|Year : 2022 | Volume
| Issue : 2 | Page : 59-62
Role of laparoscopy in complicated appendicitis in children: A 5-year single-center experience
Pramod S1, Tejashwini K2
1 Department of Pediatric Surgery, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
2 Department of Community Medicine, Dr. B. R. Ambedkar Medical College, Bengaluru, Karnataka, India
|Date of Submission||22-May-2022|
|Date of Acceptance||06-Jun-2022|
|Date of Web Publication||16-Nov-2022|
Department of Pediatric Surgery, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Appendicitis is one of the most common surgical emergencies among children. Approximately 30% of children present to the hospital with complicated appendicitis, which is associated with higher morbidity than simple appendicitis. Controversy exists in the treatment of complicated appendicitis in the pediatric age group. The goal of this study was to review the results of laparoscopic surgery in complicated appendicitis in terms of safety, efficacy, and complicationsMaterials and Methods: A retrospective observational study was conducted in a tertiary care hospital in Bangalore from 2015 to 2020 over a period of 5 years. All children who underwent laparoscopic surgery for complicated appendicitis (perforated, gangrenous, and mass) were included in the study. Thorough history with respect to symptoms and their duration were recorded followed by general and abdominal examination. Routine blood investigation and imaging were done before surgery. Intraoperative data regarding the type of complication, presence or absence of fecolith, and position of appendix were documented. Postoperatively duration of stay and complications were analyzed. Results: Sixty cases were included in the study. The mean age of presentation was 10.11 ± 0.855 years. Of 60 children, 53 were males and 7 were females. The mean operative time was 55.8333 ± 4.806 min. The rate of conversion from the laparoscopy to open surgery was 11.5%. The mean time of duration of intravenous antibiotics was 4.2778 ± 0.446 days. The mean time for starting of oral feeding was 2.8333 ± 0.307 days. The mean duration of hospital stay was 5.11 ± 0.545 days. Wound infection in the immediate postoperative period was seen in 6.6% of the children. No long-term complications were noted. Conclusion: Laparoscopic appendectomy (LA) for complicated appendicitis is safe and effective. Therefore, it should be the first choice for cases of complicated appendicitis in children.
Keywords: Complicated appendicitis, laparoscopy, post operative complication
|How to cite this article:|
Pramod, Tejashwini. Role of laparoscopy in complicated appendicitis in children: A 5-year single-center experience. D Y Patil J Health Sci 2022;10:59-62
|How to cite this URL:|
Pramod, Tejashwini. Role of laparoscopy in complicated appendicitis in children: A 5-year single-center experience. D Y Patil J Health Sci [serial online] 2022 [cited 2022 Nov 27];10:59-62. Available from: http://www.dypatiljhs.com/text.asp?2022/10/2/59/361367
| Introduction|| |
Acute appendicitis in children is one of the most common surgical emergencies. Its incidence peaks between the ages of 11 and 12 years, and it has a lifetime risk of 7%–9%. Children experience the greatest risk of disease, and incidence among children is four times greater than the overall population..
Appendicitis is often categorized as uncomplicated (early, inflamed, and simple) or complicated (gangrenous, perforated appendicitis with abscess/phlegmon, or perforated appendicitis without abscess/phlegmon). Complicated appendicitis is found in up to 30% of patients treated operatively and represents a particularly resource-intensive condition.
Children with complicated appendicitis have a longer length of stay (LOS), greater hospital cost, and higher risk of subsequent hospital visits compared with those with uncomplicated disease. Despite significant advancements in the diagnostic evaluation of children with suspected appendicitis during the past few decades, the rates of complicated appendicitis have remained unchanged.
