groups (CTPLA: 0.0% versus TULAA: 8.2%, P < .05). In complicated cases (n = 61), there were significant differences between the groups in PT (CTPLA versus TULAA: 73.4 ± 24.9 versus 42.3 ± 17.2, P < .01) and length of hospital stay (CTPLA versus TULAA: 7.0 ± 1.3 versus 8.9 ± 4.7, P < .05). Conclusions: TULAA had a shorter OT and PT than CTPLA. TULAA for PSITs shows similar safety and feasibility to CTPLA for not only uncomplicated cases but also complicated cases.

Is transumbilical laparoscopic-assisted appendectomy feasible for complicated appendicitis? A single-center experience

PURPOSE

Transumbilical laparoscopic-assisted surgery (TULS) mixed benefits of laparoscopic and open surgeries. Transumbilical laparoscopic-assisted appendectomy (TULAA) is a well-known procedure, accepted and currently used by pediatric surgeons for treatment of uncomplicated appendicitis (UA). There is no current agreement in its use for the complicated appendiceal infections (CA). We reported our results using TULAA for both UA and CA.

METHODS

We retrospectively collected TULAA performed between April 2017 and April 2022. Appendicitis were classified in UA and CA. We analyzed conversion rate, operative time, length of stay, surgical site infections (SSIs) rate, postoperative intra-abdominal abscess and costs.

RESULTS

Over 5 years, 316 children underwent TULAA. Conversion rate was 3%. Mean age at surgery was 9.36 years (IQR 2-16). Forty-nine appendicitis were CA. Operative time and hospital stay was higher in CA than in UA group (38.33 vs. 60.73 min, p < 0.00001; 4 vs. 7 days, p < 0.00001). SSIs rate showed no statistically significant difference between two groups. Incidence of postoperative intra-abdominal collections was 11% in CA and 1% in UA. TULAA's cost was 192.07 €.

CONCLUSION

In our series, TULAA seems to be safe, feasible and cost-effective for both uncomplicated and complicated appendicitis, with no disadvantage in terms of outcomes compared to what is reported in literature for CLS.

Single-incision laparoscopic appendectomy versus traditional three-hole laparoscopic appendectomy for acute appendicitis in children by senior pediatric surgeons: a multicenter study from China

Objective

The aim of this study was to evaluate the clinical efficacy of single-incision laparoscopy appendectomy (SILA) and traditional three-hole laparoscopy appendectomy (THLA) for the treatment of acute appendicitis in children.

Methods

The clinical data of children (<14 years old) who underwent laparoscopic appendectomy at Yijishan Hospital of Wannan Medical College, Hubei Provincial Maternal Health Hospital and Qingdao Women and Children's Medical Center from January 2019 to June 2022 were retrospectively analyzed. According to the operation method, the patients were assigned to the SILA group or the THLA group. The clinical data, including the efficacy, and the surgical details, including the complications, of the two surgical methods were compared. The personal information of the children and the time of disease onset were recorded.

Results

In this study, the data of 588 patients, including 385 patients in the THLA group and 203 patients in the SILA group were collected. The baseline characteristics between the two groups of patients before surgery were comparable. There was no significant difference in the average operation time between the THLA group and the SILA group (56.31 ± 1.83 min vs. 57.48 ± 1.15 min, P > 0.05). There was also no significant difference in the average length of hospital stay between the THLA group and the SILA group (6.91 ± 0.24 days vs. 7.16 ± 0.36 days, P > 0.05). However, the FLACC scores of the SILA group (3.71 ± 0.78) were significantly lower than those of the THLA group (3.99 ± 0.56) on the second postoperative day, and the difference was significant (P < 0.05). The score of the questionnaire evaluating cosmetic appearance of the postoperative abdomen was significantly higher in the SILA group (15.81 ± 0.36) than in the THLA group (13.10 ± 0.24) (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05).

Conclusion

SILA is more advantageous in terms of postoperative FLACC scores and cosmetic appearance in children than THLA. There was no significant difference in the incidence of complications or other aspects between the two surgical methods.

Intra-/Extracorporeal Single-Incision Versus Conventional Laparoscopic Appendectomy in Children: A Systematic Review and Meta-Analysis

Background: There are two approaches to single-incision laparoscopic appendectomy (SILA): intracorporeal (Intra) and extracorporeal (Extra). However, the differences in the efficacy between these procedures remain unclear. Thus, this systematic review and meta-analysis aimed to compare the safety and usefulness of these techniques with those of conventional laparoscopic appendectomy (CLA) in children. Methods: A systematic literature search was performed using the PubMed, CENTRAL, and Scopus databases. Studies comparing outcomes of "Intra-SILA and CLA" or "Extra-SILA and CLA" in children aged <18 years were included. Operative time, hospitalization duration, wound infection, intra-abdominal infection, conversion to open, additional ports, and narcotic doses were evaluated. Results: Overall, 20 studies (six randomized controlled trials [RCTs], one prospective non-RCT, and 13 retrospective cohort studies) (Intra-SILA: 322, CLA: 791 cases; Extra-SILA: 1318, CLA: 1313 cases) were included. Compared with CLA, Extra-SILA was associated with a shorter operative time (mean difference, -9.79 minutes; 95% confidence interval [CI], -18.34 to -1.24) and lower incidence of intra-abdominal infection (3.3% versus 4.6%, odds ratio [OR], 0.52; 95% CI, 0.33 to 0.82) and a higher rate of additional port (13.6% versus 0%, OR, 43.93; 95% CI, 14.79 to 130.50). Meanwhile, the outcomes of Intra-SILA were comparable with those of CLA. However, the participants in the Intra-SILA group received significantly lower doses of narcotics than those in the CLA group. Conclusion: Although the evidence was insufficient, both Intra- and Extra-SILA were comparable to CLA with respect to safety. Extra-SILA seems to have an advantage of a shorter operative time, but additional ports may be required.

