Is There a Role for Laparoscopic Appendectomy Pediatric Surgery? ByBrian
in
F. Gilchrist, Thorn E. Lobe, Kurt P. Schropp, Gail A. Kay, S. Douglas Hixson, Earle L. Wrenn, Jr, Paul G. Philippe, and Robert S. Hollabaugh Memphis,
0 Although laparoscopic procedures are currently in vogue in general surgery, the role of this approach in children has not been prospectively evaluated in the United States using the new instrumentation now available to us. To assess the value of laparoscopic appendectomy (LA) in childhood, we prospectively compared 14 LAS with 50 open appendectomies (OA) over 6 months in a single children’s hospital. Antibiotic usage was at the discretion of the surgeon regardless of the procedure performed and was not different between groups. LA was performed under the direction of a single laparoscopy-trained surgeon and patient selection was based on parental consent. A three-puncture LA technique was used; children from this group were allowed to return to full activities as soon as they were comfortable. There were no significant differences between groups for severity of disease, age, weight, hospital cost, or complications. The types of complications that developed were comparable in both groups. The percent of complicated appendicitis (gangrene or perforation) was 32% in the OA group and 36% in the LA group. Patients in the LA group spent significantly fewer days in the hospital and returned to unrestricted activities (school, athletics, etc) faster than patients in the OA group. LA is approximately $1,000 more expensive than OA, the differences being easily explainable by the cost of the disposable supplies necessary for the procedure (laser fibers, trocars, etc), but because of the shorter hospital stay in the LA group the mean total cost for each group was comparable. These data suggest that although there appears to be no cost advantage, LA shortens the hospital stay and allows children to return to unrestricted activity sooner than OA. LA should be considered as a reasonable alternative to OA and may be the procedure of choice in the hands of pediatric surgeons experienced in laparoscopic techniques. Copyright s 1992 by WA Saunders Company INDEX WORDS: Appendectomy,
laparoscopic.
L
APAROSCOPIC surgery is well-established in a number of surgical specialtieslm3 for a variety of indications,‘-’ and it is especially in vogue in current general surgical practice.8 Although Gans and others” ’ have advocated diagnostic and therapeutic laparoscopy in children for over 20 years, the concepts have not caught on. In an attempt to assess the value of laparoscopic surgery for pediatric patients today, we chose a commonly performed procedure, appendectomy, and compared the results of open appendectomy (OA) with the laparoscopic procedure (LA) in a single institution’s practice. MATERIALS AND METHODS We prospectively evaluated surgery for appendicitis in our children’s hospital between April 1990 and October 1990. SixtyJournalofPediatric Surgery, Vol27, No 2 (February), 1992: pp 209-214
Tennessee
four operations for appendicitis were performed. Selection for OA or LA was done by surgeon availability, according to the staff pediatric surgeon on-call schedule. When the laparoscopy-trained surgeon was available, all patients (regardless of the severity of their illness) were offered the laparoscopic procedure. Permission to enter the study was based on parental consent. The two groups of patients (OA and LA) were assessed for severity of disease (fever. leukocytosis, peritonitis, and duration of symptoms), age, weight, operative time and cost, hospital cost, days of hospitalization, complications, and the interval between operation and return to unrestricted activity. Severity of disease was evaluated by xz analysis. The presence of fever, magnitude of leukocytosis (2 15,000, 15,000 to 7,000, or 5 7,000), presence or absence of peritonitis, and duration of symptoms were classified as being less than 24 hours, between 24 to 48 hours, and greater than 48 hours. The differences between simple acute and complicated (gangrenous or ruptured) appendicitis between groups were evaluated by analysis of variance (ANOVA). All other data were analyzed by the unpaired Student’s t test. A