Outcomes of Transumbilical Laparoscopic-Assisted Appendectomy and Conventional Laparoscopic Appendectomy for Acute Pediatric Appendicitis in a Single Institution

Abstract

Background:

Single-incision laparoscopic appendectomy (SILA) is a potentially safe and feasible alternative to conventional laparoscopic appendectomy using three ports (CLA). However, the safety and efficacy of SILA for complicated appendicitis (gangrenous and perforated) remain unclear. The aim of this study was to evaluate the outcomes of transumbilical laparoscopic-assisted appendectomy (TULAA) not only for simple appendicitis but also for complicated appendicitis, and to compare them with the outcomes of CLA.

Methods:

All cases of acute pediatric appendicitis who underwent laparoscopic appendectomies in our hospital from 2007 to 2016 were retrospectively reviewed. CLA was performed between January 2007 and October 2011, and TULAA was performed between November 2011 and December 2016. In this study, patients' demographics and operative outcomes for simple appendicitis (catarrhal and phlegmonous) and complicated appendicitis were analyzed, comparing the results of TULAA and CLA.

Results:

In total, 262 patients underwent laparoscopic appendectomy: CLA in 103 patients and TULAA in 159 patients. All appendectomies were performed in the acute phase. Complicated appendicitis accounted for 60 CLA cases and 81 TULAA cases. There were no significant differences in patients' demographics. Mean operative time in simple appendicitis was significantly shorter in TULAA than in CLA. In addition, complication rates in complicated appendicitis were significantly lower in TULAA than in CLA. Moreover, in each comparison, the postoperative hospital stay was significantly shorter in TULAA than in CLA.

Conclusion:

In our institution, TULAA has shown to be a safe and effective alternative for both simple and complicated appendicitis in children compared with CLA.

Introduction

Acute appendicitis is one of the most common diseases causing pediatric acute abdominal pain. In younger children, the proportion of perforated appendicitis is considerably higher than in adults. For a long time, the standard treatment for acute appendicitis has been appendectomy. The procedure for appendectomy varies by institution, and less invasive techniques have become widely accepted.

Since its introduction a few decades ago, laparoscopic appendectomy has become known to improve cosmesis, decrease postoperative pain, and decrease the length of hospital stay. Recently, the efficacy of single-incision laparoscopic appendectomy (SILA) has been reported.^1–3 Several meta-analyses have shown that SILA is a potentially safe and feasible alternative to conventional laparoscopic appendectomy using three ports (CLA).^4,5 For acute complicated appendicitis (gangrene, abscess formation, and diffuse peritonitis), however, SILA has not been widely studied in comparison with CLA.^6–16 Thus, the safety and efficacy of SILA for complicated appendicitis, particularly with abscess formation or diffuse peritonitis, remain unclear.

In our hospital, we have performed early laparoscopic surgery for all cases of pediatric appendicitis in its acute phase since 2007, and since November 2011, transumbilical laparoscopic-assisted appendectomy (TULAA), a SILA procedure, has been introduced. Approximately half of these cases were complicated appendicitis. This study was designed to compare the outcomes of TULAA in pediatric patients with acute appendicitis with those of CLA.

Materials and Methods

Experimental design

This study was approved by the institutional review board (IRB #2016098) and complied with the Helsinki Declaration of 1964 (revised 2013). Because of the anonymous nature of the data, informed consent was not required.

This study was a retrospective review at a single center. All appendectomies treated with CLA between January 2007 and October 2011 and with TULAA between November 2011 and December 2016 were enrolled. All patients with acute appendicitis underwent appendectomy in the acute phase. All of them met the following criteria: (1) history of abdominal pain, associated with fever, nausea, vomiting, or diarrhea; (2) laboratory data with elevated white blood cell (WBC) count or C-reactive protein (CRP); and (3) computed tomography (CT) scan or ultrasound, showing swelling of or inflammation around the appendix.

The outcomes assessed included patient demographics (age, sex, weight, preoperative levels of WBC or CRP, and severity of appendicitis), mean operative time, amount of irrigation, length of postoperative hospital stay, analgesic requirements, and complications (wound infection, intraabdominal abscess, and ileus). The resected appendix was examined histologically. The severity of inflammation was classified as catarrhal, phlegmonous, or gangrenous. Perforation of the appendix was diagnosed intraoperatively (via the presence of an appendiceal rupture or a fecalith in the abdominal cavity). Perforated appendicitis was divided into diffuse peritonitis and abscess formation. Catarrhal or phlegmonous appendicitis was defined as simple appendicitis, whereas gangrenous or perforated appendicitis was defined as complicated appendicitis.