Since the first laparoscopic surgery for appendicitis in 1983, it has been established as the gold standard surgery for simple appendicitis. There are several hypothetical advantages of the laparoscopic approach in complicated appendicitis. It facilitates evaluation of the entire abdominal space, and diminishes the operative trauma and meticulous peritoneal lavage. The role of laparoscopic surgery in the treatment of complicated appendicitis has been more controversial. Compared with open appendectomy (OA), laparoscopic appendectomy (LA) needs higher technical skills, longer operative time, and is associated with a higher incidence of intra-abdominal collections. More recent studies have reported the safety and feasibility of this procedure is complicated appendicitis, with a low incidence of infectious complications.
The goal of this study was to review the results of laparoscopic surgery in complicated appendicitis in terms of safety, efficacy, and complications.
| Materials and Methods|| |
This was a retrospective observational study conducted in a tertiary hospital, Bengaluru over a period of 60 months from 2015 to 2020. All children diagnosed with complicated appendicitis (perforated, gangrenous, and mass) were included in the study. Children with simple appendicitis were excluded from the study.
The data of children with respect to age, sex, symptoms, and their duration were tabulated. The clinical, biochemical, and imaging findings were documented. In all the children, blood counts and renal function test were done. Initially, all children had an ultrasonography (USG) of the abdomen and pelvis. In children where ultrasonography was inconclusive, computed tomography of the abdomen was done.
Children underwent surgery within 24 h of admission after all the routine investigation. Informed consent about the procedure was taken (parents/guardians). All the children received preoperative antibiotics, combination of first-generation cephalosporin, amikacin, and metronidazole.
LA was done by standard three-port technique. Port sites were infraumbilical, left and right iliac fossa. Similar to open technique, pus was drained followed by appendectomy and lavage. In all the children a drain was placed which was subsequently removed in postoperative period.
Intraoperative findings in terms of type of complicated appendicitis, position of appendix, and presence of appendicolith were documented. Primary outcome with respect to complication was assessed. Secondary outcomes were duration of intravenous antibiotics, resumption of oral diet, and the LOS. The follow-up period ranged from 6 months to 5 years. Immediate and late complications in each group were evaluated (with follow-ups and telephonic contacts). All the data collected were entered into a Microsoft Excel sheet and a suitable analysis was carried out.
| Results|| |
During the study period, 200 children underwent LA for appendicitis. Of 200 children, 60 children underwent the laparoscopic procedure for complicated appendicitis.
Mean duration of pain at the time of presentation was 2.88 ± 0.342 days and the mean total leukocyte count was 14,125.22 ± 1234.47.
The cases were further divided into four groups according to the operative findings: group 1––perforation with localized abscess, group 2––perforation with generalized abscess, group 3––appendicular mass, and group 4––gangrenous appendix. The distribution of operative findings is presented in [Table 1]. The data with respect to position of the appendix are tabulated in [Table 2]. Twelve children had fecolith.
The mean operative time was 55.83 ± 4.80 min.
Rate of conversion
The rate of conversion from the laparoscopic approach to the open approach was 11.5% (seven cases). In five cases, conversion was due to dense adhesions of small-bowel loops forming a mass. In two cases, the appendix was retrocaecal and plastered to the lateral abdominal wall and the caecum. In view of chances of injuring the caecum decision to convert to open was taken.
Duration of intravenous antibiotics, oral feeding, hospital stay
The mean time of duration of intravenous antibiotics was 4.27 ± 0.4 days. Mean time for starting of oral feeding was 2.83 ± 0.31 days. Mean duration [Table 3][Table 4][Table 5] of hospital stay was 5.1 ± 0.5 days (range 3–10 days).
Early and late complications
The incidence of early and late complications is shown in [Table 6]. Four patients (6.6%) had early postoperative complications in the form of wound infection. All these patients were treated conservatively with regular dressing. No patient presented with features of adhesive obstruction on long-term follow-up.
| Discussion|| |
A lot of controversies do exist in the management of children with complicated appendicitis. These include the type of antibiotics, conservative management, only drainage of abscess and later appendectomy, and skin closure. Added to these controversies is the role of laparoscopy in complicated appendicitis in children.
