Laparoscopy for Acute Abdominal Conditions

50th Meeting of the Brazilian Association of Pediatric Surgeons

George W. Holcomb, III, M.D., MBA

Surgeon-in-Chief

Children’s Mercy Hospital

Kansas City, Missouri

Acute Abdominal Conditions

• Abdominal trauma

• Small bowel obstruction

• Intestinal perforation – free air

• Ovarian torsion

• Volvulus

• Intussusception

and . . . .

Acute Appendicitis

Laparoscopy -TraumaBackground

• Most intra-abdominal (and intra-thoracic) injuries can be

managed non-operatively

• Absolute indications for operation:

Shock from intra-abdominal bleeding

Pneumoperitoneum

Contrast extravasation

• Selective indications for operation

Thickened bowel loops

Mesenteric infiltration

Unexplained free fluid

Violation peritoneum on local exploration for penetrating trauma

Laparoscopy - TraumaBackground

• FAST & DPL not as helpful in deciding management in children

• Equivocal findings for an injury are sometimes found on CT scan

When To Use Laparoscopy

in Trauma

• Hemodynamically

stable patient

• Blunt trauma

Free fluid not from solid

organ injury

Persistent abdominal

pain/tenderness

• Penetrating trauma

Peritoneal violation?

Algorithm

Gaines BA, et al: The role of laparoscopy

in pediatric trauma. Sem Pediatr Surg

19:300-303, 2010

Minimally Invasive Surgery for Pediatric

Trauma – A Multi-Center Review

1. The Children’s Mercy Hospital, Kansas City, MO

2. Emory University, Children’s Healthcare of Atlanta at Egleston, Atlanta, GA

3. Children’s Medical Center, Dallas, TX

4. Children’s National Medical Center, Washington, DC

5. Children’s Hospital of Wisconsin, Milwaukee, WI

6. Akron Children’s Hospital, Akron, OH

2014 IPEG/BAPS Meeting

Hanna Alemayehu, MD1 Matthew Clifton, MD2; Matthew Santore,

MD2; Diana Diesen, MD3; Timothy Kane, MD4; Mikael Petrosyan,

MD4; Ashanti Franklin, MD4; Dave Lal, MD, MPH5; Todd Ponsky,

MD6; Margaret Nalugo, MPH6; George W. Holcomb III, MD, MBA1;

Shawn D. St. Peter, MD1

Operative Interventions

• 205 total MIS procedures

187 patients (94%) – laparoscopy

8 patients (4%) – thoracoscopy

5 patients (2%) – both

• 36% converted to open

Indications for LaparoscopyIndication for Operation Number Completed

Laparoscopically

Number

Converted to

Laparotomy

Total

Number

Conversion

Rate

Penetrating Injury 45 17 62 27%

Peritonitis 7 24 31 77%

Free fluid with abdominal pain 17 10 27 37%

Pneumoperitoneum 9 9 18 50%

Other 15 3 18 16%

Worsening abdominal pain with

seatbelt sign

8 3 11 27%

Imaging suspicious for hollow

viscus injury

5 6 11 55%

Imaging suspicious for pancreatic

duct injury

7 0 7 0%

Equivocal wound exploration 6 0 6 0%

Continued transfusion

requirement

1 0 1 0%

Conclusion

• Overall MIS was successful in excluding or

diagnosing injury, and completing therapeutic

intervention in 65% of cases

• Laparoscopy and thoracoscopy can be

performed safely and effectively for both

diagnostic and therapeutic purposes in stable

pediatric trauma patients

Pediatr Surg Int. 2014 Sep 21(epub ahead of print)

Laparoscopic Pancreatic

Resection forTrauma

• 2000 – 2012

• 13 US pediatric trauma centers

• 167 patients

95 managed nonoperatively

57 underwent resection

80% laparoscopically since 2008

Pediatr Surg Int. 2014 Sep 21

(epub ahead of print)