three-puncture LA technique modified from Semm” was used: under general anesthesia, a nasogastric tube and Foley catheter were placed to empty the stomach and bladder, respectively. A small, infraumbilical incision was made and a Verres needle was introduced into the peritoneal cavity. A drop of saline was placed on the open end of the needle to confirm its location in the peritoneal cavity. The abdominal cavity was filled with CO, to a pressure of 10 to 12 mm Hg (1 to 4 L depending on the size of the child). When the abdomen was distended, a 5-mm trocar (Surgiport, US Surgical Corp, Norwalk, CT) was inserted into the umbilical incision and a 4-mm, 0” Hopkins rod lens (Storz, Tuttlingen, Germany) with attached video camera was placed through the trocar. Two additional trocars were then placed under direct vision into the right (10 mm) and left (5 mm) lower quadrants after incisions were made in the skin. The abdominal cavity was then explored. After the appendix was identified, its tip was grasped and the mesoappendix was coagulated and divided at the base of the appendix. In cases of ruptured appendicitis, grasping forceps were used for blunt dissection, and adhesions were taken down using the laser. A 0 chromic catgut Endoloop (Ethicon, Somerville, NJ) was then introduced through the left lower quadrant port and secured around the base of the appendix. The laser was used to amputate the appendix distal to the suture, and the amputated appendix was then drawn through the trocar. Cultures were obtained from the
From the Section of Pediatric SuTety, Department of Surgery, The Universiry of Tennessee, Memphis, LeBonheur Children S Medical Center, and St. Jude Children’s Research Hospital, Memphis, TN. Presented at the 22nd Annual Meeting of the American Pediatric SurgicalAssociation, Lake Buena Vista, Florida, May 15-18, 1991. Address reprint requests to Thorn E. Lobe, MD. Chairman, Sect&n of Pediatric Surgery, LeBonheur Children’s Medical Center, 8-18 Adams Ave, Memphis, TN 38103. Copyright o 1992 by KB. Saunders Company 0022-346819212702-0014$03.00l0 209
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Table 1. Severity of Symptoms in Patients With Appendicitis by Operative Technique Fever Group
+
OA (n = 50)
66
LA (n = 14)
64
White Blood Cells
Peritonitis
Duration of Symptoms(h)
t 15,000
15.000-7,000
< 7,000
+
_
o-24
24.48
>48
34
32
64
40
62
38
48
44
a
35
50
42
7
31
69
28
64
7
Abbreviations: OA, open appendectomy;
LA, laparoscopic appendectomy;
specimen and any pockets of pus were irrigated and evacuated under direct vision. The trocars were then removed and the stab wounds were closed with 4.0 vicryl suture. Steri-strips or Op-Site (Smith & Nephew, Massillon, OH) dressings were applied. OA was performed in a standard fashion. McBurney’s point was identified and a transverse incision was used to gain access to the peritoneal cavity. The appendix was then identified and delivered into the wound. The mesoappendix was divided and ligated. The base of the appendix was crushed with a straight clamp and ligated. A 4.0 silk purse-string suture was placed and the stump of the appendix was inverted. Fascia was closed in an anatomic fashion and the skin was closed using an absorbable subcuticular suture. In neither technique was a drain used. In most cases in which perforation had occurred, the abdominal cavity was copiously lavaged with antibiotic solution. Parenteral antibiotics were used in cases of ruptured (with abscess) or gangrenous (full-thickness necrosis without abscess) appendicitis similarly in both groups. In these cases, antibiotics were administered until the patient was afebrile for 48 hours, the white blood cell count was less than 12,000 cells/mm3, and there were fewer than 5% bands on the differential cell count. When patients were ambulatory and tolerating their diet, but still required antibiotics, the drugs were continued on an outpatient basis through our home health agency, and were continued until the patient met the above criteria. These patients were followed in the outpatient office. Children from each group were allowed to return to unrestricted activities as soon as they were comfortable or at the direction of their surgeon.
f, presence of; -, absence of.
