Laparoscopic Appendectomy in Children

Background and Objectives:

The advantages of laparoscopic appendectomy over open appendectomy have not yet been clearly demonstrated. The present study evaluated our early experience with laparoscopic appendectomy in children, in terms of its safety, effectiveness, technical difficulties, and economics.

Methods:

We reviewed the records of 50 cases involving laparoscopic appendectomy performed at our affiliated institutions between September, 1994, and September, 1996. Patient age ranged from 6 to 18 years (mean, 14 years). Thirty-two patients had acute nonperforated appendicitis, six had perforated appendicitis, two had fibrosis of the appendix, and ten had a histologically normal appendix.

Results:

In five patients the laparoscopic procedures were converted to open appendectomies because of technical difficulties. There were postoperative complications in four patients: one incomplete appendectomy which subsequently required an open appendectomy for completion, one pelvic abscess, one bowel obstruction, and one minor wound infection.

Conclusions:

Laparoscopic appendectomy is a safe and effective procedure. It takes longer operative time than open appendectomy. Length of hospitalization and incidence of postoperative complications are equivalent to those of open appendectomy. Economic benefits are difficult to assess at present. In sum, we believe that with better training, surgical techniques and equipment, laparoscopic appendectomy will eventually become the surgical procedure of choice in appendicitis.     

Postoperative antibiotics are not associated with decreased wound complications among patients undergoing appendectomy for complicated appendicitis

Background

The objective of this study was to determine the role of postoperative antibiotics in reducing complications in patients undergoing appendectomy for complicated appendicitis.

Methods

We performed a 5-year retrospective cohort study of adult patients who underwent appendectomy for acute appendicitis. Patients with complicated appendicitis (perforated or gangrenous) were analyzed on the basis of whether they received postoperative antibiotics. Main outcome measures were wound complications, length of stay (LOS), and readmission to hospital.

Results

Of 410 patients with complicated appendicitis, postoperative antibiotics were administered to 274 patients (66.8%). On univariate and multivariate analyses, postoperative antibiotics were not associated with decreased wound complications or readmission, but independently predicted an increased LOS (P = .01).

Conclusions

Among patients with complicated appendicitis, postoperative antibiotics were not associated with a decrease in wound complications but did result in an increased hospital LOS.     

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.     

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

Background

The management of an appendiceal mass remains controversial with 2 schools of thought; early surgical intervention vs nonoperative management with or without interval appendectomy. The aim is to determine the role and safety of early laparoscopic appendectomy (LA) in children with acute appendicitis presenting with an appendiceal mass.

Methods

This is a prospective study of 88 consecutive pediatric patients who underwent attempted LA for suspected acute appendicitis at KK Women's and Children's Hospital, Singapore, between May and October 2003.

Results

A total of 88 patients with a mean age of 10 ± 3 years (range, 3-16 years) underwent LA for an appendiceal mass (n = 22), simple appendicitis (n = 36), other complicated (gangrenous or perforated) appendicitis (n = 23), and a normal appendix (n = 7). There were 7 conversions to open appendicectomy, 3 of which occurred in patients with an appendiceal mass. There were no perioperative or postoperative mortalities. Morbidity occurred in only one patient who underwent LA for perforated appendicitis. He had prolonged sepsis that resolved after 2 weeks of intravenous antibiotics. None of the patients with an appendiceal mass developed complications. Patients who underwent early LA for an appendiceal mass had a statistically significant (P < .05) longer operating time (median, 103 minutes; interquartile range, 90-151 minutes, vs median, 87 minutes; interquartile range, 71-112 minutes), prolonged time to ambulation (median, 2.0 days; interquartile range, 2-2.5 days, vs median, 1.0 days; interquartile, 1-2 days), increased time to resumption of diet (median, 4 days; interquartile, 3-5 days, vs median, 2 days; interquartile, 2-3 days), and longer postoperative stay (median, 6.0 days; interquartile, 5.5-6.5 days, vs median, 4.0 days; interquartile, 3-5.5 days) compared with patients presenting with appendicitis without mass formation. However, there was no statistical difference in these parameters when LA for an appendiceal mass was compared with LA for other complicated appendicitis (perforated and gangrenous).

