Appendectomy In Children Research Articles

Does peritoneal lavage influence the rate of complications following pediatric Laparoscopic Appendicectomy in Children with Complicated Appendicitis? A Prospective Randomized Clinical Trial

BackgroundThere is ongoing debate concerning the use of peritoneal irrigation in the setting of complicated appendicitis (CA) in children. Our aim was to conduct a prospective randomized controlled trial for the treatment of CA during a laparoscopic appendicectomy in children. MethodsFollowing ethical approval (REC10138B), pediatric patients (≤16 years old) were recruited from a single institution over a 3-year time period (2015–2018). Randomization occurred following intraoperative diagnosis of CA to either peritoneal lavage (PL) or suction only (SO). Primary outcome was the length of stay (LoS), and secondary outcomes were the presence of a postoperative intraabdominal abscess (IAA), wound infection (WI), or adhesive small bowel obstruction (ASBO). Data are reported as number of cases (%), median (range), odds ratio [OR] and analyzed using t-test and Fisher's exact test. A p-value ≤0.05 was considered significant. ResultsA total of 100 pediatric patients were recruited into the trial. Sixteen were excluded owing to either recruitment or protocol violations, and therefore a total of 86 underwent final analysis: 44 PL and 42 SO. There was no significant difference in the LoS: 5.7 (PL) vs 5.6 (SO) days, p = 0.75. Only 1 IAA occurred in the PL group: 1/44(2.3%) vs 0/42(0%), p = 1.0. There was 1 ASBOs in the PL group (2.3%, p = 1.0) and no WIs in either of the groups. ConclusionThis prospective randomized control trial has revealed equivalence in techniques for the treatment of complicated appendicitis. It has also revealed a low complication rate following pediatric LA with either PL or SO. Type of studyRandomized controlled trial. Level of evidenceLevel I.

Hem-o-lok clip versus hand-made loop in base closure during laparoscopic appendectomy in children

To evaluate the efficacy and safety of hem-o-lok clip in base closure during laparoscopic appendectomy (LA) in children and compare its outcomes with hand-made loop. A prospective study was performed that included all patients who underwent LA at our hospital from January 2017 to March 2018. The cases were randomly divided into two groups according to the method used for base closure; in the first group double hem-o-lok clips were used, while double hand-made loops were adopted in the second group. Data were collected and compared between groups by t and Chi-square tests including clinical data, operative time, complications, hospital stay and cost of supplies. The study included 44 patients, hem-o-lok clip group and hand-made loop group consisted of 21 and 23 patients, respectively. There were no significant differences between both groups concerning patients’ demographics, complications or hospital stay. Mean operative time was 29.95 ± 8.33 min in hem-o-lok clip group (range 18–47), whereas it was 38.78 ± 4.91 min in hand-made loop group (range 31–52) reaching statistical significance (p = 0.001). In terms of costs, a cartridge of hem-o-lok clips to be used per each case costs approximately 14 USD in our country, while a single package of Vicryl ligature 2-0 for forming hand-made loops costs 4 USD. Hem-o-lok clip is effective and safe in securing the base of appendix during LA in children. Although it is slightly more expensive than hand-made loop, it offers a significantly shorter operative time as the principal advantage when compared to hand-made loop which is superior because of its economic value.

Single-Port Needlescopic Appendectomy in Children Using a Mediflex Needle: A New Simplified Technique.

Background: Laparoscopic appendectomy is among the most common surgical procedures. Needlescopic appendectomy (NA) is an acceptable, safe technique in children, but with many drawbacks such as a high conversion rate and long operative time. We present a new technique for NA in children using only a single port, Mediflex® facial closure needle, and vascular access cannula (VAC). Patients and Methods: Single-port NA was attempted in 117 patients (51 boys, 66 girls). Under general anesthesia, a 5-mm camera port was inserted through the umbilicus. Two Mediflex needles and a 14-gauge VAC were introduced. The appendix was grasped and dissected from the surrounding tissues using Mediflex needles. In case of a mobile cecum, the appendix was pulled through the umbilical port, then an extracorporeal appendectomy was performed. In cases with a fixed cecum or severely inflamed appendix, a complete intracorporeal appendectomy was done. The suture was knotted in a sliding reef knot using a single instrument. Results: NA was completed in 117 patients (51 boys, 66 girls) with an average age of 10 years. Thirty patients underwent extracorporeal appendectomy. Eighty seven patients were treated by intracorporeal appendectomy. The mean operative time was 15 ± 3 and 25 ± 4 minutes for extracorporeal and intracorporeal appendectomy respectively. The hospital stay was 1.2 days on average (ranging 8 hours to 2 days). There was no single case of conversion. Family satisfaction was achieved in 97% of cases. Conclusion: The presented unique method for single-port NA using Mediflex® appears to be a safe, acceptable technique for appendectomy in children that allows for excellent cosmetic results.

