www.elsevier.com/locate/jpedsurg

Ten-year experience with pediatric laparoscopicappendectomy—are we getting better?

Stephanie Phillips, J. Mark Walton*, Ian Chin, Forough Farrokhyar,Peter Fitzgerald, Brian Cameron

Division of Pediatric Surgery, McMaster Children’s Hospital, Hamilton, Ontario, Canada L8N 3Z5

0022-3468/$ – see front matter D 2005

doi:10.1016/j.jpedsurg.2005.01.054

Presented at the 36th Annual Meet

of Pediatric Surgeons, Winnipeg, Ma

October 3, 2004.

T Corresponding author.

Index words:Laparoscopic;

Appendectomy;

Pediatric

AbstractBackground/Purpose: The purpose of this study was to compare our initial (1994-1997) and recent

(2001-2003) experiences in laparoscopic appendectomy (LA).

Methods: A 2-year (2001-2003) retrospective chart review of cases of appendicitis was performed and

compared with data obtained from 1994 to 1997 cases. Operating and anesthetic times as well as

postoperative outcomes were analyzed. Cases of conversion to open appendectomy were included in

the analysis.

Results: Two hundred and thirty-three LA cases from 2001 to 2003 were compared with 119 cases

from 1994 to 1997. Operating time decreased significantly from 58 to 47 minutes in acute appendicitis

(AA) and from 80 to 58 minutes in perforated appendicitis (PA). Anesthetic time decreased

significantly in both AA (82 to 71 minutes) and PA (106 to 84 minutes). There were significant

decreases in the conversion rate in PA (23.4% to 3.5%), although no change was seen in AA. In PA, the

incidence of postoperative abscess decreased from 36.2% to 16.5%. There was no significant decrease

in length of stay, amount of analgesia used, time to resume regular diet, or incidence of wound

infections and bowel obstructions.

Conclusions: Ten years of experience in LA has resulted in decreases in anesthetic and operating times

for AA and PA as well as decreases in the incidence of abscesses and conversion rates.

D 2005 Elsevier Inc. All rights reserved.

Since Semm [1] first described laparoscopic appendec-

tomy (LA) in 1983, there has been an ongoing debate

among pediatric surgeons regarding perceived benefits vs

risks. Some advocate that the advantages of LA include

better exposure, increased diagnosis of other intraabdominal

Elsevier Inc. All rights reserved.

ing of the Canadian Association

nitoba, Canada, September 30-

pathologies, efficient intraperitoneal lavage, decreased

length of stay (LOS), earlier resumption of diet, and

reduced need for analgesia [2-4]. Others remain skeptical,

citing increased vascular and bowel injuries, stump release,

longer operating and setup times, more frequent complica-

tions (especially abscesses), more expense, and fewer

opportunities to perfect these skills in the pediatric

population [5]. Most agree that these negative aspects

should decrease with increased time and practice. In this

study, we compare our initial (1994-1997, group A) and

Journal of Pediatric Surgery (2005) 40, 842–845

Table 1 Demographic data for AA and PA

AA PA

1994-1997 2001-2003 1994-1997 2001-2003

n 72 148 47 85

M/F

ratio

44:28 92:56 26:21 50:35

Age (y) 10.8 F 2.7 11.2 F 3.1 10.2 F 3.9 9.5 F 3.8

Wt (kg) 41.5 F 15.5 44.3 F 16.6 42.6 F 18.5 38.0 F 16.6

No statistical difference between groups.

Ten year experience with pediatric laparoscopic appendectomy 843

recent (2001-2003, group B) experiences with LA to

evaluate our progress.

1. Methods

The records of all patients aged 0 to 18 years who

underwent appendectomy at the McMaster Children’s

Hospital between June 2001 and July 2003 were retros-

pectively reviewed. Incidental appendectomies (during

malrotation or bowel resection) as well as interval appen-

dectomies were excluded. Cases of LA converted to

open appendectomy were included in the analysis. Data

from 1994 to 1997 were also reviewed and included

for comparison.

The data collected included patient demographics,

surgical and anesthetic times, procedure type, and intra-

operative findings. Postoperative data included LOS,

complications, and time to resume clear fluids and regular

diet. Patients were given morphine, demerol, or codeine for

pain control, all of which were converted to an analgesia

equivalent using the formula: analgesia (mg/kg) = [(mor-

phine � 10) + demerol + (codeine/1.8)]/weight.

The appendectomies were performed by staff pediatric

surgeons or surgical residents under direct supervision.

Intraoperative nasogastric tubes were not placed routinely

but were used in cases of postoperative ileus until bowel

function resumed. Intraabdominal drains were not placed at

the time of operation but were inserted percutaneously in

cases of postoperative abscess. Postoperative management

for all patients included early ambulation, early enteral

feeding, and adequate analgesia. Postoperative antibiotics

ensured gram-negative and anaerobic coverage; however,

specific antibiotic choices and their duration were dictated

by the clinical picture and preference of the staff surgeon.

