A tiered approach to optimize pediatric laparoscopic appendectomy outcomes

Background/PurposeSurgical 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.MethodsAppendectomies 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.ResultsA 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.ConclusionsSILS 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 StudyTreatment Study.Level of EvidenceLevel III.     

Single-port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture

Background/Purpose

Laparoscopic appendectomy (LA) is becoming popular for the treatment of acute and perforated appendicitis. Since it was first described, LA has been modified various times. We present the results of a new technique of LA conducted through a single port without exteriorizing the appendix to perform the operation.

Materials and Methods

Single-port LA was attempted in 38 patients (23 boys, 15 girls). Under general anesthesia, an 11-mm port with two 5-mm working channels or an 11-mm port through which a 10-mm scope (0°) with a parallel eyepiece and a 6-mm working channel was inserted through the umbilicus. The appendix was grasped and dissected from the surrounding tissues with a single dissector or grasper. With a percutaneously inserted suture from the right lower quadrant into the peritoneal cavity, the appendix was pulled toward the abdominal wall after passing the suture through the mesoappendix. After mesenteric dissection with hook cautery, the base of the appendix was ligated with 2-0 polyglactin with a fisherman knot. The appendix was withdrawn into the trocar and extracted from the abdomen together with the trocar.

Results

Laparoscopic appendectomy was completed in 35 patients through a single port. A second port insertion was required in 3 patients. No peroperative and postoperative complications were encountered. Average duration of the procedure was 38 ± 5.6 minutes.

Conclusion

This unique method further improves the minimal invasiveness of LA because a single port is used. Single-port intracorporeal appendectomy procedure is a safe, highly minimal invasive procedure with excellent cosmetic results.     

小儿腹腔镜阑尾切除术的临床评价

目的评价小儿腹腔镜阑尾切除术(laparoscopic appendectomy, LA)的效果. 方法对比分析LA组(n=89)和开腹阑尾切除术(open appendectomy,OA)组(n=90)的手术效果、住院时间、费用支出和患者满意程度. 结果 LA组较OA组手术时间显著延长 [(57±2) min vs.(43±1) min,t=6.282, P=0.000],总医疗费用显著降低[(15 291±499)元vs. (17 442±544)元,t=-2.912,P=0.004],住院时间显著缩短[(2.9±0.2) d vs.(3.6±0.2) d, t=-2.475,P=0.014],两组手术并发症发生率和病人满意度调查无明显差别(χ2=0.119,P＝0.730;χ2=0.435,P＝0.509). 结论两种术式同样有效,LA不增加医疗费用,LA微创特点和探查腹腔更具优越性,提倡用于小儿阑尾炎.     

Tissue reaction to absorbable endoloop, nonabsorbable titanium staples, and polymer Hem-o-lok clip after laparoscopic appendectomy

Background and Objectives:

The standard technique for securing the base of the appendix during laparoscopic appendectomy is by absorbable endoloop ligature, although clinical reports favor the use of the stapler. Nonabsorbable Hem-o-lok clips have been shown to be an alternative technique to this. However, it is currently not clear whether nonabsorbable clips have any effects on the intestine or promote infection in the surgical area.

Materials and Methods:

Sixty Wistar albino rats were randomized into 3 treatment groups: group I (n=20) the base of the appendix was secured by endoloop 2-0 ligature; group II (n=20) dissection of the appendix was performed by a 45-mm thick stapler; and group III (n=20) the base of the appendix was secured by a Hem-o-lok plastic clip. The animals were sacrificed on the 14th and 28th days after surgery. The secured stump was used for histopathological examination.

Results:

There were no significant differences in histopathological changes observed on the 14th postoperative day between the groups. On the 28th postoperative day, it was proved that mild and moderate inflammation is more frequent in the endoloop and Hem-o-lok groups than in the stapler group. Reaction to a foreign body is more frequent in the endoloop than in stapler and Hem-o-lok groups.

Conclusion:

The mildest postoperative inflammatory changes were seen in the stapler group, followed by the Hem-o-lok group. However, because of the price of the plastic clip and the simplicity of its application, its use is still favored during laparoscopic appendectomy.     

