Single-incision laparoscopic surgery: feasibility for pediatric appendectomies

Introduction

Single-incision laparoscopic surgery (SILS) is a novel area of minimally invasive surgery using a single incision. The end result is a lone incision at the umbilicus for a perceived scarless abdomen. We report our early experience using the SILS technique for appendectomies in the pediatric population.

Methods

A retrospective chart review was performed on our first patients to undergo SILS appendectomy (SILS-A) or laparoscopic appendectomy (LAP-A) during the same period at a freestanding children's hospital.

Results

Thirty-nine patients were reviewed. Nineteen patients underwent SILS-A (8.7 ± 0.76 [SEM] years old), and 20 patients underwent LAP-A (10.5 ± 0.87 years old, 2-17). Ages were 19 months to 14 years in the SILS-A group, with 21% (4 patients) not older than 6 years. Median weight for SILS-A was 32 kg (14.5-80.3). Twelve patients had acute nonperforated appendicitis (62%). Mean duration of operation was 58 ± 5.6 (30-135) minutes vs 43 ± 3.6 (30-85) minutes for standard LAP-A. Two patients were converted to a transumbilical appendectomy, one for inability to maintain a pneumoperitoneum and one for extensive adhesions. Postoperative complications consisted of one wound seroma. No wound infections, hernias, readmissions, or difference in length of stay were noted.

Conclusion

The SILS approach for acute appendicitis is feasible in the pediatric population even in patients as young as 19 months. Operating room times are somewhat longer than with LAP-A, but should decrease with improved instrumentation and experience. Larger studies and further technical refinements are needed before its widespread implementation.     

Early experience with single incision laparoscopic surgery: eliminating the scar from abdominal operations

Purpose

Single incision laproscopic surgery (SILS) involves performing abdominal operations with laparoscopic instruments placed through a single, small umbilical incision. The primary goal is to avoid visible scarring. This is the first report of SILS cholecystectomy in children and the first report in the literature of SILS splenectomy.

Methods

A retrospective chart review was performed in 20 consecutive inpatient SILS procedures (13 males, 7 females; ages 2-17 years) from May to December 2008. Outcome measures included need for conversion, operative time, time to oral analgesia, length of hospitalization, cosmetic outcome, and complications.

Results

There were 4 total splenectomies, 3 cholecystectomies, 2 combined splenectomy/cholecystectomies, and 11 appendectomies performed. All procedures were completed successfully without need for conversion to standard laparoscopy or open surgery. Mean operative time was 90 minutes for splenectomy, 68 minutes for cholecystectomy, 165 minutes for combined splenectomy/cholecystectomy, and 33 minutes for appendectomy. Mean hospital stay was 1 day for appendectomy, 1 day for cholecystectomy, and 2.5 days for splenectomy. One splenectomy patient received 1 U packed red blood cell transfusion. All appendectomy patients were converted to oral analgesia within 24 hours and splenectomy patients within 48 hours. All families were very pleased with the cosmetic outcome.

Conclusion

Single incision laparoscopic surgery is feasible for a variety of pediatric general surgical conditions, allowing for scarless abdominal operations. This early experience suggests that outcomes are comparable to standard laparoscopic surgery but with improved cosmesis, however, a larger series is necessary to confirm these findings and to determine if there are any benefits in pain or recovery. Surgeons performing SILS should have a firm foundation of advanced minimal access surgical skills and a cautious, gradated approach to attempting the various procedures. Technological refinements will further enable SILS.     

Single-incision laparoscopic surgery in children: initial single-center experience

Background

In continued efforts to further improve the advantages of minimally invasive surgery to patients, surgeons have developed single-incision laparoscopic techniques. We report our initial experience in children with a variety of single-site procedures.

Method

A retrospective chart review was performed on patients who underwent a single-site procedure from April 2009 to April 2010.