Conclusion

Although early LA for an appendiceal mass is a technically demanding procedure, it can be performed safely in children with minimal morbidity and mortality. In an era where patients' demand for “key-hole” surgery is rising, early LA is a safe and viable option in the management of children with an appendiceal mass. It also offers the advantage of avoiding misdiagnoses and the need for a second hospitalization.     

Single-incision laparoscopic appendectomy for treating appendicitis in a patient with gastrointestinal malrotation

INTRODUCTION

Intestinal malrotation is a rare congenital anomaly, and acute appendicitis associated with intestinal malrotation is extremely rare.PRESENTATION OF CASE We report a rare case of a 47-year-old Japanese woman diagnosed with barium-related perforated appendicitis associated with intestinal malrotation. We used a transumbilical single-incision laparoscopic approach to resect the appendix, and the procedure was completed successfully without perioperative complications.

DISCUSSION

To our knowledge, single-incision laparoscopic surgery for appendicitis associated with intestinal malrotation has not been reported yet. In cases with mobile cecum such as this one, mobilization from inflammatory adhesion of the surrounding structures is easy.

CONCLUSION

We conclude that transumbilical single-incision laparoscopic appendectomy is a simple and less invasive method for treating appendicitis associated with intestinal malrotation.     

Is it necessary to drain all postoperative fluid collections after appendectomy for perforated appendicitis?

Purpose

Children treated for perforated appendicitis can have significant morbidity. Management often includes looking for and draining postoperative fluid collections. We sought to determine if drainage hastens recovery.

Methods

Children with perforated appendicitis treated with appendectomy from 2006 to 2009 were reviewed. Patients with postoperative fluid that was drained were compared with patients with undrained fluid with regard to preoperative features and postoperative outcomes. Statistical analyses included paired Student's t tests, Mann-Whitney U test, and linear regression.

Results

Five hundred ninety-one patients were reviewed. Seventy-one patients had postoperative fluid, of whom 36 had a drainage procedure and 35 did not. There was no significant difference in white blood cell count at the time of assessment for drainage (16.4 ± 4.0 vs 14.6 ± 4.9, P = .14), days with fever (3.5 ± 3.0 vs 2.9 ± 2.5, P = .35), or readmission rate (19% vs 31%, P = .28). After multivariate linear regression, larger fluid volumes were associated with prolonged length of stay (LOS) (P = .03). For fluid collections between 30-100 mL, there was no significant difference in LOS between the drain and no-drain groups (9.8 ± 3.5 vs 10.9 ± 5.2 days, P = .51).

Conclusion

After appendectomy for perforated appendicitis, larger postoperative fluid collections are associated with prolonged LOS. Drainage of collections less than 100 mL may not hasten recovery.     

Transumbilical laparoscopic-assisted appendectomy is associated with lower costs compared to multiport laparoscopic appendectomy

Background/Purpose

Single-incision laparoscopic appendectomy has been associated with improved cosmetic benefits, and decreased postoperative pain. Less is known about costs and other outcomes. Our aim was to evaluate the costs and outcomes between transumbilical laparoscopic-assisted appendectomy (TULAA) and multiport laparoscopic appendectomy (MLA).

Methods

IRB-approved retrospective review (September 2010–July 2013) of institutional medical records identified 372 pediatric patients undergoing laparoscopic appendectomy. Outcomes included costs, LOS and readmission. Costs were fully loaded operating costs from the hospital’s cost accounting database. Generalized linear regression was used to assess costs of MLA and TULAA. A subgroup analysis was performed using only patients with non-perforated appendicitis.

