|Year : 2014 | Volume
| Issue : 2 | Page : 244-248
Laparoscopic versus open appendectomy in children
Mohamed Yasser Abdelaty1, Magdy Ahmed Lolah1, Moharam Abdel Samie Mohamed1, Ahmed Saad Arafa2
1 Department of General Surgery, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
2 Department of General Surgery, Abu Qir Hospital, Alexandria, Egypt
|Date of Submission||25-Mar-2013|
|Date of Acceptance||02-Jun-2013|
|Date of Web Publication||26-Sep-2014|
Ahmed Saad Arafa
MBBCh, 24 Ebn Shaltoot, Asafra Bahri, Alexandria
Source of Support: None, Conflict of Interest: None
The aim of the present work is to compare laparoscopic appendectomy (LA) versus open appendectomy (OA) in children in terms of the following: duration of operation, postoperative pain, analgesic requirement, hospital stay, postoperative complications, and return to normal activities.
LA is the routine technique used in the management of acute appendicitis in children in many centers. In this study, the classic three-port LA technique is compared with the OA technique in the management of acute appendicitis.
Patients and methods
This was a retrospective study of cases of noncomplicated acute appendicitis treated laparoscopically between February 2011 and February 2012. Patients treated by the laparoscopy and open techniques were compared in terms of the duration of operation, operative and postoperative complications, and the length of hospital stay.
During the study period, 40 children (18 males and 22 females) underwent LA or OA for acute appendicitis: 20 children by the laparoscopic technique (group I) and 20 children by the open technique (group II). The mean age of the children was 9.4 years (range 4-18) in group I and 12 years (range 3.5-18) in group II. The mean operative duration was 33.1 min (range 19-45) in group I and 23.7 min in group II (range 14-35). Port-site infection (redness or discharge) was the same in both groups (10%). Postoperative ileus (>48 h) occurred in one patient (5%) in group I and in two patients (10%) in group II. The mean length of hospital stay was 1.8 days in group I and 2.4 days in group II. Two patients in group I were converted to OA (conversion rate 8%).
LA has the advantage of resulting in less postoperative pain, shorter postoperative ileus, earlier postoperative recovery, lower complication rates, and shorter hospital stay, whereas OA has the advantage of being a shorter procedure.
Keywords: Acute appendicitis, appendectomy, laparoscopic appendectomy, open appendectomy
|How to cite this article:|
Abdelaty MY, Lolah MA, Mohamed MA, Arafa AS. Laparoscopic versus open appendectomy in children. Menoufia Med J 2014;27:244-8
| Introduction|| |
Appendicitis is the most common surgical emergency in pediatrics; early diagnosis and treatment considerably reduce the morbidity and the possible mortality of this condition. Appendectomy is one of the most commonly performed pediatric surgical procedures .
The documented benefits of the laparoscopic appendectomy (LA) procedure have led to its increasing acceptance for the treatment of appendicitis; it is nonetheless considered more expensive to perform than a traditional open appendectomy (OA) .
There are persistent doubts on the advantages and disadvantages of using LA for complicated appendicitis . Some authors have raised doubts because of the increased risk of intra-abdominal abscess following LA for a perforated appendix (PA) . The introduction of laparoscopy enables visualization of the entire abdominal cavity in patients of diagnostic dilemmas .
| Patients and methods|| |
Forty patients were admitted to the ER Department at the University Hospital of Menoufiya. All were subjected randomly to OAs or LAs.
They were randomized into two groups by the closed-envelope technique.
- Suspected cases of acute appendicitis.
- Age (up to 18 years).
- Inflammatory bowel disease.
- Cardiac patients.
Forty patients with a clinical diagnosis of acute appendicitis were allocated randomly to two groups:
included 20 patients for whom LA was performed.
included 20 patients for whom OA was performed.
Laparoscopic appendectomy techniques
After induction of general anesthesia, patients were placed in the supine position and a Foley catheter was placed to decompress the bladder. All patients received preoperative intravenous antibiotics.
The peritoneal cavity was accessed by an infraumbilical incision using a Veress needle. Pneumoperitoneum was induced with low-flow carbon dioxide up to a pressure of 10-12 mmHg. A 5- or 12-mm-port was then placed and a 5-mm 30° laparoscope was used for the procedure.
Two additional 3- or 5-mm ports were placed in the left lower quadrant and in the midline suprapubic position, ensuring identification and avoidance of the dome of the bladder. Instruments of 3- and 5-mm were used for the procedure.
Once the appendix was localized, dissected free, and grasped, the mesoappendix was taken down under tension using hook electrocautery. Once the base was cleared, it was ligated, and the appendix was resected using 5-mm polydioxanone endoloops deployed at the base and the appendix was sharply excised.