Frazee and Bohannon were among the first to conclude that LA is safe and beneficial for patients with complicated appendicitis
Laparoscopy is now shown to be the optimal approach to treat complicated appendicitis, but in very young children this standardized operation is not always easy to perform. Pneumoperitoneum in infants should be of low pressure for possible haemodynamic effects and so the working space could be very limited. Also the use of endoscopic mechanical staplers could be limited by the abdominal cavity dimensions.
Few studies suggested lack of concrete evidence supporting laparoscopic approach for complicated appendicitis.,,, However, others concluded that LA for complicated appendicitis is better than OA(open appendicectomy).,,, In complicated appendicitis, especially in obese children, LA benefits a patient compared with OA because it minimizes the tissues damage and allows better visualization of abdominal spaces and thorough peritoneal irrigation, avoids wound incision and extension, and is associated with less exposure of wound surface to contaminated fluids. There is also reduced postoperative pain, early return to normal daily activity, and of course superior cosmetic results.
Taking in consideration the above-mentioned debate, the aim of our study was to evaluate the efficacy of LA in children with complicated appendicitis in our institution.
The mean age of study subjects in the present study was 10.11 ± 0.855 with a range of 4–15 years. Few studies showed similar age distribution, Saquib et al., in which age of subjects ranged from 3 to 12 years, and Ikeda et al., which ranged from 2 to 15 years with median of 9 years.
The ratio of male to female children were 7.5 males to 1 female which was more compared to other studies: Menezes et al.’s, study, Saquib et al.’s, study, Wang et al.’s study, and Ikeda et al.’s. study. The mean leucocyte count in patients was 14,125.23 ± 1,234.47,similar finding was observed with study by Hackam et al., where the mean total leukocyte count was 18000 per mm3 in his cases.
The mean operative time in our study was 55.83 ± 4.8 min. This was very similar to studies by Khirallah et al. and Li et al., where the mean operative time were 56.41 min and 57.94 min, respectively. Few other studies have reported longer duration of surgery, Ikeda et al., and Moraitis et al., which showed average time of 87.3 ± 9.1 min, and 129.5 ± 13.6 min, respectively. This difference could be attributed to the difference in the level of laparoscopy skills.
Our patients, who underwent LA were able to start oral intake within 2.83 ± 0.3days. This is in agreement with L. R. Padankatti et al., in which feeds were established in 2.5 days in the LA group and to Saquib et al., who reported the mean time until return to normal diet was 1.8 ± 0.6 days.
Our study also showed that the mean duration of hospital stay in the LA group (5.11 ± 0.5),this was comparable with other studies like Meguerditchian et al., who reported postoperative hospital stay of 2.33 ± 1.23 day. Hackam et al. found that the mean length of post-operative hospital stay was 5.95 ± 1.56 days, whereas Moraitis et al. found that the mean length of post-operative hospital stay was 3.58 ± 1.98 days in cases of complicated perforating appendicitis, and Menezes et al. found the mean length of post-operative hospital stay was 7.36 ± 2.1 days.
Many studies found that LA markedly reduced the postoperative wound infection rate when compared with OA (1.3 vs. 12.5%).,, No case in our study had post operative intra-abdominal abscess. Many studies like Hackam et al., Ikeda et al., and Meguerditchian et al. have had few cases of intra- abdominal abscess. Thorough intra-abdominal lavage post surgery and drain placement might be the reason for absent post operative abscess in our study. The overall incidence of postoperative complications in our study was 6.6%.
| Conclusion|| |
It can be concluded that laparoscopic approach could be used in cases of complicated appendicitis. LA for complicated appendicitis is safe and effective. It is associated with lesser mean operative time, early start of oral feeds, low incidence of infectious complications and short duration of hospital stay. Therefore, it can be considered as the first choice for cases of complicated appendicitis in children.
The authors sincerely thank all our study subjects and their guardians and all the Hospital staff who helped in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]