Adequacy of antibiotic prophylaxis protocol in appendectomies in children.

To assess compliance of antibiotic prophylaxis in surgery for acute appendicitis in children and its effect on surgical site infection. We carried out a prospective cohort study to evaluate compliance of antibiotic prophylaxis in appendectomies in children. An assessment of the level of compliance with prophylaxis was made, as well as the causes of non-compliance. The effect of non-compliance of antibiotic prophylaxis on the incidence of surgical site infection was studied with the adjusted relative risk (RR) with a backstep logistic regression model. The study included a total of 412 patients. Antibiotic prophylaxis was indicated in 348 patients, and administered in 95.7% of cases, with an overall protocol compliance of 90.7%. The principal cause of non-compliance was time of initiation. Cumulative incidence of surgical site infection was 2.7%. No relationship was found between inadequate prophylaxis compliance and infection (RR: 1.01; 95% confidence interval: 0.95-1.11; p = 0.61). Compliance of antibiotic prophylaxis was high, but could be improved. No relationship was found between prophylaxis compliance and surgical site infection rate.

Is a nasogastric tube necessary after transumbilical laparoscopic-assisted appendectomy in children with perforated appendicitis?

This study assessed the necessity of postoperative nasogastric tube (NGT) use in acute pediatric cases of perforated appendicitis. All cases of acute pediatric perforated appendicitis managed with transumbilical laparoscopic-assisted appendectomy at our hospital from 2011 to 2017 were retrospectively reviewed. Sixty-two cases were selected and divided into two groups based on NGT placement. There were no significant differences between the two groups in most parameters of patient demographics, or surgical data. Notably, the mean time to first oral intake and to regular diet was significantly shorter in no-NGT group (1day vs 3days, P < 0.0001; and 4days vs 7days, P = 0.003, respectively). Postoperative length of stay was significantly shorter in no-NGT group (7days vs 9days, P < 0.0001). Considering the results of our analysis, we believe that routine NGT placement is not always necessary in these situations.

EXPERIENCE IN TREATING ACUTE APPENDICITIS IN TASHKENT

75% of all emergency surgeries are surgeries for acute appendicitis. Annually, only in the Republican Scientific Center 700 appendectomies in children are made, in average. The article summarizes data obtained in the retrospective analysis of case histories of 6 256 patients with acute appendicitis and its complications who were hospitalized in the pediatric department of emergency surgery for 12 years. The following incidence of acute appendicitis in children is reported: from 1 to 3 years of age - 0.6 per 1 000; from 4 to 7-1.4-2.6 per 1 000; 13 years of age - 8 per 1 000. The authors discuss specific features in the clinical picture of acute appendicitis in children depending on patient’s age and anatomical location of the appendix. The clinical picture in children of older age and of the first three years of life is discussed separately. Out of 6 256 pediatric patients with acute appendicitis 72 (1.15%) were children younger than 3. The authors have substantiated a complex of diagnostic and therapeutic manipulations as well as tactic options to the treatment of this category of patients. Widespread implementation of the laparoscopic technique into surgical practice has significantly changed the tactics of treatment. The number of surgeries for simple appendicitis in children has decreased up to 3.9-7%.

Appendectomy in Switzerland: how is it done?