The appendix was then removed through the umbilical port itself. The appendix was placed in an endocatch bag before removal.
After removal of the appendix, the abdomen and pelvis were irrigated thoroughly with warm sterile saline and then the wound was closed.
| Results|| |
A statistically significant difference was found when comparing the operative time of the LA and OA. The operating times in OA and LA were 14-35 min (mean 23.7) and 19-45 min (mean 33.1), respectively. The OA was shorter in duration, with a P value less than or equal to 0.05 (Mann-Whitney test).
Using the Wong-Baker FACES Pain Rating Scale , it was found that 15% of the patients in the LA group had pain whereas 30% of the patients in the OA group had pain.
Length of the hospital stay
The hospital stay decreased significantly with LA. The mean postoperative hospital stay in the LA group was 1.8 days, whereas in the OA group, it was 2.4 days (P ≤ 0.05) (Mann-Whitney test).
Postoperative pain was evaluated by the number of analgesic injections required. Patients who underwent LA and OA were treated with intravenous or intramuscular Ketolac injections at 12-h intervals. Analgesic requirements decrease significantly with laparoscopy (Mann-Whitney test) [Table 1].
|Table 1: Comparison between the laparoscopic appendectomy and open appendectomy groups according to operative time, hospital stay, analgesia, and return to normal activities|
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Wound infection or port-site infection was recorded in four patients: two patients (10%) in the LA group and two patients (10%) in the OA group, and all after a PA.
Postoperative ileus represents the number of days from the surgery until the ability to tolerate an oral diet without abdominal distension, nausea, or vomiting. In the present study, one patient (5%) in the LA group and two patients (10%) in the OA group were unable to tolerate oral feeding. Statistical analysis showed an insignificant difference between the two groups (Fisher's exact test).
No cases of intra-abdominal collection were observed in either group.
Return to normal activities
The mean period of return to normal activity (playing in home, go back to school) was 3.5 days earlier in the LA group (10.6 days) than in the OA group (14.1 days), which was statistically significant, with a P value less than 0.001 (Mann-Whitney test).
In this study, readmission occurred once in the LA group because of the inability to tolerate oral feeding after discharge (for 1 day), and three times in the OA group because of another pathology (2 days), wound abscess (1 day), and intolerant oral feeding (1 day) [Table 2].
|Table 2: Comparison between the laparoscopic appendectomy and open appendectomy groups according to postoperative pain, wound infection, postoperative ileus, and readmission|
Click here to view
| Discussion|| |
Appendicitis is the most common among all abdominal emergencies in pediatrics. Appendectomy is the most common and effective abdominal operation. Although LA emerged more than 20 years ago, it has not gained universal acceptance among pediatric surgeons as an option for the treatment of this problem .
The technique of LA was initiated by gynecologists and was later adopted by general surgeons . Although adopted by many centers as a gold standard, the benefits of LA over OA is still being debated by many surgeons. This may be attributed to the simplicity of the OA, which is easy to perform, its relatively low morbidity, and fewer cosmetic problems.
One of the most important benefits of laparoscopy in appendicitis is the possibility of detecting other pathologies during formal exploration, but this was not found in this study as no other pathologies were detected in any patient.
In this study, the mean operative time was about 13.9 min shorter in the OA group (38.2 min) compared with the LA group (52.1 min). The difference was statistically significant with a P value of 0.05. This is comparable with other studies reporting about a 10.7-30 min shorter mean operative time for the OA group. A prospective randomized trial comparing LA with OA was conducted in 158 patients by Hansen et al. They reported a mean operative time of 63 min in the LA group versus 40 min in the OA group. Phillips et al.  studied how the learning curve can affect the different parameters; the operative time decreased significantly for both PA and nonperforated, with P value of 0.0001 for both groups. The operation time of LA also depends on the experience of the surgeon and the competence of his/her team .
When considering operating time, the exact identification of the start of the procedure and its conclusion varies. In general, the duration of operation should be calculated from the insertion of the first trocar to the end of skin suturing. Cox et al.  defined operating time as the time from incision to wound closure. Ate et al.  defined the time as induction of anesthesia to the administration of a reversal agent.
Generally, all laparoscopic procedures are more time consuming for the following reasons :
(1) Inherent nature of the slow maneuver of laparoscopic techniques.
(2) Time taken because of careful slow insufflation.
(3) Routine diagnostic laparoscopy before starting any laparoscopic procedure.