Association between the computed tomography findings and operative time for interval appendectomy in children

PURPOSE

The purpose was to evaluate the association between operative time and findings noted on computed tomography (CT) immediately before interval appendectomy.

MATERIALS AND METHODS

Forty-two children who underwent CT before interval appendectomy were included. We evaluated the association between operative time and these image findings: (1) appendicolith, (2) increased intra-abdominal fat density around the appendix, (3) location of the appendix, (4) ascites, (5) abscess formation and (6) maximum appendix outer wall diameter. Appendix location was classified as (#1) just below the anterior abdominal wall; (#2) retrocaecal or retro-ascending colon and (#3) pelvic. Results were analysed using Pearson's correlation coefficient or Mann-Whitney U test.

RESULTS

The mean patient age and operative time were 116.24 ± 38.66 months (range, 31-195) and 67.76 ± 31.23 min (range, 30-179), respectively. Ascites was detected in only one case, and no abscess occurred in any patient; therefore, these findings were not analysed. Factors that significantly prolonged the operative time included increased intra-abdominal fat density around the appendix (absent, 59.43 ± 22.14 [range, 30-108] vs. present, 84.43 ± 40.13 [range, 32-179] min; P = 0.03) and retrocaecal or retro-ascending colon appendix (location 1, 40.83 ± 8.35 [range, 30-50]; location 2, 99.25 ± 18.56 [range, 74-135]; location 3, 64.54 ± 30.22 [range, 30-179] min; P < 0.01). There was a weak but significant association between maximum appendix outer wall diameter and operative time (R = 0.353; P = 0.02).

CONCLUSION

These pre-operative CT findings are important predictors of operative time for interval appendectomy. Radiologists and surgeons should use these specific image findings to predict the operative time and need for additional procedures during an interval appendectomy.

Update on transumbilical laparoscopic-assisted surgery in infants and neonates

BACKGROUND

Because of the restricted space of the peritoneal cavity and the easy mobility of abdominal and pelvic organs in infants and neonates, the boundary of minimally invasive surgery was extended to complete the operation outside the abdomen. The objective of this study was to report our experience with transumbilical laparoscopic-assisted surgery (TULS) in different abdominal pathologies in infants and neonates.

PATIENTS AND METHODS

A retrospective study was conducted on 59 patients who underwent TULS from 2014 to 2020. The study outcomes were the conversion to open approach, length of hospital stay and post-operative complications.

RESULTS

The most common indications were explorations for intra-abdominal testes (n = 15) and inguinal herniorrhaphy (n = 13). Patients who had surgery for pyloric stenosis were younger (1.03 ± 0.25 months). The average operative time was 45.9 ± 18.39 min. The longest operative time was reported with surgery for liver cysts (94.5 ± 10.6 min). Oral intake was started after 48-56 h in patients who had excision of duplication cysts. The average post-operative hospital stay was 2.6 ± 1.52 days. No major complications were reported. Wound infection occurred in one patient with a duplication cyst. Three patients were converted to open repair (5.1%) and no late complications were reported during the mean follow-up time of 11.2 ± 5.1 months.

CONCLUSIONS

The transumbilical approach is a safe alternative method to laparotomy in several abdominal pathologies in infants and neonates. It has a short operative time and hospital stay. The technique is associated with few complications and conversion rates.

Should single-incision laparoscopic appendectomy be the new standard for pediatric appendicitis?

BACKGROUND

To compare single-incision laparoscopic appendectomy (SILA) with conventional (CLA) and transumbilical laparoscopic appendectomy (TULA).

METHODS

This is a retrospective cohort study. Patients were divided into three groups, SILA, CLA, and TULA. SILA was defined as performing appendectomy extracorporeally or intracorporeally by using a glove-port incorporated with 3 trocars. TULA was defined as exteriorizing appendix and performing extracorporeal appendectomy by using an operative telescope. Statistical analysis was conducted in patients with simple (SA) and complicated appendicitis (CA), respectively.

RESULTS

A total of 315 patients were enrolled, including 161 in SILA, 105 in CLA, and 49 in TULA. Demographic data were similar. In patients with simple appendicitis, operation time of SILA was shorter than CLA but longer than TULA (62.8 ± 22.5 vs. 82.2 ± 24.3 and 51.6 ± 22.3 min, p < 0.01). SILA had shorter hospital stay than CLA, and similar to TULA (56.1 ± 20.4 vs. 71.5 ± 37.8 and 56.9 ± 19.0 h, p < 0.01). In patients with complicated appendicitis, SILA had shorter operation time than CLA, but a similar time to TULA (80.9 ± 22.4 vs. 105.7 ± 28.8 and 82.5 ± 31.2 min, p < 0.01). Conversion to open surgery was not required in all groups. The rates of complications, such as wound infection, intraabdominal abscess and adhesion ileus, were similar. SILA required fewer additional ports than TULA in both simple and complicated appendicitis (1.1% vs. 13.5%, and 9.6% vs. 41.7%, p < 0.01).

CONCLUSION

SILA has the advantages of shorter operation time and hospital stay over CLA as well as a lower rate of additional ports than TULA.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

A tiered approach to optimize pediatric laparoscopic appendectomy outcomes

BACKGROUND/PURPOSE

Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost.

METHODS

Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes.

RESULTS

A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes.

CONCLUSIONS

SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level III.