Nationwide management of perforated pediatric appendicitis: Interval versus same-admission appendectomy

PurposeAlthough conservative management followed by readmission for interval appendectomy is commonly used to manage perforated appendicitis, many studies are limited to individual or noncompeting pediatric hospitals. This study sought to compare national outcomes following interval or same-admission appendectomy in children with perforated appendicitis.MethodsThe Nationwide Readmission Database was queried (2010–2014) for patients <18 years old with perforated appendicitis who underwent appendectomy using ICD9-CM Diagnosis codes. A propensity score-matched analysis (PSMA) utilizing 33 covariates between those with (Interval Appendectomy) and without a prior admission (Same-Admission Appendectomy) was performed to examine postoperative outcomes.ResultsThere were 63,627 pediatric patients with perforated appendicitis. 1014 (1%) had a prior admission for perforated appendicitis within one calendar year undergoing interval appendectomy compared to 62,613 (99%) Same-Admission appendectomy patients. The Interval Appendectomy group was more likely to receive a laparoscopic (87% vs. 78% same-admission) than open (13% vs. 22% same-admission; p < 0.001) operation. Patients receiving interval appendectomy were more likely to have their laparoscopic procedure converted to open (5% vs. 3%) and receive more concomitant procedures. PSMA demonstrated a higher rate of small bowel obstruction in those receiving Same-Admission appendectomy while all other complications were similar. Although those receiving Interval Appendectomy had a shorter index length of stay (LOS) and lower admission costs, they incurred an additional $8044 [$5341-$13,190] from their prior admission.ConclusionPatients treated with interval appendectomy experienced more concomitant procedures and incurred higher combined hospitalization costs while still having a similar postoperative complication profile compared to those receiving same-admission appendectomy for perforated appendicitis.Level of evidenceIII.Type of studyRetrospective Comparative Study.     

Laparoscopic versus standard appendectomy outcomes and cost comparisons in the private sector

Minimally invasive surgery has been proposed as the preferred treatment strategy for various gastrointestinal disorders due to shorter hospital stay, less pain, quicker return to normal activities, and improved cosmesis. However, these advantages may not be straightforward for laparoscopic appendectomy, and optimal management of remains controversial. One hundred forty-eight patients with clinical and radiologic diagnoses of acute appendicitis treated in two different hospitals were retrospectively reviewed. Seventy-eight patients underwent laparoscopic appendectomy in hospital A and 70 patients underwent standard appendectomy in hospital B. Patients treated by either type of surgery were compared in terms of clinical and pathologic features, operation characteristics, complications, and costs. There were no significant differences between both groups in terms of clinical features, radiologic studies, complications, and final pathology findings (P > .05). Hospital stay was significantly shorter and bowel movements recovered quicker in the laparoscopy group. However, overall and operating room costs were significantly higher in patients treated by laparoscopy (P < .01). Our series show a subtle difference in terms of hospital stay and bowel movement recovery, favoring patients treated by laparoscopy. However, these results have to be carefully examined and weighed, because overall costs and operating room costs were significantly higher in the laparoscopy group. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

Comparison of laparoscopic versus open appendectomy for acute nonperforated and perforated appendicitis in the obese population

Background

Use of laparoscopic appendectomy (LA) has been increasing in obese patients. We evaluated the outcomes of LA compared with open appendectomy (OA) in obese patients.

Methods

By using the Nationwide Inpatient Sample database, clinical data of obese patients who underwent LA and OA for suspected acute appendicitis (perforated or nonperforated) from 2006 to 2008 were examined.

Results

A total of 42,426 obese patients underwent an appendectomy during this period. In acute nonperforated cases, LA had a lower overall complication rate (7.17% vs 11.72%; P < .01), mortality rate (.09% vs .23%; P < .01), mean hospital charges ($25,193 vs $26,380; P = .04), and shorter mean length of stay (2.0 vs 3.1 d; P < .01) compared with OA. Similarly, in perforated cases, LA was associated with a lower overall complication rate (22.34% vs 34.65%; P < .01), mortality rate (.0% vs .50%; P < .01), mean hospital charges ($36,843 vs $43,901; P < .01), and a shorter mean length of stay (4.4 vs 6.5 d; P < .01) compared with OA.

Conclusions

LA can be performed safely with superior outcomes compared with OA in obese patients and should be considered the procedure of choice for perforated and nonperforated appendicitis in these patients.     