More than 10,000 appendectomies are performed every year in Switzerland. The aim of this study was to investigate the treatment strategy for appendicitis among Swiss surgeons with particular interest in laparoscopic technique, method of appendiceal stump closure, and abdominal lavage. We performed an anonymous survey among 540 members of the Swiss Surgical Society. Technical details and differences between the surgical procedures in adults and children as well as in complicated and non-complicated appendicitis were investigated. The overall response rate was 45% (n = 243). 78% of the surgeons perform laparoscopic appendectomies in children and 95% in adult patients. Only 3% use a single incision site technique. Surgeons consider pus or stool in the abdomen (94%), an abscess (86%) or perforation of the appendix (82%), but not an inflamed appendiceal base (16%) as complicated appendicitis. 41% of surgeons use endoloops, 36% a stapling device, and 20% polymeric clips in non-complicated appendicitis for appendiceal stump closure. However, 82% of the surgeons use a stapler in complicated appendicitis. Most (76%) of surgeons do not plunge the appendiceal stump. 24% of surgeons lavage the abdomen with > 1L of fluid independent of the intraabdominal finding. Most Swiss surgeons perform multiport laparoscopic appendectomies. Endoloops and staplers are mostly used for appendiceal stump closures in uncomplicated appendicitis, and staplers in complicated appendicitis. Only a minor part of surgeons plunge the appendiceal stump or perform routine abdominal lavage.

A Prospective Randomized Controlled Trial of Single-Port and Three-Port Laparoscopic Appendectomy in Children.

Background: This study aimed to evaluate single-port laparoscopic appendectomy (SPLA) in comparison with three-port laparoscopic appendectomy (3PLA) in children about the extent of surgical trauma after SPLA and 3PLA measured by serum interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations. Materials and Methods: A total of 50 patients with a median age of 11.5 were randomized to two groups. Experts in both methods performed the surgeries. The decision on the type of planned surgery was randomly determined. Serum IL-6 and CRP levels were measured using an enzyme-linked immunosorbent assay before, and at 12 and 36 hours after surgery. Furthermore, we compared operating time, hospital stay, postoperative pain, and complication rates. Results: The operative time in the 3PLA group was shorter than that in the SPLA group (P < .05). Preoperative IL-6 levels were not different between the two groups, but the rise (pre- versus postoperative) of IL-6 in the SPLA group was remarkably higher when compared with the 3PLA group (P < .05). Similar results were obtained for CRP; basal serum CRP levels were not different between the two groups, but the rise of CRP in the 3PLA group was significantly lower compared with that in the SPLA group. During the first 12 hours postoperative, the SPLA patients reported more severe postoperative pain and longer inpatient opiate usage was noted that after 3-PLA. Only one SPLA case was converted to 3PLA. There were no conversions to open surgery. The length of hospital stay and complication rate were not different between the two groups. Conclusions: SPLA in children is associated with longer operative times, increased pain level, and more severe surgical trauma as measured by postoperative CRP and IL-6 levels in comparison with a 3PLA. The two approaches were comparable regarding the length of hospital stay and complication rate.

Effects of Carbon Dioxide Insufflation and Trendelenburg Position on Brain Oxygenation During Laparoscopy in Children.

Laparoscopic appendectomy has become more popular compared with the open appendectomy in children, but there are limited data on the effects of pneumoperitoneum and Trendelenburg position on cerebral oxygenation. This study was designed to evaluate the changes in cerebral saturation using near-infrared spectroscope during laparoscopic surgery in children. The children underwent laparoscopic (LAP Group, n=22) or open appendectomy (OPEN Group, n=22). Right and left cerebral oxygenation (RScO2-LScO2), heart rate (HR), mean arterial pressure (MAP), end-tidal CO2pressure (PETCO2), and peripheral oxygen saturations (SpO2) were recorded between anesthesia induction (T0, baseline), after induction (T1), after intubation (T2), 5 minutes after intubation (T3), 5 minutes after pneumoperitoneum-15th minute at OPEN (T4), 5 minutes after Trendelenburg-20th minute at OPEN (T5), 30 minutes after pneumoperitoneum-45th minute at OPEN (T6), 5 minutes after supine position-skin suturing at OPEN (T7), 5 minutes postextubation (T8). Groups were similar with respect to their demographic data. In LAP group, a significant increase in HR was recorded at T5. No significant difference was observed in the MAP, PETCO2, SpO2, RScO2, and LScO2 values between the groups. There was a significant increase in the perioperative T1 to T8 values compared with the T0 values in LScO2 of the LAP group. Our results suggest that pneumoperitoneum and Trendelenburg position does not alter the hemodynamic values and can be safely performed in children without altering regional brain oxygenation levels.