Results

There were 132 patients (35.5%) that underwent TULAA while 240 patients (65.5%) underwent MLA. Compared to MLA, TULAA was associated with decreased operative time (0.6 vs. 1.0 h, p < 0.0001), used in comparable proportions of interval appendectomies, but was performed less often for perforated appendicitis (9.8% vs. 22.9%, p = 0.002). Readmission and postoperative complications were similar between both groups. In the setting of non-perforated appendicitis, TULAA was associated with lower costs of $1378 relative to MLA (p = 0.009).

Conclusions

In non-perforated appendicitis, TULAA is associated with lower costs and comparable rates of readmission and postoperative complications.     

Incidental Appendectomy During Endoscopic Surgery

Background and Objectives:

The first laparoscopic appendectomy was performed over 25 years ago, and yet controversy still exists over the open method vs. the laparoscopic approach, and whether an incidental appendectomy is warranted. This study aimed to evaluate our experience in performing a laparoscopic incidental appendectomy and to address these issues.

Methods:

A total of 772 laparoscopic appendectomies were performed and analyzed and statistically evaluated.

Results:

Mean age of the patients was 30.8±7.0 years. Mean operating time for an incidental appendectomy was 12.3±4.5 minutes. Most common pathology result was adhesions, and the rarest was endometriosis. Of patients with confirmed appendicitis, 75.8% did not have an initial preoperative diagnosis of appendicitis. When warranted, 103 (13.3%) patients underwent a second-look laparoscopy: 75.5% had no adhesions, 23.5% had mild adhesions, 2% had moderate adhesions. Backward elimination logistic regression revealed that endometriosis (P=0.016), endometrioma (P=0.039), pelvic or abdominal adhesions (P=0.015) were associated with a reduced likelihood of encountering appendicitis on pathology examination. The complication rate was 0.13%. Anesthesia cost was lower for an incidental appendectomy compared with an urgent one.

Conclusion:

Laparoscopic incidental appendectomy is safe and quick to perform. Due to the complex nature of confirming the diagnosis of pelvic and abdominal pain, this study supports the routine performance of an incidental appendectomy in the female patient.     

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.

Association between the appendix and the fecalith in adults

Background

We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix.

Methods

We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith.

Results

During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10–76) years. The fecalith rate was 13%–16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma.

Conclusion

Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the presence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.     

Laparoscopic Appendectomy and Cholecystectomy During Pregnancy: Six Case Reports

Background:

Pregnancy was once considered a contraindication to laparoscopic cholecystectomy and appendectomy. The progression of laparoscopic techniques has resulted in a continued reassessment of laparoscopic procedures during pregnancy. There still exists some controversy as to the safety of laparoscopic procedures during pregnancy. This paper reviews our series of six pregnant patients treated laparoscopically for appendicitis and cholecystitis.

Methods:

Charts were reviewed of all pregnant patients who underwent laparoscopic cholecystectomy or appendectomy at St Clare''s Hospital Schenectady, New York between 1992 and 1996. Six patients were identified. Patients and obstetricians were contacted to investigate the results of the pregnancy.

Results:

All patients and fetuses survived the procedure. Two patients delivered prematurely but remote from the operative procedure. All infants were healthy postpartum. One patient underwent an elective abortion as she had planned. The abortion was remote from the surgical procedure.

Conclusion:

Our series adds to the growing evidence that laparoscopic cholecystectomy and laparoscopic appendectomy can be performed safely during pregnancy.     

Laparoscopic versus open appendectomy in children: a randomized controlled trial from a developing country

Background

Acute appendicitis is a common surgical emergency. This study was conducted to compare the outcome in terms of duration of surgery, length of hospital stay, and wound infection rate following laparoscopic versus open appendectomy in children with acute appendicitis.