Laparoscopic Traumatic

Diaphragmatic Hernia Repair

Laparoscopic Traumatic

Diaphragmatic Hernia Repair

Laparoscopy forPossible Traumatic Bowel Injury

Laparoscopy for Possible Traumatic

Bowel Injury

Laparoscopy for

Penetrating Traumatic Injury

Conclusions

• Laparoscopy can be a useful tool for diagnosis

of a traumatic injury when the diagnosis is not

clear

• Some traumatic injuries can be managed

entirely laparoscopically or with the use of a

small umbilical incision

• Patient must be hemodynamically stable if the

laparoscopic approach is utilized

Laparoscopy for Small Bowel

Obstruction• Jan 01 – Dec 08

• 34 patients

Mean age 8.1 yrs ± 5.9

Adhesions – 74%

Conversion – 11 pts

Inadeq working space

Volvulus

Could not identify source

Enterotomy

Our protocol: Initial laparoscopic management unless contraindications present

Laparoscopy for Small Bowel

Obstruction

Intestinal Perforation – Free Air

• Patient hemodynamically stable

• Reason for perforation unclear

• Allows directed open incision (if necessary)

Laparoscopy for Ovarian Torsion

Emphasis Now On Conservation Of Ovarian Tissue

• Long-term results of conservative management of

adnexal torsion in children

J. Pediatric Surgery (2005) 40: 704– 708

• Ovarian torsion in children: Management and

outcomes

J. Pediatric Surgery (2013) 48: 1946–1953

• Predominant etiology of adnexal torsion and ovarian

outcome after detorsion in premenarchal girls

Eur. J. Pediatric Surgery (2010) 20: 298 – 301

Laparoscopy for Malrotation -

Volvulus

• Hemodynamically stable

patient

• Difficult to reduce

volvulus in an infant (not

enough working space)

• Laparoscopy very good

for pt with malrotation

but no volvulus

• 1996 – 2009

• 284 Ladd procedures

Open – 241

Laparoscopic - 43

• Laparoscopic –

33% conversion – almost all

due to volvulus

• Recurrent volvulus – 6 pts

(2.4%) - all s/p open Ladd

procedure

Laparoscopy for Intussusception

• Hemodynamically stable

infant

• Our usual initial approach

• Convert if unsuccessful

• 5 mm atraumatic clamps

position across width of

bowel

• 1998 – 2008

• 22 pts (2.9 yrs, mean)

19 ileocolic

3 small bowel

• 20 pts successfully managed laparoscopically or via extending

umbilical incision ( 9 pts 7 bowel resections)

• 2 required RLQ laparotomy

Acute Appendicitis

1. When do we operate?

2. How do we define perforation?

3. What is the incidence of a postoperative

abscess?

4. Should we irrigate the abdomen?

5. Is there an advantage to a single

umbilical laparoscopic approach?

1. When to operate?Current Practice at CMH

• Patients identified with appendicitis are booked for laparoscopic appendectomy

• All receive a dose of rocephin (50mg/kg) and flagyl(30mg/kg)

• This antibiotic regimen was shown to be most cost effective in PRT

• If patients present at night, the operations are scheduled for the ‘surgeon of the week’ the next day (8 am or 1 pm start)

• Appendectomies rarely occur after 10 PM at night

Non-Operative Mgmt

• Non-operative management with antibiotics for

both acute and perforated appendicitis in

adults is successful as primary, definitive

therapy in up to 70% of patients.

• About 20-30% will fail antibiotic management

and will need an operation

• Appendectomy is now probably considered the

gold standard of treatment options, but unclear

if this will change in the next 10 years.

Operation At Presentation Versus The

Following Day

Yardeni D, Hirschl RB, Drongowski RA, et al: Delayed versus immediate

surgery in acute appendicitis: Do we need to operate during the night? J

Pediatr Surg 39:464–469, 2004.

• Retrospective comparison in children (Level 3 study) between operation < 6 hrs after presentation or the following day

• 126 patients (38 early vs 88 late)

• No differences in operating time, perforation rate, or complications

• The literature is replete with retrospective studies

regarding perforated appendicitis

• All of these studies fail to strictly define perforation

Dependent on surgeon’s definition

“Gangrenous”, “suppurative”, “perforated”

• Therefore, the conclusions from these retrospective

reports must be approached cautiously

2. How do we define perforated appendicitis?

J Pediatr Surg 43:2242-2245, 2008

Visible appendicolithHole in appendix

Definition of Perforation Used in Prospective Randomized Trial

3. What is the incidence of

postoperative abscess?