Comparison of surgical stress between laparoscopic and open appendectomy in children

Purpose

The present study aimed to evaluate laparoscopic appendectomy (LA) in comparison with conventional open appendectomy (OA) in children, with special emphasis on the extent of surgical trauma after LA and OA, and to assess whether LA had any clear advantages compared with conventional OA.

Methods

A total of 160 patients with a median age of 7.9 years (range 3-15 years) were studied. Sixty-nine of them underwent LA, and the remaining 91 underwent OA. Serum interleukin (IL) 6 and C-reactive protein (CRP) levels which are thought to play a pivotal role in the pathogenesis of surgical trauma and can also be used to monitor the magnitude of surgical trauma were measured using an enzyme-linked immunosorbent assay before surgery and 12 hours after surgery. In addition, we compared operating time, hospital stay, incidence of wound infection, and incidence of intra-abdominal infection.

Results

The operative time of normal and suppurative appendix in the laparoscopic group was significantly shorter than that in the open group, respectively, but the operative time of gangrenous appendix was not different between the laparoscopic group and open group. The hospital stay in the laparoscopic group was also significantly shorter than that in the open group. Postoperatively, 1 patient had port-site infection in the laparoscopic group, whereas 10 had wound infection in the open group; this difference was highly significant (χ² = 4.19, P < .05). Three patients in the open group and 2 patients in the laparoscopic group had intra-abdominal infection, and the difference had no statistically significant difference (χ² = 0.10, P < .05). Preoperative IL-6 levels were not different between the 2 groups, but the rise (preoperative vs postoperative) of IL-6 in the laparoscopic group was remarkably less than that in the open group. Similar results were obtained for CRP; serum CRP levels in the basal state were not different between the 2 groups, but the rise (preoperative vs postoperative) of CRP in the laparoscopic group was also substantially less compared with that in the open group.

Conclusions

LA for children was as safe and effective as the open procedure and had significant advantages over OA because of less operating time, less postoperative complications, less surgical trauma, and more rapid postoperative recovery.     

Laparoscopic appendectomy in children can be done as a fast-track or same-day surgery.

BACKGROUND: Laparoscopic surgery has reduced the length of hospital stay for common operations like cholecystectomy, gastric fundoplication, and appendectomy. We have noticed a reduction in length of hospital stay for children undergoing laparoscopic appendectomy. We, therefore, looked at our data to assess whether laparoscopic appendectomy in children could be performed as fast-track or same-day surgery (< or = 24-hour postoperative stay). METHODS: We performed a retrospective review of the records of all children who underwent laparoscopic appendectomy for suspected appendicitis during a 3-year period (7/97 to 7/00). RESULTS: Laparoscopic appendectomy was performed in 79 children (44 boys and 35 girls), between 2 to 17 years of age (mean, 11 years). In 4 (5%) children with perforated appendicitis, the laparoscopic appendectomy was converted to an open appendectomy. At operation, 51 (64.5%) had acute appendicitis, 22 (27.8%) had perforated appendicitis, 4 (5%) had ruptured ovarian cysts, and 2 (2.5%) had no pathology. The median operative time was 54 minutes. Total length of stay for all 79 patients was a median of 58 hours, and median postoperative LOS was 35 hours. Complications included wound infection (2), abdominal abscess (4), drug rash (2), and epididymo-orchitis (1). In 57 (72%) children without perforated appendicitis, the total length of hospital stay was a median of 42 hours, while median postoperative length of stay was only 28 hours. Thirty-two (56%) children went home in < or = 24 hours following laparoscopic appendectomy. No significant morbidity was noted in the nonperforated group (drug rash, 1 fever > 24 hrs, 3); and no readmissions or reoperations were necessary on follow-up. CONCLUSION: Laparoscopic appendectomy is safe and effective for treating children with appendicitis. Laparoscopic appendectomy may be safely performed as fast-track or same-day surgery, in select children without perforated appendicitis, with a postoperative stay of < or = 24 hours.     

Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience

Purpose

The purpose of the study was to determine and evaluate the incidence of postoperative bowel obstruction (PBO) after laparoscopic and open appendectomy in children.

Material and Methods

The medical files of children who have undergone an appendectomy, either via the laparoscopic or open approach, at our department from 1992 until 2007 were reviewed. Collected data included age at appendectomy, initial surgical approach, time interval to PBO, and type of definitive treatment. The incidences of PBO after laparoscopic and open appendectomy were compared with the χ² analysis.

