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PubMed · 15900359

Laparoscopic appendectomy in children.

Abdulrahman A Al-Bassam
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Abstract

OBJECTIVES: Laparoscopic appendectomy (LA) is rapidly becoming an alternative to open appendectomy for the treatment of appendicitis in children. We examined the efficacy, safety and complications of performing LA in children. METHODS: This is a critical review of the children who underwent LA between January 1999 and May 2003 at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. Demographic data, operative procedures, severity of appendicitis, histopathology, operative time, hospital stay, analgesia and complications were carefully analyzed. RESULTS: Laparoscopic appendectomy was attempted in 113 children. It was successfully completed in only 100 patients, 85 had uncomplicated appendicitis and 15 had complicated appendicitis. In 13 (11.5%) conversion to open appendectomy had to be carried out for complicated appendicitis. Their ages ranged between 2-12 years (average 8 years); 52 were males and 48 were females. Symptom duration average was 30 hours in uncomplicated appendicitis and 56 hours in complicated appendicitis. Operative time ranged between 35-80 minutes (average 53 minutes). Four patients with complicated appendicitis developed postoperative complications, 2 had wound infections and the other 2 had intra-abdominal collections. No intra-operative complications were encountered. The average hospital stay was 2 days for uncomplicated appendicitis and 6 days for complicated ones. Histopathological examination revealed 75 acutely inflamed appendices, 15 were perforated appendicitis with or without mass formation and 10 appendices reported to be normal. All patients were followed up for 6-12 months. CONCLUSION: Laparoscopic appendectomy is both a safe and effective method in managing children with acute uncomplicated appendicitis. In children with complicated appendicitis, LA should be carried out with caution and only by an experienced surgeon, as it is associated with a higher rate of conversion to open technique and more postoperative infectious complications.

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Abdulrahman A Al-Bassam. 2005. Laparoscopic appendectomy in children.. https://pubmed.ncbi.nlm.nih.gov/15900359/

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PubMed2007

The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis.

BACKGROUND: The principle of early exploration on wide indications in order to prevent perforation has been the guiding star for the management of patients with suspected appendicitis for over 100 years, dating back to a time when appendicitis was a significant cause of mortality. Since then there has been a dramatic decrease in mortality due to appendicitis. Emerging evidence calls for a new understanding of the natural history of untreated appendicitis. This motivates a reappraisal of the fundamental principles for the management of patients with suspected appendicitis. METHODS: Analysis of epidemiologic and clinical studies that elucidate the natural history of appendicitis, i.e. the possibility of spontaneous resolution or the risk of progression to perforation, the determinants of the proportion of perforations and mortality, and the consequence of in-hospital delay. RESULTS: The results presented in a number of studies suggest that spontaneous resolution of appendicitis is common, that perforation can seldom be prevented, that the risk of perforation has been exaggerated and that in-hospital delay is safe. An alternative understanding of the inverse relationship between the proportion of negative explorations and perforation and the increasing proportion of perforation with length of time is presented, mainly explaining these findings by selection due to spontaneous resolution. CONCLUSION: Evidence suggests that spontaneous resolution of untreated, non-perforated appendicitis is common and that perforation can rarely be prevented and is associated with a lower increase in mortality than was previously thought. This motivates a shift in focus from the prevention of perforation to the early detection and treatment of advanced appendicitis. In order to minimize mortality, morbidity and costs avoidance of negative appendectomies is more important then preventing perforation. In patients with an equivocal diagnosis where advanced appendicitis is deemed less likely a correct diagnosis is more important than a rapid diagnosis. These patients can safely be managed by active observation with an improved diagnostic work-up under observation, which has consistently shown a low proportion of negative appendectomies without an increase in the proportion of perforations or morbidity. A high proportion of perforations can be explained by selection due to undiagnosed resolving appendicitis. The proportion of perforation is therefore a questionable measure of the quality of the management of patients with suspected appendicitis and should be used with caution.

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