Perioperative treatment

In nonperforated appendicitis, antibiotic prophylaxis was provided through intravenous cefmetazole before surgery and continued for 1–3 days postoperatively. In perforated appendicitis, intravenous piperacillin–tazobactam or meropenem was given preoperatively and continued until the inflammation resolved.

Pain management was started immediately after the operation. Intravenous analgesics (flurbiprofen or acetaminophen) were used during the nothing-by-mouth phase. As soon as possible, the analgesics were switched to oral acetaminophen. The period of regular analgesic requirement was evaluated.

Patients in good general condition, with normal oral intake and controllable pain, were allowed to leave the hospital.

Surgical procedure

Conventional laparoscopic appendectomy

First, a 12-mm port (ENDOPATH XCEL^®; Johnson and Johnson, New Brunswick, NJ) was inserted into the umbilicus under direct view, and after creating pneumoperitoneum of 8–10 mmHg, two more 5-mm trocars were inserted in the right lower quadrant and suprapubic area. A 30° laparoscope and ultrasonic incision and coagulation instrumentation (SonoSurg^®; Olympus, Tokyo, Japan) were used to resect the mesoappendix, and the root of the appendix was ligated by ligature loop (ENDOLOOP^®; Johnson and Johnson). The resected appendix was removed through the umbilical port site using a retrieval bag (Endo Catch^®; Covidien, Dublin, Ireland).

Transumbilical laparoscopic-assisted appendectomy

First, a 20-mm single, vertical umbilical incision was made. The wound retractor (Lap Protector^®; Hakko Medical, Nagano, Japan) was inserted, and the silicon cap (EZ access^®; Hakko Medical) was mounted onto the retractor. Two or three 5-mm trocars (EZ trocar^®; Hakko Medical) were placed in the cap. After creating pneumoperitoneum of 8–10 mmHg, a 5-mm, 30° laparoscope and grasping forceps were inserted into each trocar. If adhesions around the appendix were sparse, a single forceps was used to grasp the mesoappendix and exteriorize it through the umbilical incision. The appendix was then resected outside the abdominal cavity, and the stump of the appendix was inverted using purse string suture. In perforated appendicitis, multiple adhesions in the abdominal cavity were removed manually, and abscesses around the umbilical wound were also drained with the finger. If necessary, one more 5-mm trocar was placed outside the umbilicus.

In any procedures, Trendelenburg and left-side low positions were used for an improved abdominal view around the appendix. The amount of intraabdominal irrigation by sterile normal saline depended on the degree of contamination.

Statistical analysis

Averages of continuous variables (such as age) were compared using t-tests, while chi-square tests were used to compare the proportions of categorical variables (such as sex) between the groups. The threshold for significance was P < .05. All statistical analyses were conducted using JMP ver. 12.

Results

A total of 262 patients underwent laparoscopic appendectomy, with CLA in 103 patients and TULAA in 159 patients. The mean age of all patients was 9.8 years (2.5–16.3 years), mean body weight was 28.6 kg (10.6–75.8 kg), and 66% of patients were males. A total of 121 (46%) patients were diagnosed with simple appendicitis, and 141 (54%) were diagnosed with complicated appendicitis. The results were evaluated in two groups: simple appendicitis and complicated appendicitis (Tables 1 and 2). In each analysis, several factors were compared between TULAA and CLA.

Table 1.

Patients' Demographics and Outcomes of Simple Appendicitis

	TULAA (n = 78)	CLA (n = 43)	P
Age (years)	10.6 (4.6–16.3)	10.1 (3.2–15)	.4
Sex (male)	57 (67%)	31 (72%)	.53
Weight (kg)	32.2 (14–62)	33.3 (14.2–58.7)	.6
Catarrhal	7 (9%)	1 (2%)	.16
Phlegmonous	71 (91%)	42 (98%)	.16
WBC (/μL)	14,900 (5400–24,200)	15,300 (6000–26,300)	.5
CRP (mg/dL)	1.9 (0.1–16)	3.6 (0.1–18)	.01
Operative time (minutes)	45 (20–76)	71 (35–155)	<.001
Irrigation (mL)	220 (0–3000)	780 (0–2500)	<.001
Postoperative length of stay (days)	3.4 (2–20)	4.5 (2–12)	<.001
Analgesic requirements (days)	2.3 (1–5)	2.3 (1–5)	.68
Complication	3 (4%)	3 (7%)	.45
Wound infection	2 (3%)	1 (2%)	.93
Abscess	0	2 (5%)	.05
Ileus	1 (1%)	0	.46
One additional port	0
Open conversion	0	0

