clinical study transumbilical laparo-assisted appendectomy: a...

Hindawi Publishing CorporationMinimally Invasive SurgeryVolume 2013 Article ID 216416 4 pageshttpdxdoiorg1011552013216416

Clinical StudyTransumbilical Laparo-Assisted Appendectomy A SafeOperation for the Whole Spectrum of Appendicitis inChildrenmdashA Single-Centre Experience

D Codrich12 M G Scarpa1 M A Lembo1 F Pederiva1 D Olenik1

F Gobbo1 A Giannotta1 S Cherti3 and J Schleef1

1 Unit of Pediatric Surgery and Urology Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste Italy2 Department of Pediatric Surgery Childrenrsquos Hospital Burlo Garofolo Via dellrsquoIstria 651 34100 Trieste Italy3 Operatory Theatres Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste Italy

Correspondence should be addressed to D Codrich codrichyahoocom

Received 29 November 2012 Accepted 17 February 2013

Academic Editor Othmar Schob

Copyright copy 2013 D Codrich et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

The paper reports the results of a retrospective review of the medical charts of 203 patients admitted to a pediatric surgical unitwith a diagnosis of acute appendicitis between January 2006 and December 2010 when a transumbilical laparoscopic-assistedappendectomy (TULAA) was introduced as a new surgical technique Among 203 admitted patients 7 (35) had a localizedappendiceal abscess and were treated with antibiotics All of them responded to antibiotics and underwent TULAA intervalappendectomy 8 weeks later 196 patients (965) underwent immediate surgery In 12181 (66) urgent cases conversion tolaparotomy was necessary in 3 patients because of bowel distension and in 9 for retrocecal position of appendix In all 181 TULAAcompleted procedures one trocar was used in 151 cases (894) two trocars in 16 (94) and three trocars in 2 (12) The meanoperative time for single port TULAA was 521015840 Complications included 5 wound infections and 5 intra-abdominal abscesses allmanaged conservatively In conclusion TULAA is a safe minimally invasive approach with acute appendicitis regardless of theperforation status and can be recommended in the pediatric urgical settings

1 Introduction

Appendicitis is the most frequent indication for urgentsurgery in children Since 1894 when Mc Burney describedthe laparotomic technique for appendectomy the same oper-ation has been the gold standard for acute appendicitis forover a century In 1983 Semm [1] described for the firsttime the standard three ports laparoscopic appendectomyand since then the minimally invasive approach has gainedwide acceptance among the pediatric surgeons Differentvariations of the laparoscopic technique have been proposedall aiming to better cosmetic results reduction in costsand charges for hospitals while keeping the safety of theoperation unchanged The umbilicus as the unique site togain access to the abdomen and to the appendix has beenwidely reported in the literature both as a port to exteriorizethe appendix and perform an extracorporeal operation [2 3]

and as the site to place all laparoscopic instruments andperform an intracorporeal appendectomy (SILS single-sitelaparoscopic surgery) [4 5] The trans umbilical laparo-assisted technique (TULAA) merges together the advantagesof both a good intraabdominal laparoscopic visualizationand the safety and quickness of an extracorporeal traditionalappendectomy A large series of pediatric patients operatedon with this technique was presented in 1999 by Valla et al[2] but patients were selected for absence of complicatedappendicitis Recently Ohno et al presented a paper in whichthe TULAA procedure was used in 416 patients but withoutany perforated appendicitis or local abscesses in the series [6]

We present the experience of our centre in which the useof TULAA was firstly introduced in 2006 in a team whereonly one surgeon had used the technique before and it wasdecided to perform it with every kind of appendicitis with orwithout the suspect of complicated appendicitis

2 Minimally Invasive Surgery

2 Materials and Methods

The charts of all patients admitted to our surgical departmentfrom January 2006 to December 2010 with a diagnosis ofappendicitis based on clinical (migration of pain to rightlower quadrant (RLQ) fever and rebound tenderness inRLQ) laboratory (elevated WBC count elevate C ReactiveProtein (CRP)) andultrasound (US) findingswere retrospec-tively reviewed for demographical data surgical treatmenttime for completing the operation intraoperative findingneed for conversion and surgical complications