ated abscess) or in whom the appendix was frankly perforated and an abscess was present), 16 of 50 patients (32%) in the OA group had complicated appendicitis compared with 5 of 14 (36%) in the LA group. Although there were a few cases of gangrene in the OA group, all of the 5 patients in the LA group classified as “complicated” had ruptured appendicitis with abscess. An analysis of variance of the differences between groups accounted for by the presence of complicated appendicitis is presented in Table 3. Patients with complicated appendicitis stayed longer in the hospital than did patients with acute disease regardless of the technique used. However, patients who underwent LA for acute appendicitis spent significantly fewer days in the hospital than those in the OA group. Patients who underwent LA were able to return to unrestricted activity sooner than patients who underwent OA when considering both acute and complicated appendicitis. Although LA cost approximately $1,000 more than OA, there were no cost differences noted when comparing acute versus complicated appendicitis. However, when considering operative time, LA for complicated (ruptured) appendicitis took nearly twice as long as the open procedure for the same disease. However, there was no difference between groups noted comparing the operative time required to perform surgery for acute appendicitis. There were no missed diagnoses in this series; all patients had appendicitis. In the OA group there were 10 complications (20%). These included 1 case of pneumonia in a patient with ruptured appendicitis, a wound infection in a patient with acute appendicitis, 7 postoperative fevers that lasted longer than 48 hours, and 1 pelvic abscess in a patient with ruptured appendicitis. Among the 16 patients with complicated appendicitis, the complication rate was 56%. In the LA group, there were 2 complications, both
RESULTS
There were no significant differences between the OA and LA groups regarding the severity of disease (Table 1). Age, weight, and total hospital cost were comparable in both groups (Table 2). Patients in the LA group spent significantly fewer days (P < .Ol) in the hospital and returned to unrestricted activity (P < .Ol) sooner than patients who underwent OA. LA was approximately $1,000 more expensive than OA and took slightly longer to perform. Regarding complicated appendicitis (eg, those patients in whom gangrene was present (without associ-
Table 2. Comparison of Patients Having Open or Laparoscopic Appendectomy
Age Group
w
Weight
Operative Time
Hospital Cost
Inpatient
Weeks to
Operative
(kg)
(min)
(5)
Days
Full Activity
(5)
Cost
OA
9.7 1.5)
36 (2.4)
54 (3)
5,515 (377)
5.4 1.4)
4(.1)
1,371 (62)
LA
9.8 (.8)
36 (4.0)
71 (12)
5,935 (1618)
2.9 (.7)
1.6 (.2)
2,255 (249)
NS
NS
.0422
NS
,008
.OOOl
.OOOl
P value
NOTE. Data given as mean (SEM). Abbreviations: OA, open appendectomy;
LA, laparoscopic appendectomy;
NS, not significant.
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LAPAROSCOPIC APPENDECTOMY
Table 3. Comparison of the Open and Laparoscopic Appendectomy
Techniques
Open Appendectomy Acute
Complicated
Age W)
10.1
Weight
35.7
(kg)
Operative Hospital Inpatient Weeks
time (min) cost ($)
53.4 5,364
days
Acute
38.2 55.7
34.4 56.1 6,736
8.6t
Complicated
9.9
8.8
5,835 3.9
Laparoscopic Appendectomy
9.8 39 98.8* t 4,600
1.2+
6t
to
unrestricted Operative
activity
cost ($)
3.8 1,322
4.3 1,475
*Significant
P < .05 LA v OA.
tsignificant
P < .05 acute v complicated.
1.2* 2,340”
2.2s 2,307*
of which occurred in patients with ruptured appendicitis. One patient developed pneumonia, which was treated successfully with antibiotics. Another patient was demonstrated to have a retained fecalith and he developed a pelvic abscess that required operative drainage. DISCUSSION
Laparoscopy was born of urologic innovation and otolaryngologic equipment. Human endoscopy was first done by Bozzani in 1805 when he examined the urethra of a patient using a tube and candlelight.13 Ott, in 1901, inspected the abdominal cavity by focusing a head mirror onto a speculum introduced through a small incision.14 Peritoneal endoscopy as practiced today was first described in 1902 by Kelling, who reported his technique of pneumoperitoneum followed by introduction of a Nitze cystoscope to examine the peritoneal cavity,15 and Gans was instrumental in the late 1960s and early 1970s in developing the tools and techniques now used for children.9-” Today, because of experimentation, innovation, and improvisation by both researchers and clinicians, laparoscopy has become a major component of many specialities in surgery. This minimally invasive procedure has been enhanced greatly in the last decade by the development of miniature, high-resolution TV cameras that can be sterilized and mounted on the laparoscope.‘” Recognizing the impact that laparoscopy has had on gynecology, urology, and now general surgery in this country, we asked: “Is there a role for laparoscopic surgery both therapeutically and diagnostically in a general pediatric surgical practice?” We chose to evaluate the most common pediatric surgical abdominal emergency: appendicitis, and learned that the impact of laparoscopic surgery on postoperative return to unrestricted activity (including athletics) may be profound.