The value of hyperbilirubinaemia in the diagnosis of acute appendicitis

INTRODUCTION

No reliably specific marker for acute appendicitis has been identified. Although recent studies have shown hyperbilirubinaemia to be a useful predictor of appendiceal perforation, they did not focus on the value of bilirubin as a marker for acute appendicitis. The aim of this study was to determine the value of hyperbilirubinaemia as a marker for acute appendicitis.

MATERIALS AND METHODS

A retrospective analysis of appendicectomies performed in two hospitals (n=472). Data collected included laboratory and histological results. Patients were grouped according to histology findings and comparisons were made between the groups.

RESULTS

The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (p<0.001). More patients with simple appendicitis had hyperbilirubinaemia on admission (30% vs 12%) and the odds of these patients having appendicitis were over three times higher (odds ratio: 3.25, p<0.001). Hyperbilirubinaemia had a specificity of 88% and a positive predictive value of 91% for acute appendicitis. Patients with appendicitis who had a perforated or gangrenous appendix had higher mean bilirubin levels (p=0.01) and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 70%. The specificities of white cell count and C-reactive protein were less than hyperbilirubinaemia for simple appendicitis (60% and 72%) and perforated or gangrenous appendicitis (19% and 36%).

CONCLUSIONS

Hyperbilirubinaemia is a valuable marker for acute appendicitis. Patients with hyperbilirubinaemia are also more likely to have appendiceal perforation or gangrene. Bilirubin should be included in the assessment of patients with suspected appendicitis.     

Incarcerated hernia in 11-mm nonbladed trocar site following laparoscopic appendectomy

Background:

Nonbladed trocars are considered less traumatic to the abdominal wall due to the lack of fascial incision. It has been suggested that closure of the abdominal fascia may be unnecessary when such nonbladed trocars are used.

Case Report:

We report on 2 patients who were diagnosed with trocar-site hernias 2 days after laparoscopic appendectomy performed using 11-mm nonbladed trocars.

Conclusion:

Although rare, trocar-site hernias after laparoscopic surgery with nonbladed trocars remain a cause of postoperative morbidity and require prompt intervention. Therefore, this report underscores the significance of performing meticulous closure of all trocar sites that are ≥10mm.     

The Influence of the Appendiceal Base Diameter on Appendix Stump Closure in Laparoscopic Appendectomy

Background

Closure of the appendiceal stump is the most critical part of laparoscopic appendectomy. Establishing the average diameter of the inflamed appendix, and forming the appropriate size of clip, endoloop or stapler length, would make this critical phase of laparoscopic appendectomy easier.

Methods

One hundred and fifty consecutive patients, with the diagnosis of acute appendicitis, were included in this study and divided into three groups according to the histological verification of the status of the infection, as follows: phlegmonous, gangrenous and perforated forms of acute appendicitis. The external diameter of the appendiceal base was measured, and the widest part of the appendix with the mesoappendix and the tip, with the help of Vernier callipers, and the measurement was expressed in millimetres.

Results

The average size of the appendiceal base in the phlegmonous form was 10.29 ± 3.13, in the gangrenous form 12.41 ± 3.56, and in the perforated form 12.42 ± 3.64. The maximal size of base was observed in the perforated form, 23.13 mm. The dimensions of the appendiceal base, the central part and the tip in the phlegmonous form were statistically significantly smaller than in the gangrenous and perforated forms of acute appendicitis. The size of the appendix did not differ statistically significantly in the gangrenous and perforated forms of acute appendicitis.

Conclusion

In view of the price, the size of the opening, radiological advantage and biocompatibility, the Hem-o-lok clip is the most effective, although its internal diameter should be increased. The DS clip is also effective, but the size of the opening sometimes makes application difficult, and possibly increasing the length of the legs and the opening would make this clip ideal. Staplers have the best characteristics, but their price means they are an option only for forms where it is not possible to close the stump using other methods.

     

The influence of age on the severity of peritonitis

Objective

To evaluate the influence of age on the evolution and severity of peritonitis.