Before 2006 all suspected appendicitis regardless of his-tory and perforation status were treated by open surgery andantibiotic therapy was prescribed according to the preferenceof the surgeon Since 2006 a newprotocol for the treatment ofcomplicated and uncomplicated appendicitis was introducedin our surgical department

21 Protocol of Treatment All patients with suspected non-perforated or perforated appendicitis but with a historyof less than 72 hours and no ultrasound evidence ofconsolidated appendiceal mass are offered TULAA Allpatients undergoing surgery are administered a single doseof ampicillin plus sulbactam (50mgkgdose) as prophylaxis301015840 before starting the operation If there is no perforationthe therapy with the same antibiotic is continued for 24 hoursand then stopped whenever perforation is found a regimenof ceftriaxone (100mgkgdie in one administration) plusmetronidazole (75mgkgdose every 8 hrs) is administered aslong as the patient is afebrile for at least 24 hours inflamma-tory markers are diminishing and full oral diet is restoredIn case of discharge before 7 days of intravenous antibioticspatients are put on oral amoxicillin (50mgkgdose every12 hrs) and metronidazole (75mgkgdose every 8 hrs) tocomplete a whole week of therapy

All appendiceal masses (symptoms lasting for at least 72hours before presentation and US confirming the presenceof a consolidated appendiceal abscess) are admitted to theward and treated conservatively with an antibiotic regimenof ampicillin plus sulbactam (50mgkgdose every 8 hrs)metronidazole (75mgkgdose every 8 hrs) and tobramicina(5mgkgdie in one administration) After 48 hours of antibi-otics the patients are evaluated clinically and inflammatorymarkers (CRP and WBC) are repeated if laboratory andclinical improvements are observed the antibiotic therapyis continued until the patients are afebrile for at least 48hours inflammatory markers are progressively diminishingand oral diet is resumed After 8 weeks an interval TULAAis performed If no improvements are seen after 48 hoursof antibiotics the patients are offered TULAA Appendicealabscesses with US evidence of a fecalith are treated withimmediate TULAA since the fecalith is a known risk factorfor abscess persistence [7]

Patients are started on a liquid diet 12 hours after theoperation and on semiliquid diet in the first postoperativeday Gradually in 48 hours full oral diet is restored in uncom-plicated cases Criteria for discharge are patient afebrile forat least 24 hours restoration of full oral diet and decreasinginflammatory markers

22 Surgical Technique The patient is placed in the supineposition under general anesthesia and mechanical ventila-tion No bladder catheterization is used since all patients areasked to void before entering the operatory theatre

A single-infraumbilical incision is performed and an11mm balloon trocar is inserted under direct visualizationCapnoperitoneum is maintained within a range of 8to12mmHg according to the bodyweight of the patient withinsufflation of CO

2at a rate of 15 Lmin A single-operative

laparoscope (Karl Storz Endoskope Hopkins optical devices)with a side-arm viewing is inserted through a single tran-sumbilical port (Figure 1) and a grasper is used to identifythe appendix and to dissect retroperitoneal adhesions whenthe tip of the appendix is freed it is exteriorized through theumbilicus An extracorporeal appendectomy is performedby dividing and ligating the mesoappendix suture ligationand inversion with purse string of the appendiceal baseNo endomechanical devises are used In case of difficultdissection one or two further additional 5mm trocars foradditional graspers or cautery hook might be introduced

At the end of the procedure intraperitoneal local anes-thetic drugs such as naropine 02 at a dose of 05mLkg areinstilled in the peritoneal cavity through one of the trocarsPostoperative analgesia is administered via an elastomericintravenous pump with tramadol 2ndash8mcgkgmin for 24hours plus repeated doses of paracetamol 10mgkg every 8hours Nausea is controlled by ondansetron 015mgkg every8 hours and rescue analgesic therapy consists of ketoprofene1mgkg every 8 hours

When the appendectomy is considered impossible to besafely completed with any laparoscopic technique it is con-verted to an open access

A primary open access is chosen only when the perform-ing surgeons are not trained in laparoscopy or abdominaldistension is prominent

