Laparoscopic versus Open Surgery in Complicated Appendicitis in Children Less Than 5 Years Old: A Six-Year Single-Centre Experience

Evaluation of the outcome of right subumbilical transverse incision approach for the management of complicated appendicitis in paediatric age group - A multi-institutional retrospective study

Aim

The aim is to evaluate the outcome of right subumbilical transverse incision approach for the management of complicated appendicitis in paediatric age group.

Materials and Methods

This is a retrospective multi-institutional study which was conducted in the Department of Paediatric Surgery, I Q City Medical College and Hospital, Durgapur, West Bengal, India and the Department of Paediatric Surgery, Rajiv Gandhi Super Speciality Hospital/Raichur Institute of Medical Sciences, Raichur, Karnataka, India. In this study, a review of 77 paediatric patients operated for complicated appendicitis using a right subumbilical transverse incision approach was done for a period of 3 years (from December 2017 to December 2020). All patients had proven complicated appendicular pathology like appendicular perforation, appendicular abscess or complicated appendicular lumps on ultrasonography or computed tomography scan, which mandated exploration.

Results

There was no mortality. Average operative time was 1 h 48 min (ranging from 58 min to 3 h 12 min). Average length of hospital stay was 9 days (ranging from 5 days to 13 days). There was no incidence of fecal fistula. Seventeen (22%) patients developed superficial surgical site infection which subsided with regular dressings. There was no incidence of wound dehiscence or burst abdomen. Five (6.5%) patients required the incision to be extended beyond the midline to the left side to deal with the pathology and to access the entire peritoneal cavity. Nine (11.6%) patients required loop ileostomies, which was fashioned on the lateral aspect of the transverse incision. Only one patient had a doubtful caecal injury which was repaired and loop ileostomy was done. Six patients (7.7%) had adhesive intestinal obstruction postoperatively, of which three required re-exploration. There was no incidence of incisional hernia or any stoma-related complications.

Conclusion

Complicated appendicitis is a condition which lacks standardisation of approach for management, and is inherently associated with complications. However, with a more logical incision and intra-operative approach we can keep the complications to minimum and improve outcomes to great extent in those patients requiring surgical intervention. We have been using the subumbilical transverse incision in all sizes of patients ranging from small children to adolescents with excellent results, and we believe that the same approach can be applied even in adult patients in similar clinical scenarios.

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 appendectomy: A retrospective cohort study on the management of acute appendicitis (simple and complicated) in children under 13 years of age

INTRODUCTION

Acute appendicitis is the most common surgical emergency with a lifetime incidence of 7%-8%. There are two operative modalities that are currently used for the management of this condition in the paediatric population. The objective of this cohort study was to review the outcome of the management of paediatric surgical patients presenting with acute appendicitis after either an open appendectomy (OA) or laparoscopic appendectomy (LA) was performed.

METHODS

This was a 2-year retrospective study conducted from 01 January 2016 until 31 December 2017 on paediatric surgical patients < 13 years of age undergoing appendectomies. Eighty-one (n = 81) files of patients were reviewed, and data analysis was performed on two comparative groups namely the OA group and LA group, with the aid of the SAS system with statistical significance based on P < 0.05.

RESULTS

During the study period, 81 children (male: female ratio of 2:1) underwent appendectomies. Nearly 38% (n = 31) of the cases had an OA, with 62% (n = 50) of the cases having an LA. Seven (14%) LA cases were converted to OA. Simple appendicitis accounted for 16% (n = 13) of the patients, with complicated appendicitis accounting for 79% (n = 64) and other pathologies accounting for 5% (n = 4). There were no post-operative complications in the cases of simple appendicitis. Six cases (15.38%) in the LA group versus two cases (5.26%) in the OA group developed intra-abdominal collections, which was statistically significant (P = 0.018). One (2.56%) patient in the LA group versus two patients (7.89%) in the OA group developed intestinal ileus (P = 0.09). Two patients (5.13%) in the LA group versus six patients (15.79%) in the OA group developed surgical-site infection, which was statistically significant (P = 0.013). The mean days of hospital stay was 4.51 days in the LA group versus 5.34 days in the OA group, which was statistically significant (P = 0.016). There were no re-admissions or re-operations in the simple appendicitis group. In the complicated appendicitis cases, five cases (12.82%) were re-admitted in the LA group compared to five cases (13.16%) in the OA group (P = 0.943). Two (5.13%) cases had a re-operation in the LA group compared to one case (2.63%) in the OA group (P = 0.360).

CONCLUSION

Considering that there was an increased incidence of complicated cases and operations being performed by trainees, LA appears feasible at a tertiary-level hospital in a developing country, as shown in this study. Therefore, cases of simple appendicitis can be performed laparoscopically; however with regard to complicated appendicitis, there is no superiority between the two operative modalities in this study, which is consistent with international literature. However, in this study, it can be postulated that the learning curve was a major contributory factor to the increased levels of complications, as all operations were performed by trainees. Therefore, we recommend implementation of adequate simulation practices in laparoscopy in the setting of a developing country to attain the laparoscopic expertise of our international counterparts in order to improve the standard of care.

Pediatric Appendectomy: an Analysis of 22,334 Cases from the Pediatric National Surgical Quality Improvement Program Data

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Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated Diaphragm Injury After Penetrating Trauma

BACKGROUND

Isolated diaphragm injury (IDI) occurs in up to 30% of penetrating left thoracoabdominal injuries. Laparoscopic abdominal procedures have demonstrated improved outcome including decreased postoperative pain and length of stay (LOS) compared to open surgery. However, there is a paucity of data on this topic for penetrating IDI. The aim of this study was to examine the prevalence and outcome of laparoscopic diaphragmatic repair versus open diaphragmatic repair (LDR vs ODR) of IDI.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients with IDI who underwent ODR versus LDR. A bivariate analysis using Pearson chi-square and Mann-Whitney test was performed to determine LOS among the two groups.

RESULTS

From 2039 diaphragm injuries, 368 patients had IDI; 281 patients (76.4%) underwent ODR and 87 (23.6%) underwent LDR. Compared to LDR, the ODR patients were older (median, 31 vs 25 years, P < .001) and had a higher injury severity score (mean, 11.2 vs 9.6, P = .03) but had similar rates of intensive care unit LOS, unplanned return to the operating room, ventilator days, and complications (P > .05). Patients undergoing ODR had a longer LOS (5 vs 4 days, P = .01), compared to LDR. There were no deaths in either group.

CONCLUSIONS

Trauma patients presenting with IDI undergoing ODR had a longer hospital LOS compared to patients undergoing LDR with no difference in complications or mortality. Therefore, we recommend when possible an LDR should be employed to decrease hospital LOS. Further research is needed to examine other benefits of laparoscopy such as postoperative pain, incisional hernia, and wound-related complications.