Design

A chart review.

Setting

An adult university hospital.

Patients

One hundred and twenty-two patients with acute appendicitis and 100 patients with acute colonic diverticulitis requiring operation or percutaneous drainage.

Main Outcome Measures

Patient age and sex, presence of perforation or gangrene (appendicitis), extent of peritonitis (diverticulitis); duration of symptoms prior to admission; admission leukocyte count; duration of hospitalization before surgery; length of hospital stay; and death rate.

Results

Patients with acute appendicitis who were aged 65 years or older were three times more likely than younger patients to have a gangrenous or perforated appendix (odds ratio 3.1, 95% confidence interval 1.1 to 8.4, p < 0.05); older patients with perforated diverticulitis were three times more likely than younger patients to have generalized peritonitis than localized (pericolic or pelvic) peritonitis (odds ratio 2.9, 95% confidence interval 1.2 to 7.5, p < 0.05).

Conclusion

These findings are consistent with the hypothesis that the biologic features of peritonitis differ in the elderly, who are more likely to present with an advanced or severe process than young patients.     

Stump appendicitis: a surgeon's dilemma

Background:

Stump appendicitis is defined by the recurrent inflammation of the residual appendix after the appendix has been only partially removed during an appendectomy for appendicitis. Forty-eight cases of stump appendicitis were identified in the English literature.

Database:

The institutional CPT codes were evaluated for multiple hits of the appendectomy code, yielding a total of 3 patients. After appropriate approval from an internal review board, a retrospective chart review was completed and all available data extracted. All 3 patients were diagnosed with stump appendicitis, ranging from 2 months to 20 years after the initial procedure. Two patients underwent a laparoscopic and the one an open completion appendectomy. All patients did well and were discharged home in good condition.

Conclusion:

Surgeons need a heightened awareness of the possibility of stump appendicitis. Correct identification and removal of the appendiceal base without leaving an appendiceal stump minimizes the risk of stump appendicitis. If a CT scan has been obtained, it enables exquisite delineation of the surrounding anatomy, including the length of the appendiceal remnant. Thus, we propose that unless there are other mitigating circumstances, the completion appendectomy in cases of stump appendicitis should also be performed laparoscopically guided by the CT findings.     

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis

Background

The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics.

Methods

Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using χ², Fisher exact, and Student t tests.

Results

The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain).We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 ± 5.7 vs 8.8 ± 6.7 days, P = .08).

Conclusions

When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.     

Laparoscopic versus open appendectomy: a prospective randomized trial of 81 patients

Objective

To compare the efficacy of laparoscopic appendectomy (LA) and open appendectomy (OA) in the treatment of acute appendicitis.

Design

A prospective randomized trial.

Setting

A university teaching hospital.

Patients

Eighty-one patients with a diagnosis of acute appendicitis were prospectively randomized to undergo either LA or OA. The two groups were matched for age and sex.

Interventions

LA or OA.

Main Outcome Measures

Number of days in hospital and time to full recovery.

Results

The mean hospital stay for LA was 3.23 days compared with 3.03 days for OA (p < 0.001). The mean number of narcotic injections required for patients in the LA group was 4.05 compared with 5.58 for patients in the OA group (p < 0.001). The mean time to complete recovery for patients in the LA group was 9.0 days compared with 16.2 days for patients in the OA group (p < 0.001). The mean operative time for LA was 73.8 minutes compared with 45.0 minutes for OA (p < 0.001). Three patients in the LA group had intra-abdominal abscesses (p > 0.25). No significant difference in wound infection rates was demonstrated (p > 0.05). Similarly, pain scores at 7 and 28 days showed no significant difference (p > 0.05).

Conclusions

With LA significantly fewer narcotic injections are required and there is a more rapid return to normal activities. LA takes longer to perform and was associated with three intra-abdominal abscesses. In cases of simple acute appendicitis the hospital stay for LA is significantly shorter.