An expert TULA surgeon is defined as a surgeon who hasperformed at least 30 procedures as first operator or is trainedin laparoscopy

3 Results

From January 2006 until December 2010 203 patients (79female and 124 male) with an average age of 10 years (range3ndash17) were admitted to our surgical ward with a diagnosisof appendicitis Seven (34) out of 203 patients presentedwith an appendiceal mass and were treated conservativelyaccording to the protocol none required urgent surgeryand they all underwent interval TULAA 8 weeks later Theremaining 196 patients (965) underwent urgent surgery In15 out of 196 cases a primary open access was chosen in 3cases for marked abdominal distension in one case becausethe surgical team was not sufficiently trained in laparoscopyand in 11 cases because of palpation of a mass at the inductionof anesthesia and neither surgeons was an expert operatorSixty-six percent of the primary open accesses were per-formed in the first two years of the study Urgent TULAAwascarried out in 181 patientsThe intraoperative TULAAfinding(Figure 2) was uninflamed appendicitis in 18 cases (10)

Minimally Invasive Surgery 3

Figure 1 The instrumentation for the TULAA appendectomycautery hook operative scope and long graspers

uncomplicated acute appendicitis (catarrhalphlegmonouswithout signs of perforation) in 109 (60) cases 49 (27)cases were either gangrenous or perforated appendicitis withlocal peritonitis and 5 (3) were diffuse peritonitis The 7elective cases operated on after antibiotic treatment showedan appendixwith adhesions but no acute inflammationNoneof these was converted one required an additional trocar andno complications were recorded The mean operatory timefor the elective procedure was 431015840

Of all 181 urgent TULAA 12 (66) were converted in3 cases the intraoperative finding was nonperforated appen-dicitis with retrocaecal position in 8 cases there was a perfo-ration with local peritonitis and one was a diffuse peritonitisNine operations were converted by a team of nonexpertsurgeons and 3 by a team in which at least one surgeonwas considered expert Of the 169 nonconverted TULAAprocedures 151 were carried out through the single umbilicalport 16 (94) required a second trocar and 2 (12) requireda third trocar The mean operative time for single- portTULAA was 521015840 (471015840 when the first operator was an expert551015840 when the first was a nonexpert) Among the 181 urgentoperations there were 5 wound infections (38) of whichone required a surgical revision and 5 patients (38) werediagnosed as having postoperative intraperitoneal abscesswhich were all managed conservatively with intravenousantibiotics

4 Discussion

The TULAA technique was first reported in a large pedi-atric series by Valla et al in 1999 [2] It was described asumbilical one-puncture laparoscopic-assisted appendectomy(UOPLAA) and performed in 200 of preoperatively selectedchildren that showed no signs of advanced appendicitis ordiffuse peritonitis Our choice of offering TULAA as thefirst choice operation to the whole spectrum of appendicitis(except local consolidated abscess without fecaliths) wasdictated by the fact that this technique can be easily switchedto a standard three-port laparoscopic appendectomy whichis widely reported in the literature to be feasible also inadvanced form of appendicitis [8] In our series only 10of cases (16 urgent and one elective procedure) required an

TULAA intraoperative finding

Not inflamedAcute uncomplicated Gangrenousperforated with

local peritonitis

Diffuse peritonitis

310

60

27

Figure 2 TULAA intraoperative finding Macroscopic staging ofthe appendiceal inflammation

additional port and only 2 cases (one perforated appendicitiswith local peritonitis and one gangrenous retrocecal appen-dicitis) required the positioning of 2 additional trocars Thepossibility to insert a second or a third trocar in a positionthat suites the intraoperative findings and the anatomy ofthe patient rather than using the standard positions forthe traditional laparoscopic procedure can be of great helpduring the division of adherences and omentum especially inadvanced cases Similar results in the number of additionalports were reported by Stylianos et al [9] with 98 of 359cases which required one or two additional ports by Valla etal (8) [2] while Koontz et al [3] in 2006 reported a loweruse of additional trocars in only 2 of 111 patients (2) Thelatter report has also a lower rate of conversions (2) thanin our experience and this could be explained by the factthat when TULAA was first introduced in our hospital theequipment was not well trained in laparoscopy 75 of ourconversions were made by nonexpert members of the staffand 66 of cases were converted in the first two years ofthe protocol This confirms the need of a period of learningcurve and the possibility of using this operation as a startingtraining to acquire laparoscopic abilities Our operating time(52 minutes) seems longer than other reports Stylianos et al24 minutes [9] Visnjic 33 minutes [10] these series howeverexclude perforated appendicitis while we include all stagesof appendicitis The only complication we exclude was USconfirmed appendiceal abscess with a symptom durationlonger than 72 hours where a conservative management wascarried on according to the current literature [11]

