Pediatric Annals

Laparoscopic Appendectomy

James P Miller, MD

Abstract

While laparoscopic cholecystectomy has become the procedure of choice for symptomatic biliary disease, the laparoscopic approach to acute appendicitis remains controversial. Laparoscopy for the evaluation of the pediatric acute abdomen is not new. In 1980, Leape and Ramenofsky reported the use of laparoscopy to reduce their negative appendectomy rate.1 Soon thereafter, Semm reported the incidental removal of the appendix during gynecologic procedures but recommended it not be used for the acutely inflamed appendix.2 However, as newer instrumentation has become available, multiple centers have reported successful laparoscopic appendectomies for acute appendicitis.3,4

TECHNIQUE

The procedure is performed under general anesthesia with the patient supine in the Trendelenburg position and the table tilted slightly to the left. Through the umbilicus, a pneumoperitoneum is created using a Veress needle or cut-down technique. A 10-mm cannula is introduced through the umbilical incision, and a 0° forward-viewing laparoscope is inserted through the cannula. The second and third ports are placed under laparoscopic visualization. A 10-mm cannula is positioned in the lower midline just above the symphysis, and a 5-mm one is placed in the right lower quadrant taking care to avoid the inferior epigastric artery (Figure 1).

Atraumatic grasping forceps are inserted through the latter two ports, and the appendix is identified. The mesoappendix is carefully skeletonized, and the appendicular artery is ligated with an endoscopic clip. The base of the appendix is ligated with three pretied surgical loops and divided between the second and third ties leaving two ligatures on the appendiceal stump (Figure 2). The appendix is removed through the 10-mm trocar. If the appendix is markedly enlarged or gangrenous, a sterile pouch is placed into the abdomen and the appendix is removed through one of the enlarged cannula incisions to minimize wound contamination.

If an appendiceal abscess is encountered during the dissection, the purulent material is cultured with a Leuken's trap. Necrotic material is easily debrided both with blunt and sharp dissection. At the end of the procedure, the abdomen is thoroughly examined and irrigated. A drain can be brought out through the right lower quadrant incision. The abdomen is desufflated, the cannulas are removed, and the incisions are closed with subcuticular sutures.

Table

Postoperative adhesions have been demonstrated in as many as 80% of patients undergoing a right lower quadrant incision whereas adhesions following laparoscopic appendectomy have been reported in only 10% of patients.8,12 Several studies have shown a marked decrease in the postoperative infectious complications following appendicitis treated laparoscopically. Pier et al reported a series of 625 laparoscopic appendectomies with only 14 superficial wound infections (2%) and three intra-abdominal abscesses (0.5%).7 Valla et al reported 465 laparoscopic appendectomies in children with no infectious complications.3 Comparable wound infection rates following open appendectomies are 10% to 20%.13

Laparoscopic complications related to the needle and cannula insertion are infrequent. The reported incidence of visceral injury from the Veress needle or trocar and cannula insertion is 0.05% to 0.2%. Injury to the retroperitoneal vessels is 0.03%.14"16 Early recognition of these two complications is paramount to avoid postoperative morbidity and mortality.

The disadvantages of the laparoscopic approach to appendectomy are few (Table 2). There is a one-time purchase of reusable equipment, and the surgeon must learn new techniques and instrumentation. Initially, the operative time will be longer, but as confidence and dexterity improve, the operative time will approach that of the open operation (20 to 30 minutes). The last several laparoscopic appendectomies accomplished at our institution have had an operative duration of less than 30 minutes.

