1. The IPEG Annual Congress joins with:
II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS)
VII Congress of the Federation of Pediatric Surgical
Associations of the South Cone of America (CIPESUR)

2. Appendicitis: Current Management
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, MO

3. Appendicitis History Examination Imaging - Abdominal film? Ultrasound?
CT scan?

4. Laparoscopic Appendectomy
Since 2002, used exclusively
Perforated, non-perforated, abscess
Why:
Definitely fewer wound problems c/o open operation
Less small bowel obstruction

5. Laparoscopic Appendectomy Port Positions
12 mm umbilical port - working port/stapler
5 mm LLQ - telescope/camera
5 mm L suprapubic region - retraction

6. Laparoscopic Appendectomy Technique
Window in mesoappendix
Vascular stapler across mesoappendix

7. Laparoscopic Appendectomy Technique
Regular stapler across base of appendix
Extract through 12 mm umbilical cannula
Bag used selectively

8. Acute Appendicitis - Contained Perforation
Perforated appendicitis (3 - 5 day hx)
Evacuation/irrigation
Controlled spillage
Wound problems minimized

9. Acute Appendicitis - Free Perforation Hemodynamically Stable
Laparoscopic appendectomy
reduced discomfort
selectively irrigate/evacuate pus
lyse adhesions
few wound problems
often NGT not needed

10. Acute Appendicitis - Free Perforation Hemodynamically Unstable
IVF Resuscitation
Antibx/NGT
Open appendectomy
Lower midline incision
RLQ incision
Prolonged ( days) hospitalization
Rare patient

11. Acute Appendicitis – Contained Perforation Hemodynamically Stable
5 - 7 day history
IVF
Percutaneous drainage (radiology)
PICC line - antibx
Discharge day 3-5 if stable
Antibx con’t days at home
Return 8-10 wk. for interval appendectomy - overnight hospitalization

12. Interval Appendectomy
Why?

13. Appendectomy Studies at Children’s Mercy

14. Postoperative Antibiotic Regimen for Perforated Appendicitis
Prospective, randomized trial
AGC vs CM
50 pts each arm
Definition of perforation
Hole in appendix
Stool in abdomen
AAP, 2007

15. Postoperative Antibiotic Regimen for Perforated Appendicitis
No difference b/w groups re: weight, gender, days of symptoms, temperature, WBC count on admission
Table 1 – Outcomes: CM vs AGC CM
AGC
P Value
Time to Regular Diet (Hours)
75 +/- 48
79 +/- 41
0.68
Length of Post-Op Hospitalization (Days)
6.0 +/1 2.4
6.1 +/- 2.5
0.94
Post-Operative Abscess
15.9%
17.8%
0.81
Narcotic Charges
$258 +/- $150
$361 +/- $247
0.02
Antibiotic Charges
$1,246 +/- $490
$1,919 +/- $648
<0.001
AAP, 2007

16. Postoperative Antibiotic Regimen for Perforated Appendicitis
Conclusion:
Ceftriaxone and metronidazole offers a more efficient, cost-effective antibiotic regimen than ampicillin, gentamicin, clindamycin for children with perforated appendicitis. Also, it may allow earlier resolution of symptomatic peritoneal irritation as reflected by lower narcotic needs.

17. Attempted percutaneous drainage, interval appendectomy
Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess
Retrospective study
June 00 – Dec 06
52 pts
Attempted percutaneous drainage, interval appendectomy
AAP, 2007

18. Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess
Mean age –
9.0 +/- 3.9 yrs
Mean weight -
34.4 +/ 18.8 kg
Mean symptoms -
8.4 +/- 7-6 days
Mean volume fluid -
76.3 +/ cc
Mean time to interval appy –
61.9 +/ days
Mean post-op hosp. after interval lap appy -
1.4 +/- 1.4 days
Drain complications –
ileal perforation
colon perforation
bladder perforation
buttock/thigh abscess
AAP, 2007

19. Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess
Outcome Variables
Mean +/- Std Dev
Number of CT scans
3.5 +/- 2.0
Total hospital days
7.0 +/- 3.9
Total days of drainage
6.4 +/- 7.0
Number of healthcare visits
7.6 +/- 2.8
Total charges (thousands of $)
$54.3 +/- $55.2
Recurrent abscess
19.2 %
Repeat drainage
11.5%
AAP, 2007

20. Jan 98-June 05: 1105 appendectomies-447 open, 628 lap.
Adhesive Small Bowel Obstruction After Appendectomy in Children: Comparison Between the Laparoscopic and Open Approach
Jan 98-June 05: 1105 appendectomies-447 open, 628 lap.
AAP 2006
J Pediatr Surg 42: , 2007

21. Laparoscopic versus Open Appendectomy
Laparoscopic (n = 628)
Open (n = 477)
P Value
Age (years)
11.0 +/- 3.7
9.2 +/- 5.1
p > 0.05
Gender (M/F)
355/273
301/176
SBO
1 (0.2%)
7 (1.5%)
p = 0.01
Perforated appendicitis
186
192
p = 0.03
Mean time to SBO
8 days
58 days
Median follow-up (years)
3.5 (0.8 – 6.5)
4.9 (0.9 – 8.3)
AAP 2006
J Pediatr Surg 42: , 2007

22. SBO After Perforated Appendicitis
Laparoscopic
Open
p value
Perforated appendicitis
186
192
p = 0.03
SBO
1 (0.5%)
6 (3.1%)
p = 0.03
AAP 2006
J Pediatr Surg 42: , 2007

23. Prospective Randomized Trial
Patients presenting with an abscess
IR drainage with IV antibiotics followed by laparoscopic interval appendectomy vs laparoscopic appendectomy and evacuation of abscess on admission
Pilot study: 30 patients

24. Conclusions
Lap appendectomy is our preferred approach for all forms of appendicitis
Lap appendectomy can be performed for perforated appendicitis and for patients presenting with an abscess
Lap appendectomy results in fewer wound problems and less SBO

25. ? ? ?