Comparison of Open and Laparoscopic Appendectomy in Children: A 5-year Single Center Experience

To compare the outcomes of treatment in children with acute appendicitis between laparoscopic and open surgical approaches. Retrospective study. Division of Pediatric Surgery at a tertiary-care hospital in Croatia between January 2012 to December 2016. 834 children [median (IQR) age 13 (11,15)] who underwent appendectomy; 301 in the laparoscopic group and 533 in the open group. Postoperative complications, duration of hospitalization, re-operation, and the quantity of analgesics used. The median length of hospital stay was 3 days in laparoscopic group compared to 6 days in open group (P<0.001). The amount of analgesics used was lower in patients with laparoscopic appendectomy compared to patients who underwent open procedure (P=0.042). Significantly higher number of wound infections was recorded in the open group (n=21; 3.9%) compared to laparoscopic group (n=3; 1%) (P=0.014). The frequency of re-operation in both groups was equal (1.3%). The median duration of surgery was shorter in the group of patients with laparoscopic appendectomy compared to the open approach (30 vs. 45 min; P<0.001). In five-year period, the proportion of laparoscopic appendectomies increased by 21.5%. Laparoscopic appendectomy was safe and effective in children. Advantages of laparoscopic approach were shorter hospital stay, lower number of wound infections and lower usage of analgesics.

Population-based cohort study of the correlation between provision of care and the risk for complications after appendectomy in children

PurposeTo investigate the impact of hospital administrative level and caseload of pediatric appendectomies on the morbidity and mortality after appendectomy in a population-based cohort of Swedish children. MethodsPopulation-based cohort study including all Swedish children less than 15 years of age that underwent appendectomy for suspected appendicitis, 1987–2009. Patient characteristics and data on postoperative morbidity and mortality were collected from the Swedish National Patient Register and the Swedish Death Register. Primary endpoints were postoperative morbidity and mortality. Two explanatory variables were investigated: hospital administrative level and hospital annual caseload of pediatric appendectomies. Data were analyzed in regression models adjusting for available confounders. ResultsThe cohort comprised 55,591 children. The risk for postoperative complications was reduced in specialized pediatric surgical centers and in high caseload centers, compared to other hospitals. There were only seven postoperative deaths within 90 days of appendectomy. ConclusionsWe found clinically relevant risk reductions for reoperation and for readmission after appendectomy in specialized pediatric surgical centers. Importantly, the risk for postoperative complications was also reduced with increased hospital caseload, indicating that the merit from centralizing the management of pediatric appendectomies to specialized pediatric surgical centers may also be achieved by increasing hospital caseload of pediatric appendectomies in non-pediatric surgical units. Type of studyTreatment study. Level of evidenceLevel II.

Appendectomy Pain Control by Transversus Abdominis Plane (TAP) Block in Children.

BackgroundPain control after surgery in children is very important. Despite having good analgesic effects, the use of opioids is, however, limited due to side effects.ObjectivesThis study was aimed to investigate the effect of transverse abdominis plane (TAP) block on the intensity and frequency of pain after appendectomy in children.MethodsIn a single-blinded clinical trial, 40 children aged from 4 to 16 years, candidates for the appendectomy, were divided randomly to intervention and control groups. The intervention group received ultrasound-guided TAP block using 0.25 mL/kg of 0.25% bupivacaine in the Petit triangle after general anesthesia. Postoperative pain was assessed within the first 24 hours after surgery based on the Wong-Baker FACES Pain Rating Scale (WBFP).ResultsThere was a reduction in WBFP scores at 2 hours after appendectomy in the intervention group compared with the control group (5.05 ± 2.83 vs 6.30 ± 2.2063). Also, the pain intensity within 24 hours after surgery in the intervention and control groups was 3.10 ± 1.33, and 3.60 ± 1.63 respectively according to WBFP scale (P > 0.05).ConclusionsThe TAP block was effective to reduce pain after appendectomy in children, however, there was no significant difference between intervention and control groups. Further studies with larger sample sizes are needed to be done in this area of research.