Results

There were 142 consecutive procedures: 24 cholecystectomies, 103 appendectomies for nonperforated appendicitis, 2 splenectomies, 1 combined splenectomy/cholecystectomy, 8 ileocecectomies, 2 Meckel diverticulectomies, 1 small bowel duplication resection, and 1 jejunal stricture resection. There were 12 conversions to conventional laparoscopy: 10 during appendectomy and 2 during cholecystectomy. Mean operative time was 34 minutes for appendectomy, 73 minutes for cholecystectomy, 90 minutes for splenectomy, 116 minutes for combined splenectomy/cholecystectomy, 86 minutes for ileocecectomy, and 43 minutes for the small bowel procedures. The only complications were umbilical surgical site infections after appendectomy in 6 patients.

Conclusion

This institution's preliminary experience suggests that single-incision laparoscopic surgery in children has at least comparable outcomes to conventional laparoscopic surgery. However, prospective data are needed to prove that single-incision laparoscopic surgery is superior to conventional laparoscopy.     

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 with uncomplicated and complicated appendicitis

Purpose

To address whether laparoscopic appendectomy could be an alternative to conventional open appendectomy in children with complicated appendicitis as well as uncomplicated appendicitis, a retrospective study comparing laparoscopic and open appendectomies was performed.

Methods

One hundred patients who were treated by immediate appendectomy, either laparoscopically or by the open method, between May 2000 and August 2003 were included in the study. There were 53 patients in the laparoscopic appendectomy group and 47 patients in the open appendectomy group.

Results

The operating time was significantly longer for laparoscopic appendectomy than for open appendectomy (P < .001). The length of hospital stay was significantly shorter in laparoscopic appendectomy in patients with uncomplicated appendicitis (P = .001). Thirteen of the 100 patients (13.0%) had 15 postoperative complications including wound infection (n = 8), intraabdominal abscess (n = 4), stitch abscess (n = 2), and small bowel obstruction (n = 1). In both uncomplicated and complicated appendicitis, there was no significant difference between laparoscopic and open appendectomies in the complication rates, and the incidences of each complication did not differ between the procedures. Among the 14 patients with generalized peritonitis, postoperative complications were seen in 5 patients (35.7%). Although the presence of generalized peritonitis was associated significantly with postoperative complications (P = .017), there was no significant association between the procedure and complications. Overall treatment costs were increased by 26.0% in laparoscopic appendectomy.

Conclusions

Laparoscopic appendectomy should remain an option in children with uncomplicated and complicated appendicitis, and when laparoscopy is selected, consideration of the advantages and disadvantages of the procedure is essential.     

Laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in symptomatic neonates

Purpose

Choledochal cysts require surgical excision, preferably before the onset of cholangitis. Recently, it has become feasible to accomplish the excision laparoscopically in adults and older children. Yet, whether laparoscopic excision of choledochal cyst can be performed safely in symptomatic neonates with choledochal cyst is unclear. We herewith reviewed our experience of laparoscopic excision of choledochal cysts in neonates.

Methods

We managed 9 neonates with choledochal cysts between April 2003 and February 2007. The choledochal cysts were excised laparoscopically. The Roux-en-Y hepaticojejunostomy was fashioned extracorporeally by exteriorizing the jejunum through the extended umbilical port site. End-to-side anastomosis between the common hepatic duct stump and Roux loop was carried out intracorporeally. The patients were followed up for an average of 26 months.

Results

The patients presented with jaundice, pale stool, and deranged liver function tests. The diagnosis was confirmed with ultrasonography postnatally. The median operation time was 3.6 hours. There was no operative complication and no conversion. The blood loss was minimal. The recovery was uneventful, and the median hospital stay was 6 days. The liver function tests normalized 3 to 16 weeks postoperatively. No complication was detected at the follow-up visits.

Conclusions

Our preliminary results show that laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in neonates is both feasible and safe. It curtails further complication of the cysts and reverses the derangement of liver function. In addition, the laparoscopic approach minimizes surgical trauma.     

Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach

Introduction

Adhesive small bowel obstruction (SBO) is a common postoperative complication. Published data in the pediatric literature characterizing SBO are scant. Furthermore, the relationship between the risk of SBO for a given procedure is not well described. To evaluate these parameters, we reviewed the incidence of SBO after laparoscopic appendectomy (LA) and open appendectomy (OA) performed at our institution.