Recently numerous reports appeared in the literaturedescribing the so-called SILS (single-incision laparoscopic


surgery) technique where a single umbilical trocar is used tointroduce three or four instruments or as an alternative atthe umbilical site a subcutaneous pocket is created and thenatural umbilical fascial defect plus one or two other stabincisions are used to place cannulas (or only instruments)to perform an endocorporeal laparoscopic appendectomy[4 5 12] However this kind of approach results in longeroperating times than standardmultiport laparoscopic appen-dectomy because of the clashing of instruments [12 13] andit does not have the remarkable reduction in costs that thesingle trocar operative scope have compared to standardlaparoscopic technique [9 10]

In our series 30 of cases were advanced stages ofappendicitis but we feel that this is not a condition that shouldstop from starting the operationwith a TULAA approach theonly real contraindication to TULAA is the intestinal loopsrsquohuge distension that may exist in some diffuse peritonitisThe concern for umbilical infections due to exteriorizationof a suppurative or ruptured appendix can be controlledif adequate skin gauze protection is secured around theumbilical openingwhen bringing the appendix out A routineantibiotic prophylaxis is also a recommended procedurebefore performing an appendectomy [14] Our rate of woundinfections (38) matches perfectly the one calculated forstandard three-port laparoscopic appendectomy in a recentmeta-analysis comparing open and laparoscopic appendec-tomy [15] therefore confirming that the extracorporealoperation does not endanger the umbilical scar

Petnehazy et al [16] suggest that TULAA can be a simplerapproach for appendectomy in obese children and even ifwe did not stratify our population by weight in the presentstudy a single incision has proved to be a quick and effectiveapproach for this kind of patients also in our hands

5 Conclusions

According to our experience TULAA is a safe minimallyinvasive approach to patients suffering for acute appendicitisregardless of the perforation status It is also a suitableoperation for training laparoscopic abilities and it has lowinstrumentation requirementsWe therefore recommend itswide use in the pediatric surgical settings

References

[1] K Semm ldquoEndoscopic appendectomyrdquo Endoscopy vol 15 no2 pp 59ndash64 1983

[2] J S Valla R M Ordorica-Flores H Steyaert et al ldquoUmbilicalone-puncture laparoscopic-assisted appendectomy in childrenrdquoSurgical Endoscopy vol 13 no 1 pp 83ndash85 1999

[3] C S Koontz L A Smith H C Burkholder K Higdon RAderhold and M Carr ldquoVideo-assisted transumbilical appen-dectomy in childrenrdquo Journal of Pediatric Surgery vol 41 no 4pp 710ndash712 2006

[4] O J Muensterer C Puga Nougues O O Adibe S R Amin KE Georgeson andCMHarmon ldquoAppendectomy using single-incision pediatric endosurgery for acute and perforated appen-dicitisrdquo Surgical Endoscopy andOther Interventional Techniquesvol 24 no 12 pp 3201ndash3204 2010

[5] N M Chandler and P D Danielson ldquoSingle-incision laparo-scopic appendectomy vs multiport laparoscopic appendectomyin children a retrospective comparisonrdquo Journal of PediatricSurgery vol 45 no 11 pp 2186ndash2190 2010

[6] Y Ohno T Morimura and S Hayashi ldquoTransumbilical laparo-scopically assisted appendectomy in children the results of asingle port single channel procedurerdquo Surgical Endoscopy vol26 pp 523ndash527 2012