In this series, hospitalization was reduced by 40%, with several of the patients with acute disease leaving the hospital within hours of surgery. The advantages of early discharge include early return to school with full, unrestricted activity 24 to 48 hours after the procedure. The cost of LA was higher than OA in this series. Presently, the cost of the specialized equipment and the amount of time needed in the operating room for surgeons to learn the laparoscopic techniques mitigate against it being inexpensive. Operating room time can be costly. As operating room nurses and other personnel become more familiar with setting up the equipment, time in the operating room will decrease. And, as surgeons become more adept at laparoscopic techniques and decrease their operating room time, LA will probably become less expensive. The increased cost of LA in this study was partially due to the use of lasers. The one-time cost of a laser is approximately $75,000 to $100.000, depending on the type of instrument purchased. This outlay is ultimately paid for by the patient, but laser use is not paramount. Although we agree with McKernan and Saye” and Berlein et al” and believe that laser provides the safest dissection of visceral organs through a laparoscope, there is no strong argument in favor of lasers over the use of the much less expensive electrocautery equipment. In addition to the cost of the laser, there is also the cost of the video equipment and instruments required for laparoscopy. However, these one-time purchases ($25,000 to $35,000) can be used for other types of endoscopy. We also used disposable instruments for our procedures, but these are not essential if one is willing to use nondisposable items. However, the advantages of disposable instruments are that these devices are always sharp, clean, uncontaminated, all parts are in working order, and they are conveniently packaged. We believe this justifies their added cost. If one were to use the electrocautery unit in conjunction with reusable laparoscopy trocars and instruments, the cost of the laparoscopic procedure would be no greater than that for conventional appendectomy. There is a hidden economic advantage to LA. When the patient can return to school more quickly, working couples may be freed from reliance on day care costs and baby-sitters. And parents who stay home with their children are able to return to work more quickly without a loss of pay. These considerations may well turn out to be the biggest economic advantage of laparoscopic surgery in children. Of those patients who underwent LA for perforated appendicitis, the complication rate was slightly less than that of those who underwent laparotomy for
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GILCHRIST ET AL
ruptured appendicitis by 16%. However, the small numbers at this time do not justify a conclusion favoring the use of laparoscopic surgery for perforated appendicitis. Advantages of laparoscopic treatment of ruptured appendicitis include the fact that one can see and evacuate localized pockets of pus better under laparoscopic vision than one can at laparotomy; and that, while hospitalization is no shorter for laparoscopically treated ruptured appendicitis, these patients still return to unrestricted physical activity and athletics more quickly than those treated conventionally. The single disadvantage of treating ruptured appendicitis laparoscopically is that it takes longer to complete the procedure. This prospective study confirms that laparoscopic appendectomy in children is safe and effective. It confirms what Semm” and Gotz et all9 taught regarding LA in adults: all stages of appendicitis can be treated through the laparoscope. One must become familiar with the equipment, the technical aspects of the instruments, and how to use them. There is also
an aspect of learning that involves the development of a eye-hand coordination that may at times be seemingly counterintuitive to surgeons unaccustomed to laparoscopic intervention. In childhood, LA and other laparoscopic procedures will become less expensive as surgeons shorten their operative time, and procedures such as LA can be learned at the resident level.“” The present study suggests a promising future for these procedures, but continuing evaluation and analysis will be in order as more cases are performed. However, it is evident now that there are some clear advantages of laparoscopy over conventional techniques: less hospitalization, earlier return to unrestricted physical activity, earlier return to school, and, for the parents, fewer days away from work. We believe that LA offers advantages over OA for appendicitis and that these advantages warrant the expense and time required of the surgeon to learn the procedure. LA deserves a place in general pediatric surgical practice.