Abscess and symptoms duration upon presentation should guide decision algorithms for early versus interval appendectomy in children

To compare outcomes for complicated appendicitis treated with early versus interval appendectomy and to identify which patients would likely benefit from early appendectomy. A retrospective review of complicated appendicitis was performed from 2010 to 2015. Patients were divided into early (EA) versus interval appendectomy (IA) groups. We compared demographics, complications and outcomes. Pearson's Chi square analysis and Student's T test analysis were performed. We identified 316 patients (EA group 53% vs. IA group 47%). Interval appendectomy group had longer symptom duration [IA 3.8 vs. EA 2.3 days (p=0.0001)], increased leukocytosis [IA 18.7 vs. EA 17.2 (p=0.008)], more initial abscesses [IA 35% vs. EA 13% (p=0.0001)], more complications [IA 30% vs. EA 19%, (p=0.013) and prolonged total length of stay [(LOS), p=0.009]. Subgroup analysis of all patients revealed 80% of patients presented with ≤3cm abscess and duration of symptoms (DOS) ≤5 days. Interval appendectomy patients with DOS ≤5 days and or ≤3cm abscess on admission had no differences in clinical presentation. However, these patients had prolonged total LOS (IA 7.7 vs. EA 6.3 days, p=0.01) and increased complications (IA 29% vs. EA 19%, p=0.04). The majority of patients with complicated appendicitis in children present with small abscess (≤3cm) and short symptom duration (≤5 days). This subset of patients might benefit from early appendectomy due to decreased LOS, resource utilization and reduced complications.

Intraoperative cultures during appendectomy in children are poor predictors of pathogens and resistance patterns in cultures from postoperative abscesses

BackgroundIntraoperative cultures are commonly sent in complicated appendicitis. Culture-guided antibiotics used to prevent postoperative infectious complications are debated. In this study, we describe the microbial overlap between intraoperative and abscess cultures, and antibiotic resistance patterns.MethodA local register of a children’s hospital treating children 0–15 years old with appendicitis between 2006 and 2013 was used to find cases with intraoperative cultures, and cultures from drained or aspirated postoperative intraabdominal abscesses. Culture results, administered antibiotics, their nominal coverage of the identified microorganisms, and rationales given for changes in antibiotic regimens were collected from electronic medical records.ResultsIn 25 of 35 patients who met inclusion criteria, there was no overlap between the intraoperative and abscess cultures. In 33 of 35 patients, all identified intraoperative organisms were covered with postoperative antibiotics. In 14 patients, organisms in the abscess culture were not covered by administered antibiotics. Enterococci not found in the intraoperative culture were found in 12 of 35 abscesses. We found no difference in the antibiotic coverage between rationales given for antibiotic changes.ConclusionThe overlap between intraoperative cultures and cultures from subsequent abscesses was small. Lack of antibiotic coverage of intraoperative cultures was not an important factor in abscess formation.

Intestinal Function after Early versus Late Appendectomy in Children with Perforated Appendicitis

The aim was to prospectively document the impact of early versus late appendectomy on intestinal function in pediatric perforated appendicitis. After Institutional Review Board approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. One hundred children with pathologist-confirmed transmural perforations were included. The median time to operation after pain onset was three days. Operation on day 1 or 2 (early) was compared with that on day 3 or after (late) (range, 3-9 days). Emesis, nasogastric tubes, and time to tolerate diet evaluated intestinal function. Categorical and continuous variables were analyzed by chi-square and t tests. Of the 100, there were 45 in the early and 55 in the late group, with 22/55(40%) operated on day 3. Children with early appendectomy were significantly younger, 7.8 (3.5) versus 9.5 (3.8) years (P = 0.02). Pre-appendectomy, more than 80 per cent of each group had emesis (P = 0.84), but the late group had a 10-fold increase in nasogastric tube use (P = 0.02). The early group tolerated regular diet significantly faster, 2.5 (2.1) versus 4.4 (4.1) days (P = 0.01), and had a significantly shorter hospital stay, 3.5 (2.2) versus 5.6 (4.3) days (P = 0.01). When pain onset to appendectomy is less than three days, the time to return of intestinal function is significantly reduced.

The Impact of Obesity on Laparo-Endoscopic Single-Site (LESS) Appendectomy in Children

Our study aimed to clarify the relationship between obesity and the risk of postoperative morbidity following LESS appendectomy. We performed a retrospective review of all patients who underwent LESS appendectomy from January 2013 to December 2016.LESS appendectomy was performed in 109 patients during the study period. Among these patients, 17 (15.6%) were obese.There were no significant differences in operative time, postoperative length of stay, surgical site infections, emergency department visits, or readmissions among nonobese and obese groups. In conclusion,obesity did not have any impact on the intraoperative course or short-term postoperative complications after LESS appendectomy.

Extended Antibiotic Course Prior to Interval Appendectomy in Children with Complicated Appendicitis Offers No Significant Advantage.