Methods

With institutional review board approval, all patients that developed SBO after appendectomy for appendicitis from January 1998 to June 2005 were investigated. Hospital records were reviewed to identify the details of their postappendectomy SBO. The incidences of SBO after LA and OA were compared with χ² analysis using Yates correction.

Results

During the study period, 1105 appendectomies were performed: 477 OAs (8 converted to OA during laparoscopy) and 628 LAs. After OA, 7 (6 perforated appendicitis) patients later developed SBO of which 6 required adhesiolysis. In contrast, a patient with perforated appendicitis developed SBO after LA requiring adhesiolysis (P = .01). The mean time from appendectomy to the development of intestinal obstruction for the entire group was 46 ± 32 days.

Conclusions

The overall risk of SBO after appendectomy in children is low (0.7%) and is significantly related to perforated appendicitis. Small bowel obstruction after LA appears statistically less common than OA. Laparoscopic appendectomy remains our preferred approach for both perforated and nonperforated appendectomy.     

The effect of laparoscopic excision vs open excision in children with choledochal cyst: a midterm follow-up study

Purpose

Cyst excision with hepaticojejunostomy has been the classic procedure for treating choledochal cysts. Recently, laparoscopic treatment of the disease has gained popularity worldwide. The aim of this study is to evaluate whether laparoscopic management of choledochal cysts is as feasible and safe as conventional open surgery in children with this disease.

Methods

A retrospective study comparing the laparoscopic and the open procedures was performed in 77 consecutive patients with choledochal cyst in our hospital. Thirty-nine patients operated on between June 2001 and September 2003 were in the laparoscopic group, whereas 38 patients in the open group were operated on between February 1999 and May 2001.

Results

Patient demographics were similar between the 2 groups. The duration of operation was significantly longer in the laparoscopic group than in the open group (median, 230 vs 190 minutes; P < .001). In contrast, the durations of delayed oral feeding and hospital stay postoperatively were significantly shorter in the laparoscopic group (median, 4 vs 5 days [P < .01] and median, 5 vs 7 days [P < .01], respectively.) There were no differences in the early and late complication rates between the 2 groups.

Conclusions

Laparoscopic treatment of choledochal cyst in children is feasible and safe. For experienced centers, this procedure can be recommended.     

Laparoscopic unroofing of splenic cysts results in a high rate of recurrences

Purpose

Laparoscopic unroofing is described as an appropriate treatment modality of nonparasitic splenic cysts. However, we repeatedly encountered recurrences with this technique. Because splenic cysts are rare, we analyzed the combined experience of 3 German pediatric surgical departments.

Materials and Methods

Between 1995 and 2005, primary and secondary nonparasitic splenic cysts were unroofed laparoscopically in 14 children (aged 5-12 years; median, 8.5 years). In 3 patients, the inner surface was coagulated with the argon beamer. In most children, the cavity was surfaced with omentum. In addition, in 4 patients the omentum was sutured to the splenic parenchyma.

Results

No intraoperative complications occurred, and no inadvertent splenectomy or blood transfusions were necessary. However, in 9 children (64%) the cysts recurred at intervals ranging from 6 to 12 months (median, 12 months). Also, argon laser treatment of the surface resulted in recurrence.

Conclusion

Laparoscopic unroofing of true splenic cysts alone proved inadequate in this series. Either removal of the inner layer or partial splenectomy appears to be necessary to prevent recurrences.     

Laparoscopic drainage of intraabdominal abscess after appendectomy: an alternative to laparotomy in cases not amenable to percutaneous drainage

Purpose

Postoperative abscesses after appendectomy occur in 3% to 20% of cases and are more common in cases of perforated appendicitis. Smaller abscesses are often amenable to antibiotic therapy, but surgical drainage remains the mainstay of treatment for larger collections. Surgical options generally include percutaneous drainage and open laparotomy. Laparoscopic drainage of these abscesses has not been well characterized in the pediatric population.

Objective

The aim of this study was to describe our experience with laparoscopic drainage of postappendectomy abscesses that were not amenable to percutaneous drainage.

Methods

This study is a retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis at a tertiary pediatric medical center during a 4-year period (2006-2009). The review focuses on patients who developed abscesses after appendectomy, were unable to undergo percutaneous drainage, and were treated with laparoscopic abscess drainage.