Table 2 Operative parameters for AA and PA

AA

1994-1997 (n = 72) 2001-2003 (n = 148)

Anesthetic time (min) 82.0 F 18.2 71.8 F 13.5

Surgical time (min) 58.0 F 17.9 46.7 F 12.9

Conversions

(LA Y OA)

1.48% (1) 0% (0)

Patients were discharged when afebrile, nontender to

abdominal examination, and tolerating regular diet. Fol-

low-up occurred in the pediatric surgery clinic within

2 weeks postdischarge.

A descriptive analysis was performed. The categorical

data were reported as proportions and v2 analysis or

Fisher’s Exact test was used for between-group compar-

isons. The continuous data were tested for normal

distribution. Mean and SD of the mean are reported.

T Test or nonparametric Mann-Whitney test was used for

between-group comparisons whenever appropriate. Cases

of LA converted to open appendectomy were analyzed

with the laparoscopic group. P values less than .05 were

considered for statistical significance. The data were ana-

lyzed using SPSS statistical software (SPSS, Chicago, IL).

2. Laparoscopic technique

Carbon dioxide insufflation was performed using a Veress

needle to a maximum of 12 to 15 mm Hg. A 3-port technique

was used, placing two 5-mm ports in the left lower quadrant

and the suprapubic site and a 10-mm port in the umbilicus. In

the first 3 years (1994-1997), one of the 5-mm ports was

placed in the right midabdomen instead of the suprapubic

position. A 5-mm laparoscope was used. The mesoappendix

was identified, controlled using clips or cautery, and then

divided. The appendiceal base was secured using Endoloops

(Ethicon, Cincinnati, OH) and divided. The appendix was

removed through the 10-mm umbilical port with or without

the use of a laparoscopic retrieval bag. When peritoneal

contamination was present, the abdomen and pelvis were

irrigated with warmed normal saline and then suctioned dry.

3. Results

From June 2001 to July 2003, there were 233 LAs

performed, including 148 cases of acute appendicitis (AA)

and 85 cases of perforated appendicitis (PA). There were

3 cases of conversion to open appendectomy (1.3%) during

the 2001-2003 period, which were included in all analyses.

From 1994 to 1997, there were 119 LAs, including 72 AAs

and 47 PAs. During this period, there were 12 conversions

(10.1%), which were also included in the analysis.

Demographic data including age, weight, and sex showed

no statistical differences between groups (Table 1).

PA

P 1994-1997 (n = 47) 2001-2003 (n = 85) P

.0001 106.8 F 29.5 84.1 F 19.2 .0001

.0001 80.2 F 29.3 58.0 F 19.1 .0001

.151 23.4% (11) 3.5% (3) .0001

Table 3 Postoperative indices

AA PA

1994-1997 (n = 72) 2001-2003 (n = 148) P 1994-1997 (n = 47) 2001-2003 (n = 85) P

LOS (d) 2.4 F 1.1 2.1 F 1.0 .64 8.6 F 6.1 6.3 F 3.3 .175

Clear fluids (POD#) 1.06 F 0.3 0.84 F 0.4 .0001 2.74 F 3.2 1.49 F 1.1 .017

Diet (POD#) 1.7 F 0.8 1.6 F 0.68 .288 4.9 F 3.9 4.2 F 2.1 .886

Analgesia use (mg/kg) 3.6 F 3.1 4.0 F 2.4 .079 15.7 F 13.5 14.1 F 11.2 .919

S. Phillips et al.844

Surgical and anesthetic times have decreased significant-

ly from group A to group B (Table 2). Anesthetic times have

decreased from 82 to 72 minutes (P b .0001) in AA and

from 106 to 84 minutes (P b .0001) in PA. Similarly,

surgical time decreased from 58 to 46 minutes (P b .0001)

in AA and from 80 to 58 minutes (P b .0001) in PA.

Included in the analysis were 3 conversions (3.5%) from LA

to open appendectomy in the PA group during the 2001-

2003 period. These were analyzed in the laparoscopic

group. This number is significantly decreased from the

11 conversions (23.4%; P = .000) that occurred in the PA

group during the 1994-1997 period. Only one conversion

occurred in an AA case that took place in the 1994-1997

period. This occurred because of difficulty in mobilizing the

appendix, although no gross perforation was seen.

Postoperative indices including LOS, days to resume

clear fluids and full diet, and analgesia use showed no

statistically significant changes (Table 3). In both AA and

PA, the LOS remained constant for each group (2.4 to

2.1 days and 8.6 to 6.2 days, respectively) although there was

a trend toward a shorter LOS. Early resumption of clear

fluids was encouraged during postoperative recovery. The

start of clear fluids decreased from 1.06 to 0.84 postoperative

days (P b .0001) in the AA group as most patients began

drinking within the first few hours after surgery. Similarly in

the PA group, the start of clear fluids decreased from 2.74 to

1.49 postoperative days (P = .017). A full diet was started

after 1.6 postoperative days in AA and 4.9 postoperative

days in PA, averages that have remained constant from 1994

to 2003. The amount of demerol, morphine, and codeine

administered was converted to an analgesia equivalent,

which showed little change from group A to group B (PA,

15.7 to 14.1 mg/kg; AA, 3.1 to 4.0 mg/kg).