[7] S H Ein J C Langer and A Daneman ldquoNonoperative man-agement of pediatric ruptured appendix with inflammatorymass or abscess presence of an appendicolith predicts recurrentappendicitisrdquo Journal of Pediatric Surgery vol 40 no 10 pp1612ndash1615 2005

[8] S L Lee A Yaghoubian and A Kaji ldquoLaparoscopic vs openappendectomy in childrenOutcomes comparison based on agesex and perforation statusrdquo Archives of Surgery vol 146 pp1118ndash1121 2011

[9] S Stylianos L Nichols N Ventura L Malvezzi C Knight andC Burnweit ldquoThe ldquoall-in-onerdquo appendectomy quick scarlessand less costlyrdquo Journal of Pediatric Surgery vol 46 pp 2336ndash2341 2011

[10] S Visnijc ldquoTrans umbilical laparo assisted appendectomy inchildren High-tech low-budget surgeryrdquo Surgical Endoscopyvol 22 pp 1667ndash1671 2008

[11] C Simillis P Symeonides A J Shorthouse and P P Tekkis ldquoAmeta-analysis comparing conservative treatment versus acuteappendectomy for complicated appendicitis (abscess or phleg-mon)rdquo Surgery vol 147 no 6 pp 818ndash829 2010

[12] S C Oltmann N M Garcia B Ventura I Mitchell and AC Fischer ldquoSingle-incision laparoscopic surgery feasibility forpediatric appendectomiesrdquo Journal of Pediatric Surgery vol 45no 6 pp 1208ndash1212 2010

[13] D J Ostlie ldquoSingle-site umbilical laparoscopic appendectomyrdquoSeminars in Pediatric Surgery vol 20 pp 196ndash200 2011

[14] B RAndersen F L Kallehave andHKAndersen ldquoAntibioticsversus placebo for prevention of postoperative infection afterappendicectomyrdquo Cochrane Database of Systematic Reviews no3 Article ID CD001439 2005

[15] X Li J Zhang L Sang et al ldquoLaparoscopic versus conventionalappendectomy - a meta-analysis of randomized controlledtrialsrdquo BMC Gastroenterology vol 10 article 129 2010

[16] T Petnehazy A K Saxena H Ainoedhofer M E Hoellwarthand J Schalamon ldquoSingle-port appendectomy in obese chil-dren an optimal alternativerdquo Acta Paediatrica vol 99 no 9pp 1370ndash1373 2010

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


2 Materials and Methods

The charts of all patients admitted to our surgical departmentfrom January 2006 to December 2010 with a diagnosis ofappendicitis based on clinical (migration of pain to rightlower quadrant (RLQ) fever and rebound tenderness inRLQ) laboratory (elevated WBC count elevate C ReactiveProtein (CRP)) andultrasound (US) findingswere retrospec-tively reviewed for demographical data surgical treatmenttime for completing the operation intraoperative findingneed for conversion and surgical complications

Before 2006 all suspected appendicitis regardless of his-tory and perforation status were treated by open surgery andantibiotic therapy was prescribed according to the preferenceof the surgeon Since 2006 a newprotocol for the treatment ofcomplicated and uncomplicated appendicitis was introducedin our surgical department

21 Protocol of Treatment All patients with suspected non-perforated or perforated appendicitis but with a historyof less than 72 hours and no ultrasound evidence ofconsolidated appendiceal mass are offered TULAA Allpatients undergoing surgery are administered a single doseof ampicillin plus sulbactam (50mgkgdose) as prophylaxis301015840 before starting the operation If there is no perforationthe therapy with the same antibiotic is continued for 24 hoursand then stopped whenever perforation is found a regimenof ceftriaxone (100mgkgdie in one administration) plusmetronidazole (75mgkgdose every 8 hrs) is administered aslong as the patient is afebrile for at least 24 hours inflamma-tory markers are diminishing and full oral diet is restoredIn case of discharge before 7 days of intravenous antibioticspatients are put on oral amoxicillin (50mgkgdose every12 hrs) and metronidazole (75mgkgdose every 8 hrs) tocomplete a whole week of therapy