It is known that laparoscopic procedures cause less postoperative pain than their conventional counterparts. In this study, the postoperative analgesia used was less after LA compared with OA. The mean analgesic requirement was 3.6 days in the OA group and 2 days in the LA group, Statistical analysis showed a significant difference between the two groups with a P value of less than or equal to 0.05. In one study carried out by Ortega et al., linear analogue pain scores were recorded in 135 patients blinded to the procedure of operation by special dressing and the pain score was very low in the LA group compared with OA group. This could have resulted from the expectation that laparoscopic procedures are painless, because of a lower level of endorphins released, or the peritoneal injury from the pneumoperitoneum.
The reduction in wound infection is a significant advantage of LA. The probability of wound infection is greater in OA partly because the inflamed appendix is removed from the abdominal cavity directly through the wound, whereas in LA, it is extracted through a bag or a trocar. In addition, the port-site wounds in LA are smaller compared with the larger wounds of OA, especially in obese patients.
The wound infection rate in the present study was the same with LA, as two patients (10%) developed port-site infection, and OA, with two patients (10%) developing wound sepsis; yet, this was not statistically significant. All of the four cases were after PA. Other studies reported infection rates of 0-4% for LA group and 9-11% for the OA group, which was statistically significant ,. Rohr et al. reported higher wound infection rates after LA, but most of the literature supports the view that wound infection is less common after a laparoscopic procedure. It should be kept in mind that the definition of wound infection varies between studies .
In the present study, one patient (5%) in the LA group and two patients (10%) in the OA group could not tolerate oral feeding. Statistical analysis showed an insignificant difference between the two groups (P value = 1). Other studies carried out on 100 patients reported two patients (4%) in LA versus 12 patients (24%) in OA with prolonged paralytic ileus for more than 48 h .
There are several explanations for the reduction in ileus following LA. First, decreased handling of the bowel during the procedure leads to less postoperative adhesion, and this adhesion may be responsible for ileus. Second, after LA, patients received fewer opiate analgesics, which inhibited bowel movements in the postoperative period. Finally, earlier mobilization after LA may have also contributed toward the reduction in adhesion .
The hospital stay is the time between surgery and discharge. Decrease in the postoperative inpatient period of surgical procedures is one of the main advantages of laparoscopy has provided to surgery in general.
On comparing the mean hospital stay between the LA and OA groups in the present study, we found that it decreased significantly with LA. The mean postoperative hospital stay in the LA group was 1.8 days, whereas in the OA group, it was 2.4 days; yet, the effect is demonstrated more with a P value of 0.005. A comparative study carried out by Vernon and colleagues was not in agreement with this as in his study, on comparing LA and OA in pediatrics, he found no significant between the two groups in the hospital stay (P = 0.59) . Oka et al.  reported that the length of hospital stay was 5.2 days in the OA group and 4.3 days in the LA group; this was again statistically insignificant.
Readmission was reported in one patient who had undergone LA in this study because of inability to tolerate oral feeding after discharge. Readmission was reported in three patients of OA, the first one complaining of prolonged postoperative vomiting and pain after OA (for catarrhal inflammation); readmission occurred after 10 days of the discharge, and computed tomographic examination indicated Rt. pelviuretric stone and Rt. ovarian cyst (hospital stay 2 days). The second patient was readmitted for evacuation of infected seroma (abscess) in the operating room (hospital stay 1 day). In the last patient, readmission occurred because of inability to tolerate oral feeding after discharge (hospital stay 1 day). Yang et al. , reported no readmissions in his study on 15 patients with acute appendicitis who had undergone LA using Ligasure, neither did Aydogan 18 when comparing Ligasure with endoclips. Ponsky 19 also did not report any readmissions; he depended solely on Monopolar Diathermy in the devascularization step.
The mean period of return to normal activity was 3.5 days earlier in the LA group (10.6 days) than the OA group (14.1 days), which was statistically significant, with a P value less than 0.001. In another study, the mean period of return to normal activity was 7 days earlier in the LA group (12.5 days) than the OA group (19.5 days), and this is comparable with the figures reported in other studies ,,.
In the present study, two patients were converted from LA to OA because of extensive adhesion of a retrocecal appendix and uncontrollable bleeding from the mesoappendix. Yang converted two out of 15 patients into OA: one because of bleeding and the other because of inability to dissect extensively inflamed retrocecal appendix.
It is difficult to understand why the conversion rate from LA to OA increased over time. Perhaps as experience with the laparoscopic procedure is gained, surgeons might attempt to perform LA for complicated cases such as gangrenous and PA .
| Conclusion|| |
From the previous study, we concluded that:
- LA is safe and feasible for the management of acute appendicitis in children.
- LA has the advantage of producing less postoperative pain, shorter postoperative ileus, earlier postoperative recovery, lower complication rate, and shorter hospital stay, whereas OA has the advantage of being a shorter procedure.