Results

Twelve patients (7 male and 5 female) underwent laparoscopic drainage of postappendectomy abscesses. The mean age was 8.5 years old (range, 3-14 years). A clinical diagnosis of postoperative abscess was made when fevers, pain, and leukocytosis persisted despite broad-spectrum antibiotics. Computed tomography was performed in all patients. Abscesses ranged between 3 and 11 cm in size. The mean length of time between initial appendectomy and drainage procedure was 10 days. There were no complications specifically related to the laparoscopic drainage procedure. The mean length of the drainage procedure was 77 minutes (range, 30-196 minutes). The mean hospital length of stay after laparoscopic drainage was 6.5 days (range, 3-13 days) with patients maintained on intravenous antibiotics until afebrile and without leukocytosis.

Conclusion

Laparoscopic drainage is a safe and effective alternative for intraabdominal abscesses that occur after laparoscopic appendectomy. We recommend it as an alternative to open laparotomy when percutaneous drainage is not an option.     

Laparoscopic hernia repair in children by the hook method: a single-center series of 433 consecutive patients

Background

The relatively high recurrence rate reported in laparoscopic hernia repair in children using intracorporeal suturing technique remains a concern. We aimed to investigate the effectiveness of the hook method during hernia repair that allows extraperitoneal passage of suture to close the hernia sac without creating any tension or skip areas and does not require laparoscopic suturing skills.

Methods

A retrospective review was conducted on 433 consecutive children who underwent laparoscopic hernia repair using the hook method by 1 of 4 surgeons from July 2004 to June 2007.

Results

A total of 572 successful laparoscopic hernia repairs were performed among the 433 children with an age range of 1 week to 15 years (mean = 56 months). Conversion rate was 1.04%. Contralateral patent processus vaginalis was found in 26.8%. Mean operating time was 23.8 and 40.2 minutes for unilateral and bilateral repair, respectively. At a median follow-up of 20 months, there were 2 recurrences (0.35%), 2 hydroceles, 1 ascending testis, and 1 instance of testicular atrophy. No serious complications were associated with the procedure.

Conclusions

Medium-term results suggest that laparoscopic hernia repair with the hook method is a sound alternative to open herniotomy in children.     

Initial experience with complex laparoscopic biliary surgery in children: biliary atresia and choledochal cyst

Background

Laparoscopic approaches are possible for many pediatric surgical diseases, including complex biliary disorders. The authors describe their early experience with laparoscopic procedures for biliary atresia and choledochal cysts.

Methods

A retrospective review was performed with Institutional Review Board (IRB) approval of children undergoing laparoscopic Kasai portoenterostomy (n = 2) or laparoscopic excision of a choledochal cyst with Roux-en-y biliary reconstruction (n = 3). The authors report the operative technique for these procedures and present their initial results.

Results

All procedures were performed with 4 to 5 trocars using 3- and 5-mm ports. Excision of the fibrous biliary remnant (biliary atresia) or of the cyst (choledochal cysts) was performed laparoscopically in all cases. The Roux-en-y limb was created through a 1-cm extension of the umbilical port site. Laparoscopic biliary reconstruction was performed successfully in 4 of 5 patients. In one child, the proximal extent of the choledochal cyst was at the bifurcation of the hepatic duct, and the biliary reconstruction was performed via an open incision with separate anastomoses of the right and left ducts. The gallbladder was used as a handle for retraction of the liver for portal visualization, as in a cholecystectomy, and was resected at the end of the procedure. All children with choledochal cysts have normal bilirubin values. One of 2 children who underwent laparoscopic Kasai has a normal postoperative bilirubin level, whereas the other child did not drain bile and underwent a successful liver transplantation. Mean length of surgery was 338 minutes; mean length of stay was 5.5 days. There were no significant postoperative complications. Cosmesis was excellent in all cases.

Conclusions

Laparoscopic approaches for children with biliary atresia and choledochal cysts are possible. Excellent visualization of the portal structures can be achieved laparoscopically with adequate retraction of the liver. Further follow-up is needed to determine broader application.     