REFERENCES 1. Lewis A, Archer TJ: Laparoscopy in general surgery. Br J Surg 68:778-780,198l 2. Perty CP, Upchurch JC: Pelviscopic adnexectomy. Am J Obstet Gynecol162:79-81,199O 3. Iberti TJ, Salky BA, Onofrey D: Use of bedside laparoscopy to identify intestinal ischemia in postoperative cases of aortic reconstruction. Surgery 105:686-689,1989 4. Watt I, Stewart I, Anderson D, et al: Laparoscopy, ultrasound, and computed tomography in cancer of the oesophagus and gastric cardia: A prospective comparison for detecting intraabdominal metastases. Br J Surg 76:1036-1039,1989 5. Teisala K, Heinonen PK, Punnonen R: Laparoscopic diagnosis and treatment of acute pyosalpinx. J Reprod Med 3519-21, 1990 6. Caldironi MW, Roman0 M, Bozza F, et al: Progressive pneumoperitoneum in the management of giant incision hernias: A study of 41 patients. Br J Surg 77:306-308, 1990 7. Deutsch AA, Zelikovsky A, Reiss R: Laparoscopy in the prevention of unnecessary appendectomies: A prospective study. Br J Surg 69:336-337, 1982 8. Foster, HMc: Laparoscopy . . a useful technique for the general surgeon. N Z J Surg 58:47-50, 1988 9. Gans SL: A new look at pediatric endoscopy. Postgrad Med 61:91-loo,1977
10. Gans SL, Berci G: Peritoneoscopy in infants and children. J Pediatr Surg 8:399-405,1973 11. Gans SL, Berci G: Advances in endoscopy of infants and children. J Pediatr Surg 6:199-233,197l 12. Semm K: Operationslehre fur Endosckopische Abdominalchirurgie. Stuttgart, Germany, Schattauer, 1984 13. Gunning JE: History of laparoscopy, in Phillips JM, Corson SL (eds): Laparoscopy. Baltimore, MD, Williams & Wilkins, 1977. pp 6-16 14. Ruddock JC: Peritoneoscopy. Surg Gynecol Obstet 65:623639,1937 15. Kelling G: Ueber oesophagoskopie, gastroskopie und kolioskopie. Muenchn Med Wochenschr 49:21,1902 16. Das S, Amar A: The impact of laparoscopy on modern urologic practice. Urol Clin North Am 15:537-540, 1988 17. McKernan JB, Saye WB: Laparoscopic technique in appendectomy with argon laser. South Med J 83:1019-1020,199O 18. Berlien HP, Muller G, Waldschmidt J: Lasers in pediatric surgery. Prog Pediatr Surg 25:5-22,199O 19. Gotz F, Pier A, Bather C: Modified laparoscopic appendectomy in surgery. Surg Endosc 4:6-9,199O 20. Meyers WE, Branum GD, Farouk M, et al: A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 324:1074-1078, 1991
Discussion A.I. Philippart (Detroit, MI): The first step in offering any alternative to a time-honored procedure is to prove that your results are no worse than that prior procedure. Dr Gilchrist and Dr Lobe have provided evidence to suggest that. I have had the opportunity to read their manuscript and they provide some data on comparable distribution between the two groups
between what they call complicated, which includes gangrenous or perforated appendicitis, and nongangrenous or nonperforated. I would ask if they can separate these groups because we think of it in terms of differentiation between perforated and nonperforated because of the emphasis on cost and length of stay. Length of stay has in large part two determi-
LAPAROSCOPIC
APPENDECTOMY
nants. One is the length of antibiotic course that is required. The second and very important one is the motivation of the surgeon. We studied our own group a couple of years ago, and found significant variation in length of stay in perforated and nonperforated appendicitis. Simple identification of that fact dropped length of stay significantly and length of stay particularly for uncomplicated appendicitis can be comfortably less than 2 days and in some hands has been done on 23-hour programs. How much do you believe, and I’m looking across the room on purpose, surgeon motivation has to do with those changes in length of stay figures? I look forward to the rest of the discussion of this paper and to more data from what is an interesting small series to start. G. W: Holcomb (Nashville, TN): At Vanderbilt, we have also been interested in laparoscopic procedures in the pediatric patient and have performed seven laparoscopic cholecystectomies and eight laparoscopic appendectomies. I applaud the group from Memphis and their results. As regards to the experience with laparoscopic appendectomy, how many cases were converted from the laparoscopic technique to the open technique especially in the complicated cases? Were drains placed at the time of laparoscopic appendectomy in the complicated cases? Do you have any experience with the laparoscopic gastrointestinal stapling device, which should decrease the time necessary for this procedure? And in your experience, at this time at your hospital, how do you differentiate between who gets a laparoscopic appendectomy and who gets an open appendectomy? R.E. Sonnino (Cleveland, OH): I have questions about your indications. Was it the surgeon who was the indication for a laparoscopic procedure? Did you take all comers, including a patient you expected to have a ruptured retrocecal appendix, or did you try to differentiate ahead of time? We found the best candidates to be those whom we weren’t sure had appendicitis. Was this true in your experience? D.R. King (Columbus, OH): There are a couple of internal inconsistencies in the data that I would like to see addressed that relate to the duration of hospitalization. Since the incidence of complicated appendicitis in both groups was the same, then our only conclusion is that the 2.3 days of the hospitalization is related to the wound in the right lower quadrant. This seems to be a modest hospital stay for an incision. I think this is unreasonable. How many of these cases were gangrenous and how many were frankly perforated? What were the complications? I presume for the open group that they are complications of the disease. In the laparoscopic group, were they complications of disease or were they complica-
213