The widespread use of LA is routinely recommended in hospitals where laparoscopic expertise and equipment are available as it is a reproducible technique that has both therapeutic and diagnostic advantages.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
|1.||Taqi E, Al Hadher S, Ryckman J, Su W, Aspirot A, Puligandla P, et al. Outcome of laparoscopic appendectomy for perforated appendicitis in children. J Pediatr Surg 2008; 43 :893-895. |
|2.|| Wehrman WE, Tangren CM, Inge TH. Cost analysis of ligature versus stapling techniques of laparoscopic appendectomy in children. J Laparoendosc Adv Surg Tech A 2007; 17 :371-374. |
|3.|| Vegunta RK, Ali A, Wallace LJ, Switzer DM, Pearl RH. Laparoscopic appendectomy in children: technically feasible and safe in all stages of acute appendicitis. Am Surg 2004; 70 :198-201. discussion 201-2 |
|4.|| Oka T, Kurkchubasche AG, Bussey JG, Wesselhoeft CWJ, Tracy TFJ, Luks FI. Open and laparoscopic appendectomy are equally safe and acceptable in children. Surg Endosc 2004; 18 :242-245. |
|5.|| Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P. Wong′s essentials of pediatric nursing. St Louis: 2001. |
|6.|| Appendectomy in pediatrics open or laparoscopic. Egypt J Surg 2004; 23 :226-229. |
|7.|| Schreiber JH. Early experience with laparoscopic appendectomy in women. Surg Endosc 1987; 1 :211-216. |
|8.|| Phillips S, Walton JM, Chin I, Farrokhyar F, Fitzgerald P, Cameron B. Ten-year experience with pediatric laparoscopic appendectomy - are we getting better? J Pediatr Surg 2005; 40 :842-845. |
|9.|| Chung RS, Rowland DY, Li P, Diaz J. A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg 1999; 177 :250-256. |
|10.||Cox MR, McCall JL, Toouli J, Padbury RTA, Wilson TG, Wattchow DA, et al. Prospective randomized comparison of open versus laparoscopic appendectomy in men. World J Surg 1996; 20 :263-266. |
|11.||Ate JJT. Laparoscopic appendicectomy. Br J Surg 83 :1169-1170. |
|12.||Mishra RK, Hanna GB, Cuschieri A. Laparoscopic versus open appendectomy for the treatment of acute appendicitis. World J Surg 2008; 1 :19-28. |
|13.||Laine S, Rantala A, Gullichsen R, Ovaska J. Laparoscopic appendectomy: is it worthwhile? A prospective, randomized study in young women. Surg Endosc 1997; 11 :95-97. |
|14.||Attwood SE, Hill AD, Murphy PG, Thornton J, Stephens RB. A prospective randomized trial of laparoscopic versus open appendectomy. Surgery 1992; 112 :497-501. |
|15.||Basant K, Abdul Samad TWK, Muhammad HL, Abdul Razaque S. Superiority of laparoscopic appendectomy over open appendectomy: the Hyderabad experience. Rawal Med J 2008; 33 :165-168. |
|16.||Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, et al. Laparoscopic versus conventional appendectomy - a meta-analysis of randomized controlled trials. BMC Gastroenterol 2010; 10 :129. |
|17.||Yang HR, Wang YC, Chung PK, Jeng LB, Chen RJ. Laparoscopic appendectomy using the Ligasure vessel sealing system. J Laparoendosc Adv Surg Tech A 2005; 15 :353-356. |
|18.||Aydogan F, Saribeyoglu K, Simsek O, Salihoglu Z, Carkman S, Salihoglu T, et al. Comparison of the electrothermal vessel-sealing system versus endoclip in laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A 2009; 19 :375-378. |
|19.||Ponsky TA, Rothenberg SS. Division of the mesoappendix with electrocautery in children is safe, effective, and cost-efficient. J Laparoendosc Adv Surg Tech A 2009; 19 :S11-S13. |
|20.||Reiertsen O, Larsen S, Trondsen E, Edwin B, Faerden AE, Rosseland AR. Randomized controlled trial with sequential design of laparoscopic versus conventional appendicectomy. Br J Surg 1997; 84 :842-847. |
|21.||Pedersen AG, Petersen OB, Wara P, Rønning H, Qvist N, Laurberg S. Randomized clinical trial of laparoscopic versus open appendicectomy. Br J Surg 2001; 88 :200-205. |
|22.||Vernon AH, Georgeson KE, Harmon CM. Pediatric laparoscopic appendectomy for acute appendicitis. Surg Endosc 2004; 1:75-79. |
[Table 1], [Table 2]