Laparoscopic appendectomy for simple and perforated appendicitis in children: The procedure of choice?

doi:10.1053/jpsu.2000.18319

Journal of Pediatric Surgery

Volume 35, Issue 11, November 2000, Pages 1582-1585

Presented at the 33rd Annual Meeting of the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, May 15-19, 2000.

https://doi.org/10.1053/jpsu.2000.18319 Get rights and content

Abstract

Background/Purpose: Whether laparoscopic appendectomy (LA) is superior to open appendectomy (OA) for simple (SA) and perforated appendicitis (PA) in children is debatable. The operative experience of 4 senior pediatric surgeons at a single institution was studied over a 6-year period during a transition from OA in all cases to LA in all cases, to answer this question. Methods: All appendectomies from December 1993 to December 1999 were reviewed for operative technique (OA, LA), presence of perforation (SA, PA), operating time (OT), length of stay (LOS), morbidity, and mortality. Results: There were 1,128 appendectomies in children aged 14 months to 19 years, including 955 LA (653 in SA, 302 in PA) and 173 OA (86 in SA, 87 in PA). OT was equal for LA and OA in SA (52 minutes), but has dropped to less than 40 minutes for LA in the past year. OT in PA was slightly longer in LA versus OA (68 v. 58 minutes; P <.001) but recently has dropped in LA to less than 60 minutes. LOS in SA was 2 days for LA and 3 days for OA; in PA, LOS was 7 days in both LA and OA, but has dropped to 5 days for LA recently. Postoperative abscess rates and incidence of bowel obstruction did not differ between LA and OA in either group. There was no mortality. Conclusions: LA is at least as safe and effective as, if not superior to, OA for both simple and perforated appendicitis. Postoperative pain is less, and recovery is faster, thereby reducing LOS and overall cost. The growing demand for this procedure can be satisfied without increase in cost, morbidity, or mortality. Laparoscopic appendectomy is our procedure of choice in children. J Pediatr Surg 35:1582-1585. Copyright © 2000 by W.B. Saunders Company.

Section snippets

Materials and methods

The records of all patients undergoing appendectomy by 4 surgeons at the San Diego Children's Hospital from December 1993 to December 1999 were analyzed with regard to operative technique (LA v. OA), presence of perforation (SA v. PA), operating time (OT), length of stay (LOS), morbidity, and mortality. Return to normal function was not studied separately, as in children, this occurs on or shortly after discharge. The conversion from LA to OA was noted. The determination of perforation was

Results

There were 1,128 appendectomies performed in children aged 14 months to 19 years. LA was performed in 955 patients including 653 for SA and 302 for PA. OA was performed in 173 patients, including 86 for SA and 87 for PA. OA was performed in over 80% of cases in the initial year of study (1993 to 1994); from 1994 to 1995, LA became increasingly common (>50%), and by 1996 was the initial technique of choice. The last elective OA was in mid 1996. There have been 10 cases of conversion from LA to

Discussion

Laparoscopic techniques have the potential of offering many benefits to children for an increasing number of procedures. They are certainly less traumatic, cause less pain, result in faster recovery and return to normal function, and produce significantly less abdominal scarring both internally and externally. These “truths” have been well documented for laparoscopic appendectomy in many studies for both children and adults and certainly in this large single institution study.1, 3, 4, 5, 6, 7, 8

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Cited by (103)