tions of technique ? How many of each group had positive cultures? We can talk about gangrenous appendicitis and ruptured appendicitis but how many of those were confirmed by culture? How many normals were in each group? What are contraindications to initiating a laparoscopic appendectomy and what are the indications to abort the procedure? J.M. Warden (Anaheim, CA): How are we going to credential pediatric surgeons to do endoscopic surgery? In adult surgery, this has now become an established practice but people do have to take courses and demonstrate some proficiency. I wonder what pediatric surgery is going to do and I wonder if the author has an answer? K. Georgeson (Birmingham, AL): Last summer, I spent a few days in Germany watching Dr Gotz who has done about 700 appendectomies in both adults and children. In the first 56, he had to open 15. In the next 500, he opened none. They were all laparoscopitally done. That included about a 30% perforation rate so that there seems to be a learning curve and it’s fairly significant in that you have to open quite a few when you first start and you open fewer later on. The other thing I would caution is that I know there are many people who are satisfied with what we are doing at the present time. It’s time-honored, but if you will recall what happened with gastrointestinal endoscopy, surgery and surgeons just ho-hummed that right out of their own armenentarium and the gastroenterologists lapped it up. So I think we should take a lesson from that, that shouldn’t push us into something prematurely. The credentialing issue is important, but it certainly should spur us into looking at it as an alternative. K. Ashcraji (Kansas Cit)i MO): I am going to go kicking and screaming into the future, hanging on to the old operation techniques. One of the things I would like to hear you discuss is the economic impact on the surgeon. I had a discussion with a number of general surgical colleagues the other day who were doing laparoscopic cholecystectomies, which take hours more than the open method, particularly early on. What do you do with the rest of your schedule while you diddle around all that time with this gimmick? A. Kosloske (Baltimore, MD): I think from the discussion it is abundantly clear that until you do a clinical trial with randomization, no one will be convinced that one procedure is superior or that the procedures are equivalent. This is a very important question. I urge the authors to go ahead and design and carry out such a clinical trial. S. Rothenbeg (Houston, TX): 1 have two technical questions. We have also recently embarked on trying
214
to do laparoscopic appendectomies, although we are being somewhat selective at this time. The first question is on the patient whose incision you showed the picture of, you showed a right lower quadrant incision and a left lower quadrant incision. I wonder if you have had problems with the point of your trocar introducer in the right lower quadrant getting adequate tension on the appendix to be able to adequately move it around and take down the mesentery? The second question is in taking out perforated appendix. Have you had problems with wound infection at the site of the trocar and are you using some kind of sleeve or something to cover up the appendix? T. Lobe (Memphis, TN): I would like to make one comment about credentialing because I think it is important. Right now there are no valid credentialing bodies for laparoscopic procedures in adults or children. I hate to sound like an advertisement but we are preparing a series of laparoscopy courses specified for pediatric surgeons, which will be given in Memphis. I will be sending out appropriate brochures to those who may be interested. B.F. Gilchrist (response): To begin with Dr Holcomb’s questions first, before we began this study we converted several cases to open procedures. This study was started after we were comfortable with the procedure and we did not have to convert to open appendectomy any of the cases presented to you today. We did not use drains, although their placement with the trocar would be easily accomplished if that is your practice. We have not used the endoscopic GIA stapler device for abdominal operations yet. However, we have found this device useful for thorascopic lung resections. Dr Ring, as far as the
GILCHRIST ET AL
length of hospitalization and your perceived discrepancy, when ruptured appendectomy patients are ambulating and eating, but require parenteral antibiotics, we use home antibiotic therapy and follow the patients in the office; thus, the average stay for ruptured appendicitis is rarely more than 7 days. Regarding complications, these are discussed in the manuscript and were comparable in both groups. None of the complications in the laparoscopic group were due to the procedures with the exception of a retained fecalith which I may have dropped into the field. We always perform a thorough inspection and lavage, in cases of ruptured appendectomy, before removing the trocars. As far as cultures are concerned, I don’t have that data. And, all of the complicated appendectomy cases in the laparoscopic group were ruptured with abscesses. Dr Ashcraft, many of these cases are performed at night and on weekends and are not disruptive of the operating schedule. When one of these procedures becomes long and tedious we open another room and get another surgeon to do the other case. Regarding patient selection: when the laparoscopically trained surgeon was available, we offered laparoscopy to all patients. The technique is discussed in the manuscript. We use three incisions: 5 mm in the umbilicus, 5 mm in the left lower quadrant, and 10 mm in the right lower quadrant. We are able to use new more miniaturized equipment for these pediatric cases without very much difficulty. I think when Dr Gans was first discussing these concepts, back in the late 1960s and 1970s the equipment didn’t exist and I realize that Dr Gans met with the manufacturers back then and really had a great impetus in so far as getting the equipment to be what it is today.