CLA, conventional laparoscopic appendectomy using three ports; CRP, C-reactive protein; TULAA, transumbilical laparoscopic-assisted appendectomy; WBC, white blood cell.

Table 2.

Patients' Demographics and Outcomes of Complicated Appendicitis

	TULAA (n = 81)	CLA (n = 60)	P
Age (years)	9.2 (2.5–15.7)	8.4 (2.6–14.1)	.13
Sex (male)	54 (66%)	31 (52%)	.07
Weight (kg)	30.3 (10.6–75.8)	26.3 (13.5–70)	.15
Gangrenous	30 (37%)	21 (35%)	.8
Abscess	30 (37%)	17 (28%)	.28
Diffuse peritonitis	21 (26%)	22 (37%)	.17
WBC (/μL)	16,600 (2900–33,100)	16,500 (4200–31,300)	.87
CRP (mg/dL)	9.8 (0.1–29.1)	12 (0.2–32.7)	.5
Operative time (minutes)	98 (43–243)	102 (50–255)	.73
Irrigation (mL)	3700 (0–11,000)	3500 (0–14,000)	.71
Postoperative length of stay (days)	7.1 (2–25)	9.3 (3–29)	.001
Analgesic requirements (days)	3.4 (1–7)	3.1 (1–7)	.15
Complication	15 (19%)	20 (33%)	.04
Wound infection	3 (4%)	3 (5%)	.71
Abscess	9 (11%)	11 (18%)	.22
Ileus	3 (4%)	6 (10%)	.38
One additional port	24 (30%)
Open conversion	0	0

CLA, conventional laparoscopic appendectomy using three ports; CRP, C-reactive protein; TULAA, transumbilical laparoscopic-assisted appendectomy; WBC, white blood cell.

In simple appendicitis, there were no significant differences in patient demographics, except for the preoperative CRP levels; the levels were significantly lower in TULAA than in CLA (1.9 mg/dL versus 3.6 mg/dL, P = .01). The operative time and postoperative length of hospital stay were significantly shorter in TULAA than in CLA (45 minutes versus 71 minutes, P < .001; 3.4 days versus 4.5 days, P < .001). The amount of intraabdominal irrigation was significantly less in TULAA than in CLA (220 mL versus 780 mL, P < .001). There were no significant differences in the duration of analgesic requirement and in complication rates.

In complicated appendicitis, there were no significant differences in patient demographics. TULAA was superior to CLA in mean length of postoperative hospital stay (7.1 days versus 9.3 days, P < .001) and complication rates (19% versus 33%, P = .04). There were no significant differences in mean operative time, the amount of irrigation, and the period of analgesic requirement.

One additional port outside the umbilicus was used for 24 patients (30%) in the group with complicated appendicitis in TULAA. There were no open conversions for any of the appendectomies.

Discussion

Recently, SILA such as TULAA has been widely performed, and its efficacy has been reported.^1–24 Although there are some reports that SILA often had a higher incidence of wound infection and longer operative time than CLA, previous systematic reviews and meta-analyses have demonstrated no significant differences in most postoperative outcomes between CLA and SILA.^4,5

Moreover, SILA has been gradually performed even for complicated appendicitis.^17–23 Although there are some previous studies on the efficacy of SILA for complicated appendicitis in comparison with CLA, the number of cases of complicated appendicitis was relatively small in those studies.^6–16 The safety and efficacy of SILA for complicated appendicitis, particularly with abscess formation or diffuse peritonitis, remain unclear.

In this retrospective study, the outcomes after TULAA or CLA for any type of acute pediatric appendicitis during the acute phase were compared. The results showed that the patient demographics and preoperative clinical data were mostly the same between TULAA and CLA, and there was no significant difference in the severity of appendicitis. More than 50% of the cases were complicated appendicitis. The higher number of complicated appendicitis is accounted for in part by the role of our hospital in the city. This hospital is a tertiary care pediatric center and expected to treat severe cases. Therefore, patients with complicated appendicitis are referred to our department from secondary emergency hospitals. In contrast, simple appendicitis can be treated in those secondary care hospitals, and consequently, the total number of patients in our study is relatively small for this time frame (262 patients over 9 years).

