Laparoscopic Appendectomy in Complicated Appendicitis of Children

Abstract

I read with great interest your article, which describes the value of laparoscopy in management of complicated appendicitis (1). You should be congratulated for the excellent results and for providing the best standards of care to your patients. I have an experience of about 1000 appendicectomies; half of that number was done by laparoscopic approach in the UK and overseas. The conversion rate was 0.4%. I believe laparoscopic approach should be the gold standard for managing complicated appendicitis with systemic signs of sepsis, for the following reasons: 1) Laparoscopy will provide diagnostic and therapeutic options. It will provide an excellent view and access to the whole peritoneal cavity including liver and splenic areas, paracolics, pelvic and interloop spaces. 2) Using laparoscopy, surgeons can levage the whole peritoneal cavity with copious saline under direct vision until the returning fluid is clear, thus it’s better than open approach when the surgeon is limited by access through grid iron incision. 3) Recovery, post-operative pain, cosmesis and wound complications are far better than open approach. 4) Induction of pneumoperitoneum may be challenging in complicated appendicitis. I had no major difficulties using Veress needle. Hasson’s technique is equally safe and can be used by surgeons who have no experience or not familiar with Veress needle technique. 5) In the UK, about 26% of our peadiatric patients are overweight. Lapraoscopic approach will add the benefits of easy access and again avoids wound complications. My approach in complicated appendicitis is: 1) Any child with complicated appendicitis, history of right iliac fossa pain and show signs of sepsis should undergo an urgent laparoscopy. An urgent laparoscopy rather than laparotomy can be repeated if the patient shows signs of deterioration after initial laparoscopy. 2) If on clinical examination there is a mass and controlled sepsis (no systemic signs): I will start antibiotics and arrange an abdominal scan. If the scan showed collection then this will be drained radiologically under Ultrasound guidance. If the child and family are not happy for radiological drainage under local anesthetics, laparoscopic drainage +/appendicectomy (if seen) is performed. This has worked for me very well without problem. You have cited Horwits et al. and Krisher et al. studies that represent an early laparoscopic experience to manage appendicitis, both studies published in 1997 and 2001 and they are out of date! Both had worse outcomes compared to Yagmurlu A et al. and Esposito C et al. studies, which were published in 2006 and 2007. You have mentioned appendicitis together with peritonitis is mostly managed with open surgery with a midline or large transverse incision and wound would be open for many days as a rule (2). This study is published in 1995, which mean it was reported patients outcome and experience before laparoscopic era. The incidence of complications especially the postoperative abdominal abscess is negligible. Our study of 200 cases (including 7.5% of perforated appendicitis) in 2008 (3) reported no single case of abdominal abscess.