All appendiceal masses (symptoms lasting for at least 72hours before presentation and US confirming the presenceof a consolidated appendiceal abscess) are admitted to theward and treated conservatively with an antibiotic regimenof ampicillin plus sulbactam (50mgkgdose every 8 hrs)metronidazole (75mgkgdose every 8 hrs) and tobramicina(5mgkgdie in one administration) After 48 hours of antibi-otics the patients are evaluated clinically and inflammatorymarkers (CRP and WBC) are repeated if laboratory andclinical improvements are observed the antibiotic therapyis continued until the patients are afebrile for at least 48hours inflammatory markers are progressively diminishingand oral diet is resumed After 8 weeks an interval TULAAis performed If no improvements are seen after 48 hoursof antibiotics the patients are offered TULAA Appendicealabscesses with US evidence of a fecalith are treated withimmediate TULAA since the fecalith is a known risk factorfor abscess persistence [7]

Patients are started on a liquid diet 12 hours after theoperation and on semiliquid diet in the first postoperativeday Gradually in 48 hours full oral diet is restored in uncom-plicated cases Criteria for discharge are patient afebrile forat least 24 hours restoration of full oral diet and decreasinginflammatory markers

22 Surgical Technique The patient is placed in the supineposition under general anesthesia and mechanical ventila-tion No bladder catheterization is used since all patients areasked to void before entering the operatory theatre

A single-infraumbilical incision is performed and an11mm balloon trocar is inserted under direct visualizationCapnoperitoneum is maintained within a range of 8to12mmHg according to the bodyweight of the patient withinsufflation of CO

2at a rate of 15 Lmin A single-operative

laparoscope (Karl Storz Endoskope Hopkins optical devices)with a side-arm viewing is inserted through a single tran-sumbilical port (Figure 1) and a grasper is used to identifythe appendix and to dissect retroperitoneal adhesions whenthe tip of the appendix is freed it is exteriorized through theumbilicus An extracorporeal appendectomy is performedby dividing and ligating the mesoappendix suture ligationand inversion with purse string of the appendiceal baseNo endomechanical devises are used In case of difficultdissection one or two further additional 5mm trocars foradditional graspers or cautery hook might be introduced

At the end of the procedure intraperitoneal local anes-thetic drugs such as naropine 02 at a dose of 05mLkg areinstilled in the peritoneal cavity through one of the trocarsPostoperative analgesia is administered via an elastomericintravenous pump with tramadol 2ndash8mcgkgmin for 24hours plus repeated doses of paracetamol 10mgkg every 8hours Nausea is controlled by ondansetron 015mgkg every8 hours and rescue analgesic therapy consists of ketoprofene1mgkg every 8 hours

When the appendectomy is considered impossible to besafely completed with any laparoscopic technique it is con-verted to an open access

A primary open access is chosen only when the perform-ing surgeons are not trained in laparoscopy or abdominaldistension is prominent

An expert TULA surgeon is defined as a surgeon who hasperformed at least 30 procedures as first operator or is trainedin laparoscopy

3 Results

From January 2006 until December 2010 203 patients (79female and 124 male) with an average age of 10 years (range3ndash17) were admitted to our surgical ward with a diagnosisof appendicitis Seven (34) out of 203 patients presentedwith an appendiceal mass and were treated conservativelyaccording to the protocol none required urgent surgeryand they all underwent interval TULAA 8 weeks later Theremaining 196 patients (965) underwent urgent surgery In15 out of 196 cases a primary open access was chosen in 3cases for marked abdominal distension in one case becausethe surgical team was not sufficiently trained in laparoscopyand in 11 cases because of palpation of a mass at the inductionof anesthesia and neither surgeons was an expert operatorSixty-six percent of the primary open accesses were per-formed in the first two years of the study Urgent TULAAwascarried out in 181 patientsThe intraoperative TULAAfinding(Figure 2) was uninflamed appendicitis in 18 cases (10)





4 Discussion




local peritonitis

Diffuse peritonitis

310

60

27








5 Conclusions


References






















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of




















4 Discussion




local peritonitis

Diffuse peritonitis

310

60

27








5 Conclusions


References






















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of




















5 Conclusions


References






















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















clinical study transumbilical laparo-assisted appendectomy: a...

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