For simple appendicitis, the mean operative time and postoperative length of stay were shorter in TULAA than in CLA. The reduction of operative time in TULAA may be associated with the easier technique compared with CLA (exteriorization of the appendix, extracorporeal resection, or manual adhesiolysis). However, the lower amount of irrigation in TULAA may be responsible for the shorter operative time. There was a significant difference in the preoperative CRP levels between the two groups, but the difference is not likely to have much clinical importance.

Recent studies of complicated appendicitis have shown that operative time in SILA including TULAA was longer than in CLA, and other operative outcomes were similar in both groups.^{6,7,9,13–15} In this study, however, the results differed from previous reports. In complicated appendicitis, no significant differences were found in the operative outcomes, except for postoperative length of stay and the complication rate. The two factors are probably related. The decrease of postoperative length of stay can result from the lower complication rate, which seems associated with the technique in TULAA. As described in the procedure for TULAA, the manual approach from the umbilical wound is considered feasible in children, because the distance from the umbilicus to the appendix is small and the abdominal wall is flexible.²³ The manual adhesiolysis and drainage of the abscess through the umbilical wound may have a positive impact on the decrease in the postoperative complication rate.

The mean operative time of TULAA varied in previous reports from 15 minutes in only simple appendicitis¹ to 72.9 minutes in only complicated appendicitis.²² It may not be valid to compare them with this study, because the severity of appendicitis differed in each study. However, the present operative times in both TULAA and CLA were relatively longer than those observed in previous studies.^6,11 This is partly because the amount of irrigation can influence the operative time. Although the previous reports did not clearly note whether intraabdominal irrigation was performed,^6–16 5–30 minutes was usually spent on the irrigation, depending on the degree of peritoneal contamination, in this study. Considering this, the present operative time in TULAA (45 minutes for simple appendicitis and 98 minutes for complicated appendicitis) might not be very different from the average.

The rate of adding ports to SILA ranged from 0% to 20%, and the percentage of open conversion was reported to be from 0% to 10%.^6–23 The results suggest that SILA for simple appendicitis can be completed with high probability, while it is sometimes difficult to complete it for complicated appendicitis, especially when the appendix is severely adherent to the surrounding organs. The problem would be solved by adding trocars for better triangulation and easier adhesiolysis, which has been shown to reduce operative time, complication rates, and analgesic requirements compared with SILA.²⁵ The total percentage of additional ports in this study (15%, 24/159) might be close to average, compared with the previous large series including severe cases (10.4%–16.8%).^17,21,23 Of note, only one additional trocar was used, and there were no conversions to three ports or open surgery. In this regard, it appears that TULAA can be performed for any severe pediatric appendicitis, and, even if it cannot be completed due to the intraabdominal condition, adding just one port helps safely dissect the difficult appendix.

There was no significant difference in analgesic requirements between TULAA and CLA. This is in agreement with other previous studies that found no difference in postoperative pain between SILA and CLA.^6,13,24 This result is likely due to no trocar being inserted through the muscle in SILA, despite the larger umbilical incision.^2,13 Also in terms of postoperative pain, TULAA is a feasible alternative to CLA.

Some limitations of this study should be acknowledged: First, this was a retrospective study at a single center. Second, other outcomes are lacking, such as cost of care and duration of refraining from normal activities. In addition, the local health care systems are likely to influence the length of hospital stay, which was slightly longer than that in previous studies (in this study, 3–4 days in simple appendicitis and 7–9 days in complicated appendicitis). Since the system supports pediatric patients to have a hospital treatment for almost free, their parents want to avoid the complications that will occur after discharge. Further study is needed to evaluate the effectiveness of TULAA for any type of acute pediatric appendicitis.

This is the first report of the feasibility of TULAA for acute pediatric appendicitis, including a reasonable number of perforated appendicitis cases, in comparison with CLA. Although this study is a retrospective and nonrandomized trial in a single institution, we believe that TULAA is a safe and effective alternative treatment for acute pediatric appendicitis, even for complicated appendicitis.

Footnotes

Disclosure Statement

No competing financial interests exist.

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