Outpatient interval appendectomy after perforated appendicitis

Background

Interval appendectomy may be advisable after successful nonoperative treatment of perforated appendicitis. To reduce the perceived morbidity of interval appendectomy, we sought to determine if the operation could be done on an outpatient basis. This study is focused on patient comfort and safety after laparoscopic interval appendectomy (LIA).

Methods

This is a retrospective review of the clinical course and length of stay of 24 children who had LIA during a 4-year period.

Results

Of the 24 patients, 12 were discharged on the evening of surgery without incident. Nine additional patients were observed for the first postoperative night—2 for short episodes of temperature elevation, 3 for pain treated within the first 4 hours of recovery and requiring no further treatment, and 4 because the idea of outpatient appendectomy had yet to become popular. None of these patients was febrile overnight, none required narcotic or parenteral analgesics after leaving the recovery room, and all accepted feedings without nausea or vomiting. It is likely that all 9 of these patients could have been discharged on the day of operation. Three other patients stayed in the hospital for treatment of pain, low-grade fever, or slow resumption of feeding.

Conclusion

Of 24 patients, 21(88%) were or could have been discharged on the day of operation. When interval appendectomy is indicated, LIA can be performed safely as an outpatient surgical procedure in most children.     

Gastric volvulus in children

Purpose

The aim of the study was to review the records of all children who presented with gastric volvulus in the past 10 years.

Methods

The study group consisted of 21 children with an age range from 0.2 months to 4.3 years who were operated for gastric volvulus from 1992 to 2003.

Results

Initial symptoms included acute abdominal pain after meals, vomiting, and in 8 cases, acute apnea associated with pallor, cyanosis, and hypotonia. After the first episode, barium studies revealed an organoaxial gastric volvulus in all cases. The surgical procedure was an anterior gastropexy with reinforcement of the esophagogastric angle performed by laparoscopy in 13 cases and by laparotomy in 8 (1 converted laparoscopy). An associated antireflux fundoplication was done in 3 patients. All children received postoperative antireflux medication for at least 1 month.The follow-up ranged from 4 months to 4.8 years. Two children in the laparotomy group required reoperation (Toupet fundoplication) for persistent gastroesophageal reflux disease. All children are currently symptom-free and without treatment.

Conclusions

Gastric volvulus is a clinical and radiological reality, which can be treated by a gastropexy. Initial fundoplication is not mandatory. The laparoscopic gastropexy is a good option and allows a repeat laparoscopic procedure if needed.     

Laparoscopic treatment of hydatid cyst of the liver in children. A report on 34 cases

Purpose

This study evaluated the safety and efficiency of laparoscopically treated liver cysts in children.

Methods

From September 2001 to July 2004, 34 patients underwent laparoscopic treatment of hydatid cysts of the liver. All patients had chest x-ray, abdominal sonography, and hydatid serology. The different stages of the procedure were the same as in open surgery: puncture, aspiration, injection of scolicidal agent, reaspiration, removal of proligerous membrane, and resection of the dome.

Results

The patients' mean average age was 7 years and 7 months (range, 3-14 years). The number of cysts ranged from 1 to 10 with a diameter of 40 to 150 mm (mean diameter, 65.5 mm). One case had a mesenteric associated hydatid cyst, another splenic hydatid cyst. The average length of hospital stay was 5 days (range, 4-14 days). No per- or postoperative complications were reported. At 12 to 45 months follow-up, no recurrence has been reported.

Conclusion

Laparoscopy represents an excellent approach for the treatment of hydatid cyst of the liver in children.     

Effective use of laparoscopy for long-term peritoneal dialysis access

Background

Laparoscopy is an underused modality for peritoneal dialysis access procedures. The strengths of laparoscopy are that it can both prevent and resolve the common mechanical problems that adversely effect dialysis catheter outcomes.

Method

Laparoscopically enabled catheter implantation and rescue procedures included rectus sheath catheter tunneling, omentopexy, adhesiolysis, resection of epiploic appendices, colopexy, salpingectomy, and appendectomy. Using these techniques, the outcomes of 428 laparoscopically implanted catheters were studied.