in
F. Gilchrist, Thorn E. Lobe, Kurt P. Schropp, Gail A. Kay, S. Douglas Hixson, Earle L. Wrenn, Jr, Paul G. Philippe, and Robert S. Hollabaugh Memphis,
0 Although laparoscopic procedures are currently in vogue in general surgery, the role of this approach in children has not been prospectively evaluated in the United States using the new instrumentation now available to us. To assess the value of laparoscopic appendectomy (LA) in childhood, we prospectively compared 14 LAS with 50 open appendectomies (OA) over 6 months in a single children’s hospital. Antibiotic usage was at the discretion of the surgeon regardless of the procedure performed and was not different between groups. LA was performed under the direction of a single laparoscopy-trained surgeon and patient selection was based on parental consent. A three-puncture LA technique was used; children from this group were allowed to return to full activities as soon as they were comfortable. There were no significant differences between groups for severity of disease, age, weight, hospital cost, or complications. The types of complications that developed were comparable in both groups. The percent of complicated appendicitis (gangrene or perforation) was 32% in the OA group and 36% in the LA group. Patients in the LA group spent significantly fewer days in the hospital and returned to unrestricted activities (school, athletics, etc) faster than patients in the OA group. LA is approximately $1,000 more expensive than OA, the differences being easily explainable by the cost of the disposable supplies necessary for the procedure (laser fibers, trocars, etc), but because of the shorter hospital stay in the LA group the mean total cost for each group was comparable. These data suggest that although there appears to be no cost advantage, LA shortens the hospital stay and allows children to return to unrestricted activity sooner than OA. LA should be considered as a reasonable alternative to OA and may be the procedure of choice in the hands of pediatric surgeons experienced in laparoscopic techniques. Copyright s 1992 by WA Saunders Company INDEX WORDS: Appendectomy,
laparoscopic.
L
APAROSCOPIC surgery is well-established in a number of surgical specialtieslm3 for a variety of indications,‘-’ and it is especially in vogue in current general surgical practice.8 Although Gans and others” ’ have advocated diagnostic and therapeutic laparoscopy in children for over 20 years, the concepts have not caught on. In an attempt to assess the value of laparoscopic surgery for pediatric patients today, we chose a commonly performed procedure, appendectomy, and compared the results of open appendectomy (OA) with the laparoscopic procedure (LA) in a single institution’s practice. MATERIALS AND METHODS We prospectively evaluated surgery for appendicitis in our children’s hospital between April 1990 and October 1990. SixtyJournalofPediatric Surgery, Vol27, No 2 (February), 1992: pp 209-214
Tennessee
four operations for appendicitis were performed. Selection for OA or LA was done by surgeon availability, according to the staff pediatric surgeon on-call schedule. When the laparoscopy-trained surgeon was available, all patients (regardless of the severity of their illness) were offered the laparoscopic procedure. Permission to enter the study was based on parental consent. The two groups of patients (OA and LA) were assessed for severity of disease (fever. leukocytosis, peritonitis, and duration of symptoms), age, weight, operative time and cost, hospital cost, days of hospitalization, complications, and the interval between operation and return to unrestricted activity. Severity of disease was evaluated by xz analysis. The presence of fever, magnitude of leukocytosis (2 15,000, 15,000 to 7,000, or 5 7,000), presence or absence of peritonitis, and duration of symptoms were classified as being less than 24 hours, between 24 to 48 hours, and greater than 48 hours. The differences between simple acute and complicated (gangrenous or ruptured) appendicitis between groups were evaluated by analysis of variance (ANOVA). All other data were analyzed by the unpaired Student’s t test. A three-puncture LA