Page 29 - World Journal of Laparoscopic Surgery

Analyzing the Outcomes of Laparoscopic Appendectomies in Children
Appendicitis is a condition that does not just affect adults approach had a shorter ALOS compared to those treated with an
but is also very commonly seen in the pediatric age-group. In the open approach. 13
pediatric age-group, the lifetime risk of appendicitis is about 7−9% The common postoperative complications, within 30 days
and the mortality risk from the same is about 0.01% (non-perforated postoperative appendectomy, include drainage of surgical
appendicitis) to 0.06% (perforated appendicitis). 5 wound infections, intra-abdominal abscesses, and postoperative
Thanks to surgical advancements, especially in the last 40 adhesions causing bowel obstruction. The rate of complications
years, the approach for appendectomies has shifted from an in our study was divided into 3 groups of 51 surgeries each, that
open surgical approach towards a minimally invasive approach. is, 1−51 surgeries (first group), 52−102 surgeries (second group),
The first-ever laparoscopic appendectomy was performed by and 103−153 surgeries (third group). In these 3 groups, we had
6
Semm in 1983 in an adult patient, and the first-ever laparoscopic 2 postoperative complications related to the appendix in the
appendectomy in a pediatric patient was done about a decade first 51 surgeries, whereas no postoperative complications in the
later in 1992 by Ure et al. However, it was Gilchrist et al. who second and third groups which demonstrates that with increased
first presented evidence explaining the benefits of laparoscopic experience, the postoperative complication rates for laparoscopic
7
appendectomies over the open surgical approach. The one appendectomies showed a decreasing trend.
drawback that is still of concern is the cost of laparoscopic Out of 153 patients, only 3 patients required reoperation, 1 of
appendectomy over the open approach. However, the reduced which was for a post-appendectomy abscess which was reoperated
postoperative pain, shortened length of hospital stay as well as and treated with insertion of a pig-tail for drainage, the other was
recovery time along with minimal abdominal scarring with the reoperated for postoperative adhesive obstruction and the tgird
former approach are the advantages that can help reduce the case was reoperated for removal of a retained fecolith. We have a
cost difference. 8,9 strict policy regarding the use of disposable trocars and EndoCatch
The minimally invasive approach initially only included the bags especially in cases of complicated appendicitis. In our view, the
conventional laparoscopic approach; however, in recent years, use of this equipment has contributed to and helped us achieve a
laparoscopic appendectomy via single incision has gained lower postoperative complication rate in our study. Similar findings
popularity, as it offers advantages such as less pain, better were seen, where the use of an endoscopic loop to retrieve the
cosmetics, and an overall reduced operative time. appendix to reduce the potential for wound infections by preventing
Canty Sr, et al. and Foulds et al., in their series of pediatric contact of the specimen with the abdominal wall during removal,
laparoscopic appendectomies, have mentioned that they found in the study done by Goudet et al. in their modified technique
14
a significant improvement in terms of operative time and risk of for laparoscopic appendectomy. The use of these may increase
conversion to open appendectomy after 5 years of laparoscopic the cost of surgery upfront but it may save the cost in terms of
experience. 10,11 This makes it reasonable to assume that the learning postoperative complications requiring re-operation, which have
curve for laparoscopic appendectomies is ~20 procedures and been seen to occur at a higher incidence rate when this equipment
as the experience increases, the proficiency of the surgeon also is not used. 15
12
increases. This has been shown in the study done by York et al., An important intraoperative complication was the rate of
where they found that after the completion of the learning curve, conversion from laparoscopic to open surgery. In our study,
laparoscopic appendectomies become comparable to the open we had a 0% conversion rate, in both complicated as well as
approach in terms of operative time and the former has a decreased uncomplicated appendectomies. Gosemann et al. in their
postoperative length of stay and faster recovery of bowel function nationwide cohort analysis found that they had a conversion rate
to normal compared to the latter. 12 of 1.2% which was associated with increased risk of complication
16
In our study, we aimed to determine whether the laparoscopic compared to individual laparoscopic or open surgery groups.
approach can be used as a standard of care for any type of They also found a higher conversion rate in surgeries performed
appendectomy, complicated or uncomplicated. We retrospectively by pediatric surgeons, whereas in our study all the surgeries
analyzed a prospectively collected data of 153 consecutive were performed by trained pediatric surgeons but had a 0%
laparoscopic appendectomies done at our institution over the conversion rate. This could be attributed to increased surgical
course of 6.5 years, between January 2015 to August 2021. The experience and the findings seen in Gosemann’s study may be a
various parameters that we looked into were the demographics of confounding factor.
presentation in terms of age and sex of the patients, as well as the Markus Schäfer et al. also in their study reported a 6.8 and a
17
ALOS in hospital and postoperative complications if any. 25.5% conversion rate in overall and perforated appendicitis cases.
After analyzing our data, we found that in our cohort of 153 They also reported an overall reoperation rate of 3%, which was
patients, males (n = 102) were twice as likely to present with close to our number of 1.96%.
appendicitis requiring appendectomies compared to females
(n = 51) (male:female = 2:1). Our data also suggests that out of 153 conclusIon
patients, most of the patients presenting with appendicitis were In conclusion, our study only reiterates the fact that a pediatric
in the age-group of 6−10 years of age (n = 84), followed by 11−15 laparoscopic appendectomy is a safe approach in all types
years (n = 48). Vernon et al. in their study on pediatric laparoscopic of appendicitis, complicated or uncomplicated, in reducing
appendectomy in acute appendicitis in 200 patients reported complications and ensuring a reduced rate of conversion, but
that there was an equivalent number of patients presenting with it does have a learning curve, which when achieved, makes the
appendicitis in both genders and that there was an equivalent laparoscopic approach comparable to open approach in terms of
number of patients of all ages up to the age of 16 years. They operative time and offers advantages over the latter in terms
also found that laparoscopic appendectomy was used more of postoperative pain, length of hospital stay and earlier return of
in heavier patients and that patients treated with laparoscopic bowel function to normal.

World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022) 125