No consensus exists regarding duration of antibiotic therapy for complicated appendicitis treated with interval appendectomy. We hypothesized that more than two weeks of antibiotic therapy does not decrease complication rates in asymptomatic patients. A retrospective review of all patients with complicated appendicitis treated with interval appendectomy from 2010-2015 was performed. We divided the patients in two groups (group 1, ≤2 weeks of antibiotics; group 2: >2 weeks of antibiotics). Demographics, antibiotic agents, and complications were collected. Pearson χ analysis and Student t-test analysis was performed with significance of p < 0.05. Total of 158 patients met inclusion criteria (group 1 [47.4%] vs. group 2 [52.5%]). Mean length of stay was 7.5 days. Abscess on admission was 26% (n = 41). The groups were demographically similar. Total complication rate was 39.2% (abscess development, n = 19; re-admissions, n = 16; interval appendectomy <28 days, n = 13; unplanned emergency department visits, n = 7; fistula, n = 4, wound infection/dehiscence, n = 3; and conversion to open surgery, n = 4). All fistulas and conversions occurred in the less than two-week group. Mean course of antibiotics was 4.1 weeks. There was no significant difference in the complication rates based on duration or type of antibiotics (p = 1.0). Treatment with more than two weeks of antibiotic therapy for complicated appendicitis does not confer any clinical benefit prior to interval appendectomy. Complications were not reduced by a prolonged course of antibiotic therapy.

Outcomes and costs of pediatric appendectomies at rural hospitals

Background/PurposeDespite policy efforts to support rural hospitals, little is known about the quality and safety of pediatric surgical care in geographically remote areas. Our aim was to determine the outcomes and costs of appendectomies at rural hospitals. MethodsThe Kids’ Inpatient Database (2003–2012) was queried for appendectomies in children <18 years at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), cost) were analyzed with bivariate and multivariable regression analysis. ResultsRural hospitals performed 13.6% of appendectomies. On multivariable analysis, rural hospitals were associated with higher negative appendectomy rates (OR 1.49, 95% CI 1.39-1.60, p < 0.001), decreased appendiceal perforation rates (OR 0.86, 95% CI 0.83-0.89, p < 0.001), less laparoscopy use (OR 0.48, 95% CI 0.47-0.50, p < 0.001), higher complication rates (OR 1.29, 95% CI 1.19-1.39, p < 0.001), shorter LOS (IRR 0.90, 95% CI 0.89-0.91, p < 0.001), and slightly increased costs (exponentiated log$ 1.02, 95% CI 1.01-1.02, p < 0.001) ConclusionsRural hospitals care for fewer patients with advanced appendicitis but are associated with higher negative appendectomy rates, lower laparoscopy use, and higher complication rates. Additional studies are needed to identify factors that drive this disparity to improve the quality of pediatric surgical care in rural settings. Type of StudyTreatment/Cost Study (Outcomes). Level of EvidenceLevel III.

Bilateral Ureteral Obstruction Caused by Stone Formation After Laparoscopic Appendectomy in Children

In children, urologic complications are rare after laparoscopic appendectomy (LA). In this article, we report the case of a 9-year-old boy with bilateral hydronephrosis caused by ureteral calculi 10 days after he had undergone LA. The patient's urinary output normalized and renal function recovered after stone extraction and bilateral ureteral stent insertion.

Use of standardized visual aids improves informed consent for appendectomy in children: A randomized control trial

BackgroundObtaining informed consent for surgical procedures is often compromised by patient and family educational background, complexity of the forms, and language barriers. We developed and tested a visual aid in order to improve the informed consent process for families of children with appendicitis. MethodsFamilies were randomized to receive either a standard surgical consent or a standard consent plus visual aid. Univariate and multivariate analyses were performed to assess the effectiveness of adding the visual aid to the consent procedure. ResultsParents in both cohorts were similar in age, gender and education level (p > 0.05). On multivariate analysis, visual consent had the strongest influence on parent/guardian comprehension (OR 4.0; 95%CI 2.2–7.2; p < 0.01), followed by post-secondary education (OR 2.7; 95%CI 1.5–4.9; p < 0.01), and use of external resources to look up appendicitis (OR 2.0; 95%CI 1.1–3.6; p = 0.02). ConclusionVisual aids improve understanding and retention of information given during the informed consent process of children with appendicitis.