Results

During a mean follow-up of 21.6 months, mechanical obstruction complicated 3.7% of implantation procedures. The incidence of pericatheter leak was 2.6%. There were no occurrences of pericatheter hernia or subcutaneous cuff extrusion. Laparoscopic salvage procedures limited losses from mechanical catheter problems to .9%. Cumulative revision-free and assisted catheter survival probabilities for loss from mechanical complications at 5 years were .96 and .99, respectively.

Comments

Because it is enabled by techniques not available to other catheter-placement methods, laparoscopy produces superior outcomes.     

A role for laparoscopic approach in the treatment of biliary atresia and choledochal cysts

Background/Purpose

Indications for a laparoscopic approach in the management of biliary atresia and choledochal cysts in children are not clearly defined. We present our initial experience with 9 consecutive laparoscopic cases, and compare them to the traditional open approach.

Methods

A retrospective comparison of all consecutive operations for biliary atresia and choledochal cysts from January 2000 to May 2006 was undertaken. We evaluated the patient's age at operation, operative time, return of bowel function postoperatively, length of hospital stay, complications, and the need for subsequent liver transplantation. Mann-Whitney U test was used for statistical analysis.

Results

A total of 45 portoenterostomies and choledochojejunostomies were performed, including 9 laparoscopic and 36 open procedures. Patients with choledochal cysts were older than patients with biliary atresia. All the compared parameters were similar and there was no difference in outcomes between the laparoscopic and the open groups.

Conclusions

Our initial experience is encouraging and indicates that the laparoscopic approach is technically feasible, safe, and effective, with a low morbidity and a comparable outcome to the open technique. Longer follow-up of a larger patient cohort is needed.     

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

Introduction

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens.

Methods

After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an α of .5 and a power of 0.82.

Results

One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group.

Conclusions

Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.     

Routine interval appendectomy in children is not indicated

Background

This study evaluates outcomes for children treated without interval appendectomy (IA) after successful nonoperative management of perforated appendicitis.

Methods

A retrospective study of pediatric patients with appendicitis was performed from 12 regional acute-care hospitals from 1992 to 2004 with mean length of follow-up of 7.5 years. Main outcomes were recurrent appendicitis and cumulative length of hospital stay.

Results

The study included 6439 patients, of which 6367 (99%) underwent initial appendectomy. Seventy-two (1%) patients were initially managed nonoperatively and 11 patients had IA. Of the remaining 61 patients without IA, 5 (8%) developed recurrent appendicitis. Age, sex, type of appendicitis, and abscess drainage had no influence on recurrent appendicitis. Cumulative length of hospital stay was 6.6 days in patients without IA, 8.5 days in patients with IA, and 9.6 days in patients with recurrent appendicitis.

Conclusion

Recurrent appendicitis is rare in pediatric patients after successful nonoperative management of perforated appendicitis. Routine IA is not necessarily indicated for these children.     

Laparoscopic placement of peritoneal dialysis catheters in children

Background

Peritoneal dialysis (PD) is preferred over hemodialysis. The aim of this study was to evaluate our experience with laparoscopic PD catheter placement and omentectomy in children.

Methods

We reviewed all children (N = 21) who underwent laparoscopic placement of PD catheters and omentectomy. Ages ranged from 3 months to 16 years. Five children had previous major abdominal surgery and required extensive lysis of adhesions. During the same intervention, other surgical procedures were performed using laparoscopy or open technique, including umbilical hernia repair in 3, bilateral inguinal hernia repair in 3, ventral hernia repair in 2, gastrostomy in 4, kidney biopsy in 2, and cholecystectomy in 1.

Results

Thirteen children received successful kidney transplantation and no longer needed dialysis. Two children still have functioning PD catheters. One patient developed membrane failure and was converted to hemodialysis. Four patients recovered enough renal function and no longer need dialysis. There were no complications related to the laparoscopic procedure.

Conclusion

Laparoscopy is ideal for PD catheter placement. It facilitates omentectomy, and it allows for the catheter to be placed in the proper position under direct vision and for lysis of adhesions to increase peritoneal surface. Other abdominal procedures can be performed laparoscopically at the same time.