An Individualized Approach to Appendectomy in Children Based on Anatomico-Laparoscopic Findings

Abstract

Whether an appendectomy should be performed "open" or laparoscopically is the subject of considerable debate. This study in children was undertaken to test the hypothesis that an individualized approach, based on disease stage, body habitus, and laparoscopic findings should dictate the removal technique. Data on 108 consecutive pediatric appendectomies were prospectively recorded. Except in complex cases, a 5 mm laparoscope was inserted umbilically, the findings were evaluated, and the best removal approach was selected. Depending on the degree of inflammation and mobility, the appendix was fully delivered and resected, either through the initial umbilical trocar site or, more commonly, through a second right lower quadrant (RLQ) trocar site. The second RLQ trocar incision was enlarged for limited or full conversion to an open approach, if needed. In overweight children, three trocars and a stapler were used. Children (63 boys, 45 girls) ranged in age from 3 to 18 years (mean, 11 years). A single umbilical port was used in 16 patients with low-grade appendiceal inflammation. A two trocar, laparoscopically-assisted appendectomy was used in 63 cases. Of these 63, a limited extension of the RLQ trocar incision was necessary in 4 patients and conversion to an open incision was needed in 4 children. The three trocar technique was used 21 times. Twelve of these were cases involving obese patients. A stapler was used 13 times. Four trocars were needed once. Seven patients with complex appendicitis did not undergo laparoscopy. Twenty-nine appendices were perforated, and there were 3 complications: 2 intra-abdominal abscesses and one trocar site wound infection. Because appendiceal disease is a spectrum, and children encompass a wide range of ages and sizes, an individualized approach, based on the anatomical parameters and the clinical and laparoscopic findings, allows for an efficient, patient-specific appendectomy: single trocar for minimally inflamed appendices, two trocars for the most common types, three trocars plus a stapler for overweight children, and an "open" procedure for complex cases.