Careful surgical judgment is important to establish a successful laparoscopic surgical program. Although easily performed in young children (<4 years),…

While laparoscopic cholecystectomy has become the procedure of choice for symptomatic biliary disease, the laparoscopic approach to acute appendicitis remains controversial. Laparoscopy for the evaluation of the pediatric acute abdomen is not new. In 1980, Leape and Ramenofsky reported the use of laparoscopy to reduce their negative appendectomy rate.1 Soon thereafter, Semm reported the incidental removal of the appendix during gynecologic procedures but recommended it not be used for the acutely inflamed appendix.2 However, as newer instrumentation has become available, multiple centers have reported successful laparoscopic appendectomies for acute appendicitis.3,4

TECHNIQUE

The procedure is performed under general anesthesia with the patient supine in the Trendelenburg position and the table tilted slightly to the left. Through the umbilicus, a pneumoperitoneum is created using a Veress needle or cut-down technique. A 10-mm cannula is introduced through the umbilical incision, and a 0° forward-viewing laparoscope is inserted through the cannula. The second and third ports are placed under laparoscopic visualization. A 10-mm cannula is positioned in the lower midline just above the symphysis, and a 5-mm one is placed in the right lower quadrant taking care to avoid the inferior epigastric artery (Figure 1).

Atraumatic grasping forceps are inserted through the latter two ports, and the appendix is identified. The mesoappendix is carefully skeletonized, and the appendicular artery is ligated with an endoscopic clip. The base of the appendix is ligated with three pretied surgical loops and divided between the second and third ties leaving two ligatures on the appendiceal stump (Figure 2). The appendix is removed through the 10-mm trocar. If the appendix is markedly enlarged or gangrenous, a sterile pouch is placed into the abdomen and the appendix is removed through one of the enlarged cannula incisions to minimize wound contamination.

If an appendiceal abscess is encountered during the dissection, the purulent material is cultured with a Leuken's trap. Necrotic material is easily debrided both with blunt and sharp dissection. At the end of the procedure, the abdomen is thoroughly examined and irrigated. A drain can be brought out through the right lower quadrant incision. The abdomen is desufflated, the cannulas are removed, and the incisions are closed with subcuticular sutures.

Table

TABLE 1Initial Experience With Laparoscopic Appendectomy at Cook-Fort Worth Children's Medical Center*

TABLE 1

Initial Experience With Laparoscopic Appendectomy at Cook-Fort Worth Children's Medical Center*

Postoperative analgesia begins during the procedure with the administration of intravenous methadone (0.1 mg/kg) and the local infiltration of 0.5% buptvacaine preperitoneally as well as in the skin surrounding the cannula sites. Although postanesthetic nausea usually is not a problem, it can be minimized with a 1.5-mg scopolamine patch placed behind the patient's ear.

RESULTS

Over a 10-month period, 27 consecutive cases of acute nonperforated appendicitis have been managed by the author. After discussing the option of laparoscopic versus an open appendectomy with the parents, 20 procedures were performed laparoscopically and seven by the standard open technique (Table 1). Histopathologic examination of the specimen confirmed acute appendicitis in all 27 cases. None of the laparoscopic procedures were converted to an open procedure. The mean operative time was 54 minutes for the laparoscopic appendectomy and 28 minutes for an open appendectomy. The time from surgery to discharge was 30 hours laparoscopically compared with 51 hours for the open technique. Narcotic usage also was less in the laparoscopic group compared with the open group. Although the cost of the operative procedure was significantly higher for the laparoscopic group, the overall hospital costs between the two procedures was not statistically different.

Figure 1. The positions and size (millimeters) of the cannulas for laparoscopic appendectomy in a child are indicated.

Figure 1. The positions and size (millimeters) of the cannulas for laparoscopic appendectomy in a child are indicated.

DISCUSSION

Historically, Semm's report of laparoscopic appendectomy preceded the report of laparoscopic cholecystectomy by 5 years.2 Although he initially recommended this approach for noninflamed appendices, the development of newer instrumentation has allowed laparoscopic appendectomy to be developed into a safe procedure for acute appendicitis. The benefits of such a procedure will be easily recognized as one in seven people will develop acute appendicitis during their lifetime with the highest risk group being those individuals aged 10 to 19 years.5

The procedure is now well defined, and techniques have been described for both the antegrade and retrograde removal of the appendix. Semm's original article carefully mirrored an open technique with careful dissection and ligation of the appendicular artery and subsequent ligation of the appendiceal stump.2 The appendiceal stump was carefully inverted into the cecum but subsequent comparable studies have shown no advantage to this step.6 Although most surgeons prefer clip ligation of the appendicular artery, it also can be ligated with a pre-tied surgical loop, the endoscopic linear stapler, or cautery. Similarly, the appendiceal base can be ligated with clips, pre-tied surgical loops, or the stapler. The procedure usually requires three cannulas but occasionally a fourth port will be necessary to aid in exposure.