There were few postoperative complications and no

mortality during both periods (Table 4). From group A to

group B, there were no decreases in the number of wound

infections in both AA and PA (1 to 0 and 4 to 2,

respectively), although the overall incidence was very low

Table 4 Postoperative complications

AA

1994-1997 (n = 72) 2001-2003 (n = 148

Wound infections 1.4% (1) 0%

Postoperative abscess 1.4% (1) 0.68% (1)

Bowel obstructions 0% 0%

in all groups. There was only one case of bowel obstruction,

which occurred in the PA group during the 1994-1997

period. This occurred secondary to an infected omentum

and was relieved by surgical intervention. The incidence of

postoperative ileus was unchanged in both AA and PA. In

AA, there was no decrease in the incidence of postoperative

abscess development (1.4% to 0.6%; P = .6). However, the

incidence of postoperative abscess in the PA group

decreased dramatically from 36.2% to 16.5% (P = .01).

4. Discussion

It is recognized that laparoscopic surgery offers many

benefits over the traditional open appendectomy in postop-

erative course and recovery. Yet in the search for suitable

evidence-based guidelines, the question whether laparo-

scopic surgery can approach or even surpass open appen-

dectomy in operating time, costs, and complications arises.

In the pediatric population, there are few high-quality

randomized control studies that can answer whether the

open or the laparoscopic approach to appendicitis is superior

[5-9]. Among these 5 studies, there were only 436 children

randomized between open and laparoscopic approaches.

Wound infections seem to be more common in the open

appendectomy group, but this was skewed by Yeung et al’s

study [8]. There were no intraabdominal abscesses in 4 of

the 5 randomized studies, making it hard to draw con-

clusions regarding the incidence of intraabdominal abscess-

es in the pediatric population [6-9]. In the other randomized

study, there was only one intraabdominal abscess in each

group [5]. Large retrospective pediatric studies have

reported good results with LA but have no control groups.

One series of 1379 cases reported only 4 postoperative

intraabdominal abscesses [4]. In this series, there were

9 conversions to laparotomy (b0.7%). However, we decided

to look at our own experience to assess the long-term

refinement in the laparoscopic approach for appendicitis to

PA

) P 1994-1997 (n = 47) 2001-2003 (n = 85) P

.15 8.5% (4) 2.3% (2) .11

.60 38% (18) 16.3% (14) .02

NA 2.1% (1) 0% .17

Ten year experience with pediatric laparoscopic appendectomy 845

see the evolution of the risks and benefits of this procedure

over a longer period.

One of the arguments against LA is the longer setup and

operating times required [5,10-12]. As we gained experience

over the last 10 years, both anesthetic time and operating

time have decreased and recent publications have confirmed

similar operating times for their LAs [9,10,13]. As well,

Canty et al [10] report operating times for their open

appendectomies that are similar to the times obtained for our

LAs. This suggests that as we progress along the learning

curve, LA may equalize with open appendectomy in these

technical aspects.

Another barrier to the widespread acceptance of LA has

been high morbidity, especially in cases of PA. Current

recommendations from a recent Cochrane review [11]

suggest that LAs be reserved for AA or special circum-

stances such as those involving obese patients or women of

reproductive age because of the diagnostic and therapeutic

advantages. This systematic review also suggests that LA

be discouraged in cases of perforated or gangrenous

appendicitis because of the 3-fold increase of abscess

formation as seen in adults [11]. The numbers in the

pediatric age group are insufficient to assess abscess rate

[11]. We have found that the rate of intraabdominal abscess

formation has decreased over the last 10 years. This

decrease may be reflective of changes in our practice over

the last 10 years. In the beginning, irrigation was used

frequently with large volumes of normal saline; however, in

the recent years, our center has focused on complete

suctioning with more judicious use of irrigation. It was

thought that irrigation was simply spreading the contami-

nation around the abdomen, thus leading to a higher abscess

rate. This change in practice is a direct reflection of our

progress along the learning curve. Our results suggest that

continued performance of LAs in cases of PA is necessary

to progress along this learning curve and ultimately

decrease the number of these complications. Although we

recorded no change in the frequency of wound infections or

bowel obstructions, these complications occurred very

infrequently. Similarly, in AA, the frequencies of all

complications were too small to notice any statistical

change over 10 years. Other studies have confirmed similar

infrequencies of these complications [5,9-13]. This overall

decrease in morbidity may caused by better visualization

within the peritoneal cavity as well as judicious irrigation

with more complete suctioning.

Current literature does not reveal a clear-cut answer to

the question of whether LA is equal or superior to open

appendectomy. As with any new procedure, there exists a

learning curve, and surgeons must evaluate where they are

along this curve. At our institution, 10 years of progressing

along the bLA learning curveQ has brought a decline in

operating and anesthetic times as well as a decrease in the

frequency of abscesses and conversion rates. At the same

time, the positive aspects such as decreased LOS, better pain

control, less time to resume regular diet, and fewer

complications have remained relatively constant.

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