• Acute, non-perforated appendicitis

609 pts (Apr 03 – Nov 06)

3 postop abscesses (0.49%)

• Perforated appendictis

20%

4. Should we irrigate and suction

the abdominal cavity for

perforated appendicitis?

• Perforated appendicitis: hole in appendix or fecalithin abdomen

• Minimum irrigation 500 cc saline

ResultsPatient Demographics

No Irrigation(n = 110)

P Value

Age (years)

Weight (kg)

BMI (%tile)

Gender (% male)

9.7 +/- 3.6

41.2 +/- 19.8

65.0 +/- 32.3

59.1%

10.4 +/- 3.8

41.5 +/- 18.8

60.7 +/- 31.9

52.7%

0.17

0.92

0.36

0.89

Irrigation(n = 110)

ASA 2012

Ann Surg 256:581-585, 2012

ResultsOutcomes

No Irrigation(n = 110)

Abscess (%)

Op Time (mins)

Initial PO’s (days)

Reg Diet (hrs)

Narcotic Doses

Days of Stay

Charges ($K)

P Value

19.1%

38.7 +/- 14.9

2.6 +/- 1.5

3.4 +/- 1.7

11.4 +/- 5.4

5.5 +/- 3.0

48.1 +/- 20.1

18.3%

42.8 +/- 16.7

2.5 +/- 1.3

3.5 +/- 1.5

11.6 +/- 6.3

5.4 +/- 2.7

48.1 +/- 18.2

1.0

0.06

0.70

0.63

0.76

0.93

0.97

Irrigation(n = 110)

ASA 2012

Ann Surg 256:581-585, 2012

Conclusions

There is no advantage to irrigation of the

peritoneal cavity over suction alone during

laparoscopic appendectomy for perforated

appendicitis

ASA 2012

Ann Surg 256:581-585, 2012

5. Is a single umbilical laparoscopic approach advantageous?

Prospective Randomized Trial

• 360 total patients

• Acute non-perforated appendicitis

• August 09 – November 10

• Primary outcome variable – postoperative wound

infection

• Standardized pre and postoperative management

• Quality of life surveys at 6 weeks and 6 months

Single Umbilical Incision vs 3-PortLaparoscopic Appendectomy

ASA 2011

Ann Surg 254:586-590, 2012

Patient Characteristics at Operation

Single Incision

(N=180)

3-Port

(N=180)

P-value

Age (yrs) 11.05 ± 3.47 11.04 ± 3.41 0.98

Weight (kg) 42.7 ± 18.5 42.5 ± 17.4 0.90

Gender (% male) 54.4% 51.1% 0.53

Leukocyte count 14.7 ± 5.2 14.6 ± 5.4 0.89

ASA 2011

Ann Surg 254:586-590, 2012

Outcome Data

Single

Incision

(N=180)

3-Port

(N=180)

P-

value

Wound Infection 3.3% 1.7% 0.50

Operative Time (mins) 35.2 ± 14.5 29.8 ± 11.6 <0.001

Postoperative Length

of Stay (hours)22.7 ± 6.2 22.2 ± 6.8 0.44

Hospital Charges ($) 17.6K ± 4.0K 16.5 ± 3.8K 0.005

ASA 2011

Ann Surg 254:586-590, 2012

Other OutcomesSingle Site

(N=180)

3-Port

(N=180) P-

Value

Surgical Difficulty

(1 – Easy to 5 –

Difficult)

2.3 +/- 1.4 1.7 +/- 1.0 < 0.001

Abscess 0.0% 0.6% 0.99

Time to Liquid Diet

(Hours)

4.1 +/- 3.7 3.7 +/- 3.1 0.25

Time to Regular Diet

(Hours)

7.2 +/- 5.1 6.9 +/- 5.2 0.48

Total Doses of

Analgesics

9.6 +/- 4.9 8.5 +/- 4.3 0.04

ASA 2011

Ann Surg 254:586-590, 2012

QUESTIONS

www.cmhclinicaltrials.com

www.cmhmis.com