The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review
2024, Journal of Pediatric Surgery
Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach.
A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769).
Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35–2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)).
Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing.
Level II.
Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis
2022, Journal of Pediatric Surgery
Citation Excerpt :
There is high risk of statistical heterogeneity for the combined analysis (I2 = 58%; p < 0.0001) as well as for the RCT subgroup analysis (I2 = 90%; p < 0.0001). 23 studies (2 RCTs [26,28] and 21 CCTs [5,22,31,32,34–36,38,39,45,47,49,51–54,56,57,59,60,62]) reported the overall complication rate in the LA and OA groups, respectively (Fig. 5). The incidence of complications occurring after LA was 18.63% (232 out of 1245 cases) and in OA, it was 30.26% (367 out of 1213 cases).
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.
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.
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.
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.
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.
Adhesive small bowel obstruction after appendectomy in children – Laparoscopic versus open approach
2020, Journal of Pediatric Surgery
The aims of this study were to compare the incidence of small bowel obstruction (SBO) requiring laparotomy after laparoscopic appendectomy (LA) and open appendectomy (OA) in children and to identify risk factors for SBO.
Medical records of patients who underwent appendectomy from 2000 to 2014 at our department of Pediatric Surgery were reviewed. Risk factors were analyzed using Cox proportional hazard regression.
Totally 619 out of 840 patients were included. OA was performed in 474 (76.6%), LA in 130 patients (21%), and 15 (2.4%) were converted from LA to OA. Age, sex and proportion of perforated appendicitis were comparable in the LA and OA groups. Median follow-up time was 11.4 years (2.6–18.4). The incidence of SBO after LA was 1.5%, after OA 1.9% and in the converted group 6.7% (p = 0.3650). There were no significant differences in the incidence of postoperative intraabdominal abscess, wound infection or length of stay between LA and OA. Perforation and postoperative intra-abdominal abscess were identified as risk factors with 9.03 (p < 0.001) and 6.98 (p = 0.004) times higher risk of SBO, respectively.
The risk for SBO after appendectomy in children was significantly related to perforated appendicitis and postoperative intra-abdominal abscess and not to the surgical approach.
Level III.
Pediatric appendectomy in developing countries: How does it differ from international experience?
2020, International Journal of Pediatrics and Adolescent Medicine
A review of the English literature indicates the faint superiority of laparoscopic (LA) over open appendectomy (OA) in the pediatric population; however, a developing-country’s experience in the field is not available yet. This study presents our experience in LA versus OA over the last 7 years in one university hospital in Lebanon and compares our results to the international ones.
A single center retrospective study was done including all patients aged less than 15 years who underwent appendectomy. A description of each operative technique is presented. Patients’ characteristics, intraoperative finding, operative timing (OT), length of stay (LOS) and short term postoperative complications including surgical site infection (SSI) rate, intra-abdominal abscess formation (IAA) rate and reoperation rate were all studied. Statistical analysis was done using Chi-square or Fisher’s exact test, as for continuous, Student’s t test was used or one-way ANOVA in case of more than 2 categories.
Appendectomy was performed in 84 patients. 52 patients underwent OA through a Rocky Davis incision, and 32 patients underwent a LA. We found an advantage of LA over OA in reducing SSI, otherwise both approaches were similar.
In accordance with international results, in our experience, LA is superior to OA only with regards to SSI.
Current practice patterns for postoperative activity restrictions in children
2019, Journal of Pediatric Surgery
Postoperative activity restrictions are designed to prevent undue stress on a recent repair and minimize the risk of surgical complication, however, there is little evidence to support certain restrictions in clinical practice. For the pediatric population, there is a paucity of formal evaluations of postoperative activity restrictions, and little is known about current practice patterns among pediatric surgeons. This study aimed to describe national practice patterns of pediatric surgeons for postoperative activity recommendations following three common general surgical procedures.
A 7-item survey was sent to all American Pediatric Surgical Association (APSA) members regarding surgeon practice of recommended activity restrictions for school attendance, participation in playground or gym, participation in contact sports, and heavy lifting in children following 3 procedures: exploratory laparotomy, laparoscopic appendectomy, and inguinal hernia repair. Information on type and duration of clinical practice was also collected for each surgeon. Descriptive and bivariate analyses were performed.
The survey was completed by 293 pediatric surgeons for a response rate of 28.9%. There was wide national variability in the recommended activity restrictions for children < 12 years old among pediatric surgeons. Following laparoscopic appendectomy, 30.7%, 51.9% and 47.8% of surgeons recommends restriction of gym, contact sports, and heavy lifting for 2–3 weeks respectively, but 26.7%, 19.8%, and 22.2% do not recommend any restriction whatsoever of these three activities. Following inguinal hernia repair, 31.7%, 49.1% and 44.4% of surgeons recommend restriction of gym, contact sports, and heavy lifting for 2–3 weeks, but 30.8%, 30.8%, and 29.2% do not recommend any restriction of these three activities. Only 22% of surgeons change their activity restriction recommendations for children ≥ 12 years old, this decision was not associated with surgeon years in practice or type of practice.
There is considerable variability in surgeon recommendations for activity restrictions following three general surgery procedures in children. While activity restrictions are rooted in the physiology of wound healing, there is little evidence to support the benefit of these restrictions in clinical practice. In addition, activity restriction may have unintended deleterious effects on a child's psychosocial well-being and quality of life. Further investigation should be pursued to understand the utility of activity restrictions in children and their impact on clinical outcomes and patient quality of life.
Treatment study.
Level V, expert opinion.
Gangrenous appendicitis: No longer complicated
2019, Journal of Pediatric Surgery
Citation Excerpt :
The care of children with appendicitis has undergone a significant evolution over the past two decades. Despite initial concerns for increased risk of intraabdominal abscess formation in cases of perforated appendicitis, most appendectomies are safely performed laparoscopically [10,11]. Furthermore, multiple recent studies suggest that acute uncomplicated appendicitis can be successfully managed nonoperatively with antibiotics alone [1].
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.
In February 2016, we strictly defined complex appendicitis as a hole in the appendix, extraluminal fecalith, diffuse pus or a well-formed abscess. We switched gangrenous appendicitis to a simple pathway and reviewed all patients undergoing laparoscopic appendectomy for 12 months before (Group 1) and 12 months after (Group 2) the protocol change. Data collected included demographics, appendicitis classification, LOS, presence of a postoperative infection, and 30-day readmissions.
Patients in Group 1 and Group 2 were similar, but more cases of simple appendicitis occurred in Group 2. Average LOS for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (p < 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses.
Gangrenous appendicitis can be safely treated as simple appendicitis without increasing postoperative infections or readmissions.
Prognosis study.
Level II.

View all citing articles on Scopus

^☆: Address reprint requests to Timothy G. Canty, Sr, MD, 3030 Children's Way, Suite 401, San Diego, CA 92123.

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Laparoscopic appendectomy for simple and perforated appendicitis in children: The procedure of choice?☆

Abstract

Section snippets

Materials and methods

Results

Discussion

J Pediatr Surg

J Pediatr Surg

Semin Pediatr Surg

Am J Surg

J Pediatr Surg

J Pediatr Surg

Am J Surg

Am J Surg

J Pediatr Surg

Laparoscopic appendectomy versus open appendectomy: A single institution study

J Soc Laparoendosc Surg

Laparoscopic appendectomy in children

Semin Laparosc Surg