Table

TABLE 2Advantages and Disadvantages to Laparoscopic Appendectomy

TABLE 2

Advantages and Disadvantages to Laparoscopic Appendectomy

The advantages of laparoscopic appendectomy have been confirmed by several studies7'9 (Table 2). In general, there is lower morbidity, shorter hospital stay, and improved cosmesis with the laparoscopic approach. Other studies have indicated a subjective reduction of pain in the postoperative period while our patients objectively required fewer narcotics postoperatively compared with patients who underwent the open procedure. Only two of our 20 laparoscopic procedures required parenteral narcotics postoperatively. Although hospital stay is a difficult parameter for comparison, using an end point of ambulation and tolerating a regular diet, a fester discharge following the laparoscopic procedure (30 hours versus 51 hours) was evident in these 27 patients. The three small incisions are far less obvious than the right lower quadrant incision used in the open technique. Several studies have documented the shorter hospital stay but few discuss the cost effectiveness. In the literature, the range of hospital costs for a laparoscopic appendectomy varies from $5935 to $9656.lon Our hospital costs are markedly below these estimates. Moreover, the cost of the surgical procedure can be minimized by careful use of reusable instruments.

Although obesity was originally considered a contraindication to laparoscopic surgery, experience with the technique quickly proved this to be incorrect. Surgeons with endoscopic experience agree that the exposure and visualization achieved during a video laparoscopy far exceeds the exposure of an open technique whether it is a biliary procedure or another intta-abdominal procedure. The laparoscopic approach is especially advantageous when the appendix is normal as a more thorough evaluation of the abdominal cavity is possible laparoscopically compared with a limited right lower quadrant incision. Initially, the procedure was performed for nonperforated appendicitis, but indications for laparoscopic exploration have expanded to include practically all forms of appendicitis. The added visualization allows a more thorough irrigation and debridement of the abdominal cavity than can be obtained through a small right lower quadrant incision.3

Figure 2. The mesentery of the appendix has been ligated with endoscopic clips and divided. Two pre-tied ligatures have been placed on the base of the appendix, and a third one is being applied distal to the first two. The appendix will be divided between the second and third ligatures, which will leave the appendiceal stump ligated with two ligatures.

Figure 2. The mesentery of the appendix has been ligated with endoscopic clips and divided. Two pre-tied ligatures have been placed on the base of the appendix, and a third one is being applied distal to the first two. The appendix will be divided between the second and third ligatures, which will leave the appendiceal stump ligated with two ligatures.

Postoperative adhesions have been demonstrated in as many as 80% of patients undergoing a right lower quadrant incision whereas adhesions following laparoscopic appendectomy have been reported in only 10% of patients.8,12 Several studies have shown a marked decrease in the postoperative infectious complications following appendicitis treated laparoscopically. Pier et al reported a series of 625 laparoscopic appendectomies with only 14 superficial wound infections (2%) and three intra-abdominal abscesses (0.5%).7 Valla et al reported 465 laparoscopic appendectomies in children with no infectious complications.3 Comparable wound infection rates following open appendectomies are 10% to 20%.13

Laparoscopic complications related to the needle and cannula insertion are infrequent. The reported incidence of visceral injury from the Veress needle or trocar and cannula insertion is 0.05% to 0.2%. Injury to the retroperitoneal vessels is 0.03%.14"16 Early recognition of these two complications is paramount to avoid postoperative morbidity and mortality.

The disadvantages of the laparoscopic approach to appendectomy are few (Table 2). There is a one-time purchase of reusable equipment, and the surgeon must learn new techniques and instrumentation. Initially, the operative time will be longer, but as confidence and dexterity improve, the operative time will approach that of the open operation (20 to 30 minutes). The last several laparoscopic appendectomies accomplished at our institution have had an operative duration of less than 30 minutes.