Results

From the 1684 children who were found, 1371 had nonperforated appendicitis and 313 had perforated appendicitis. Laparoscopic appendectomy was performed in 954 patients of the nonperforated group and in 221 of the perforated group. Open appendectomy was performed in 417 and 92 patients of the 2 groups, respectively. Overall, the incidence of PBO development was 2.2%. In the laparoscopic appendectomy population, a significantly low incidence of 1.19% of PBO development was detected, compared with the 4.51% of the open appendectomy group (P < .0001).

Conclusion

Laparoscopic appendectomy diminishes the potential of PBO development. The overall incidence of PBO is not related to the severity of the disease but only to the initial operative approach.     

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.

Appendiceal stump abscess as an early complication of laparoscopic appendectomy: report of a case

We report the case of an appendiceal stump abscess that was treated by relaparoscopy 4 days after a laparoscopic appendectomy (LA). Surgeons should be aware of the possibility of appendiceal stump abscess occurring as an early complication of LA. When performing LA, the appendiceal stump should be as short as possible, and the ligation of the root of the appendix should be only moderately tight, so as not to cause ischemic change of the stump, indicated by discoloration or edema. The insertion of a drain for monitoring exudate, as well as sonography, and relaparoscopy are helpful for diagnosing and treating this complication. Received: September 28, 2001 / Accepted: March 5, 2002     

Amyand's hernia: a case report describing laparoscopic repair in a pediatric patient

Amyand's hernia is a rare hernia in which an incarcerated or perforated appendix is found in the right inguinal canal. This case report looks at the clinical presentation, the modalities for preoperative evaluation, and finally a combined approach of laparoscopic appendectomy and open repair of the hernia. To our knowledge, this is the first report of this type of management, and we feel that it is a safe and effective option.     

Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis

Background

In 2012, a same-day discharge protocol following appendectomy for acute appendicitis was initiated. Our objective was to determine the success of the protocol by reviewing the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) outcomes following protocol development.

Preoperative and postoperative levels of interleukin-6 in patients with acute appendicitis: comparison between open and laparoscopic appendectomy

Background Cytokine interleukin-6 (IL-6) is an early marker of systemic inflammatory response and tissue damage. This study aimed to evaluate the levels of IL-6 after open and laparoscopic appendectomy to compare the degree of surgical stress associated with these procedures.Methods The levels of IL-6 were measured pre- and postoperatively in the plasma of 37 consecutive patients with a diagnosis of acute appendicitis. After preoperative randomization, 22 patients underwent open appendectomy, and 15 patients underwent laparoscopic appendectomy.Results The preoperative concentrations of IL-6 were 7.2 ± 5.6 pg/ml in the open appendectomy group, as compared with 12.1 ± 9.7 pg/ml in the laparoscopic appendectomy group (p < 0.05). The postoperative levels were 16.9 ± 15.7 and 23.2 ± 19.4 pg/ml, respectively. The mean postoperative to preoperative ratio of IL-6 was slightly higher for open (2.7 ± 2.4) than for laparoscopic (2.3 ± 1.6) appendectomy, but the difference did not reach statistical significance.Conclusion The operative stress in open as compared with laparoscopic appendectomy is not reflected by circulating levels of IL-6.     

Laparoscopic versus open appendectomy in acute appendicitis: A randomized prospective study

Background: Laparoscopic appendectomy is a safe and effective procedure, as both a diagnostic and therapeutic tool. It seems to be more effective than the corresponding open procedure. Aim of this study is to evaluate a group of patients randomly allocated either to laparoscopic appendectomy (LA) or to open appendectomy (OA). Methods: From January 1998 to December 2002, 252 consecutive and nonselected patients, 155 women and 97 men, were randomized either to LA or OA. Recorded data were operative time, postoperative length, of stay and complications. Results: Mean operative time was 45 min (range 30–120) for OA and 36 min (25–60) for LA, mean postoperative stay was 5.5 days (4–12) for OA and 3.4 days (2–8) for LA. Complication occurred in 20 patients (14.5%) for OA and in four patients (2.6%) for LA. Conclusion: We believe that LA is effective in any kind of clinical situation, with low traumatic impact and best comfort for the patient.