One Less: Single-Incision Laparoscopic Appendectomy Facilitates Postoperative Opioid Avoidance

Introduction

Appendectomy is one of the most common surgical procedures performed in the pediatric population. At our institution, single-incision laparoscopic appendectomy is used, which has been shown to be safe and well tolerated with comparable outcomes to conventional laparoscopic techniques. ¹ There has been debate regarding postoperative pain in single-incision laparoscopy. Treating postoperative pain is a complex and multifaceted problem. The opioid epidemic is an increasing problem affecting both children and adults in the United States. ² A large cohort of children enrolled in Medicaid without severe comorbid conditions analyzed between 1999 and 2014 showed that there was an opioid-related adverse event (emergency department visit, hospitalization, or death) for 1 of every 2611 opioid prescriptions written, with 71.2% of these cases showing no deviation from their prescribed dosage. ³ This shows us that even families who carefully follow the prescriptions given by their trusted medical provider are still at significant risk for an opioid-related adverse event. Outpatient surgeries/medical procedures were the second most common group to receive opioids at 25.1%. ³ Enhanced recovery protocols have been implemented in institutions to standardize management and reduce opioid requirements. These recent pushes have shown that multimodal pain management decreases opioid usage in even notoriously painful procedures, such as pectus excavatum surgery. ⁴ The aim of this project was to review opioid utilization in children who have undergone single-incision appendectomy at our institution.

Methods

A retrospective review, approved by the University of Illinois College of Medicine Institutional Review Board, of 500 patients at a single tertiary care children’s hospital in children (<18 yr) who had an appendectomy between May 1, 2018, and December 1, 2021. We excluded 67 cases of non-single-incision appendectomy and one non-appendectomy case. Single incision appendectomy is the adopted technique by all surgeons at this institution and is used for both acute and suspected perforated appendicitis. Outcomes measured were hospital length of stay (days), patient age, perforation status, and opioids prescribed at discharge. While patients were admitted to the pediatric services, patients were treated with rotating acetaminophen and ibuprofen for pain. This institution uses 10 mg/kg oral Tylenol and 10 mg/kg ibuprofen and alternate doses every 3–4 hours. Also, use of Bupivacaine with epinephrine as a local block intraoperatively. The usual multimodal regimen included acetaminophen and a nonsteroidal anti-inflammatory medication.

The technique utilized in single-incision laparoscopic appendectomy at our facility is as follows. ⁵ The patient is prepped and draped in the usual standard fashion. The abdomen is entered directly at the umbilicus via the Hasson technique using a vertical incision within the umbilical ring. A 1.2 cm vertical fasciotomy is then made to allow placement of a commercially available multiport. The abdomen is insufflated, and a 30-degree bariatric length laparoscopic camera is placed. The appendix is isolated, and the mesoappendix is divided with electrocautery. A polydioxanone suture ligature is used to ligate the base of the appendix. The appendix is divided and brought out of the umbilical port. After assuring hemostasis, the abdomen is desufflated and the gel port removed. The port site is closed with a running polyglactin suture, and the skin is closed with an absorbable monofilament. 0.25% bupivacaine with epinephrine is used at both the fascial and subcutaneous level for local anesthesia. The incision is covered with a sterile dressing.

Results

Four hundred and thirty-two (432) children underwent a single incision laparoscopic appendectomy. The average age in this study was 11.1 years. The overall length of stay was 2.1 days. Length of stay was calculated from arrival at the emergency department to discharge from the hospital. No children were sent home on opioids. In a subset analysis evaluating children with perforated appendicitis (n = 169), LOS was 4 days, the average age was 10.33 years, and 61.5% were male. The perforated population was determined with the requirement of a hole in the appendix, a free appendicolith, and/or abscess formation. Meanwhile, the nonperforated appendix population (n = 264), LOS 0.8 days, average age of 11.59 years, and 54.2% male. As expected, the differences between perforated and nonperforated appendectomies are significant for LOS (P < .001) and age (P < .01) Table 1. Following discharge of these patients, standard practice for this clinic is phone or in-person visits. All follow-up visits were performed, and no complaints of pain were recorded.

Discussion

Some studies have suggested that the single-incision approach has a significantly longer intraoperative duration than conventional laparoscopic surgery, but caution must be exercised as a large systematic review and meta-analysis of single-incision versus conventional laparoscopic appendectomy have shown the majority of such studies are nonrandomized. ¹ Unfortunately, this leaves many of these comparison studies open to bias, as the technique chosen may have been left up to surgeon preference or situation-dependent. Truly randomized studies would be better comparisons of operative time.

Technique aside, with a multimodal pain plan that includes intraoperative injection of local anesthesia, typically liposomal bupivacaine or lidocaine, as well as Acetaminophen and Ibuprofen by mouth postoperatively, postoperative pain can be adequately controlled without the use of postoperative narcotics. Being cognizant of opioid utilization in the management of postoperative pain control is important to address the current opioid crisis. ⁶ Our data show that opioids do not need to be the standard implement in our armamentarium against postoperative pain, as every child that underwent single incision laparoscopic appendectomy in this study received no narcotics upon discharge and no follow-up visits with complaints of worsening pain that cannot be resolved with PO Acetaminophen or Ibuprofen.

Conclusion

Single-incision laparoscopic appendectomy is a viable option for routine appendectomy in the pediatric population. This procedure is well tolerated, though it does have an initial learning curve that the learning surgeon must overcome. A nonnarcotic approach to postoperative pain is a viable option in single incision laparoscopic appendectomy.