Careful surgical judgment is important to establish a successful laparoscopic surgical program. Although easily performed in young children (<4 years), one can argue that their small abdominal cavity and the virtual overnight recovery from the open technique makes a laparoscopic approach more difficult to justify.

As in other institutions, the aggressive use of ultrasonography has led to a higher sensitivity and specifically in the diagnosis of appendicitis.1' These early cases are more amenable to a laparoscopic procedure than the advanced case of appendicitis with associated abscess formation. Similarly, the laparoscopic approach offers a better opportunity to explore the abdomen when the diagnosis is initially uncertain. If other surgical pathology is found secondary cannulas can be inserted, and the identified problem can be managed laparoscopically.

SUMMARY

Laparoscopy offers the surgeon better visibility for performing an appendectomy, which is to the advantage of the child. When the appendix is normal, the offending etiology usually can be managed through the same cannulas. With proper judgment and training, the laparoscopic technique can be used on almost any patient suspected of appendicitis. The ease of the technique, coupled with the decreased postoperative morbidity and shorter hospitalization, make the laparoscopic operation an important addition to the surgical armamentarium for managing acute appendicitis.

REFERENCES

1. Leape LI, Ramenofslcy ML. Laparoscopy for questionable appendicitis: can it reduce the negative appendectomy rate: Ann Surg. 1980; 191:4 10-41 3.

2. Semm K. Endoscopic appendectomy. Endoscopy, 1983:15:59-64.

3. Valla JS, Limone B, Montupet P, et al. Laparoscopic appendectomy in children: report of 465 cases. Surg Laparosc Endose. 1991;1:166-172.

4. Attwood SE1 Hill ADi Murphy PG, et al. A prospective randomized trial of laparoscopic versus open appendectomy. Surgery. 1992;112:497-501.

5. Addisi DG1 Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendectomy in the United States. Am} Epidemiol. 1990;132:910-925.

6. Engström L, Fenyö G. Appendectomy: an assessment of stump invagination: a prospective randomiïed trial. Br J Surg. 1985;72:971-972.

7. Pier A, Götz F, Bacher C. Laparoscopic appendectomy in 625 cases: from innovation to routine. Surg Laparosc Endose. 1991;1:8-13.

8. Save WB, Rives DA, Cochran EB. Laparoscopic appendectomy: three years' experience. Surg Laparosc Endose. 1991;1:109-115.

9. McAnena OJ, Austin O, O'Connell PR, et al. Laparoscopic versus open appendectomy: a prospective evaluation. BrJ Surg, 1992;79:818-820.

10. Gilchrist BF, Lobe TE, Schnipp KP, et al. Is there a role for laparoscopic appendectomy in pediatric surgery! J Pediatr Surg. 1992;27:209-214.

11. Cohen MM, Dangleis K. The cost .effectiveness of laparoscopic appendectomy, 1 Laparoendosc Surg. 1993;3:93-97.

12. DeWilde RL. Goodbye to late bowel obstruction after appendectomy. Lancet. 1991;338: 1012. Letter.

13. Lewis FR, Holcroft JW, Boey J, et al. Appendicitis: a critical review of diagnosis and treatment in 1000 cases. Arch Surg. 1975;110:677-684.

14. Kane MG, Kreijs GJ. Complications of diagnostic laparoscopy in Dallas: a 7-year prospective study. Gastromiest Endose. 1984;30:237-240.

15. Mlntz M. Risk and prophylaxis in laparoscopy: a survey of 100000 cases. J Reprod Med. 1977;18:269-272.

16. Phillips JM. Complications in laparoscopy. lut J Gynaecol Obstó!. 1977;15:157-162.

17. Rubin SZ, Martin DJ. Ultrasonography in the management of possible appendicitis in childhood. J Pedaitr Surg. 1990;25:737-740.

TABLE 1

Initial Experience With Laparoscopic Appendectomy at Cook-Fort Worth Children's Medical Center*

TABLE 2

Advantages and Disadvantages to Laparoscopic Appendectomy

10.3928/0090-4481-19931101-06

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