technique modified from Semm” was used: under general anesthesia, a nasogastric tube and Foley catheter were placed to empty the stomach and bladder, respectively. A small, infraumbilical incision was made and a Verres needle was introduced into the peritoneal cavity. A drop of saline was placed on the open end of the needle to confirm its location in the peritoneal cavity. The abdominal cavity was filled with CO, to a pressure of 10 to 12 mm Hg (1 to 4 L depending on the size of the child). When the abdomen was distended, a 5-mm trocar (Surgiport, US Surgical Corp, Norwalk, CT) was inserted into the umbilical incision and a 4-mm, 0” Hopkins rod lens (Storz, Tuttlingen, Germany) with attached video camera was placed through the trocar. Two additional trocars were then placed under direct vision into the right (10 mm) and left (5 mm) lower quadrants after incisions were made in the skin. The abdominal cavity was then explored. After the appendix was identified, its tip was grasped and the mesoappendix was coagulated and divided at the base of the appendix. In cases of ruptured appendicitis, grasping forceps were used for blunt dissection, and adhesions were taken down using the laser. A 0 chromic catgut Endoloop (Ethicon, Somerville, NJ) was then introduced through the left lower quadrant port and secured around the base of the appendix. The laser was used to amputate the appendix distal to the suture, and the amputated appendix was then drawn through the trocar. Cultures were obtained from the
From the Section of Pediatric SuTety, Department of Surgery, The Universiry of Tennessee, Memphis, LeBonheur Children S Medical Center, and St. Jude Children’s Research Hospital, Memphis, TN. Presented at the 22nd Annual Meeting of the American Pediatric SurgicalAssociation, Lake Buena Vista, Florida, May 15-18, 1991. Address reprint requests to Thorn E. Lobe, MD. Chairman, Sect&n of Pediatric Surgery, LeBonheur Children’s Medical Center, 8-18 Adams Ave, Memphis, TN 38103. Copyright o 1992 by KB. Saunders Company 0022-346819212702-0014$03.00l0 209
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Table 1. Severity of Symptoms in Patients With Appendicitis by Operative Technique Fever Group
+
OA (n = 50)
66
LA (n = 14)
64
White Blood Cells
Peritonitis
Duration of Symptoms(h)
t 15,000
15.000-7,000
< 7,000
+
_
o-24
24.48
>48
34
32
64
40
62
38
48
44
a
35
50
42
7
31
69
28
64
7
Abbreviations: OA, open appendectomy;
LA, laparoscopic appendectomy;
specimen and any pockets of pus were irrigated and evacuated under direct vision. The trocars were then removed and the stab wounds were closed with 4.0 vicryl suture. Steri-strips or Op-Site (Smith & Nephew, Massillon, OH) dressings were applied. OA was performed in a standard fashion. McBurney’s point was identified and a transverse incision was used to gain access to the peritoneal cavity. The appendix was then identified and delivered into the wound. The mesoappendix was divided and ligated. The base of the appendix was crushed with a straight clamp and ligated. A 4.0 silk purse-string suture was placed and the stump of the appendix was inverted. Fascia was closed in an anatomic fashion and the skin was closed using an absorbable subcuticular suture. In neither technique was a drain used. In most cases in which perforation had occurred, the abdominal cavity was copiously lavaged with antibiotic solution. Parenteral antibiotics were used in cases of ruptured (with abscess) or gangrenous (full-thickness necrosis without abscess) appendicitis similarly in both groups. In these cases, antibiotics were administered until the patient was afebrile for 48 hours, the white blood cell count was less than 12,000 cells/mm3, and there were fewer than 5% bands on the differential cell count. When patients were ambulatory and tolerating their diet, but still required antibiotics, the drugs were continued on an outpatient basis through our home health agency, and were continued until the patient met the above criteria. These patients were followed in the outpatient office. Children from each group were allowed to return to unrestricted activities as soon as they were comfortable or at the direction of their surgeon.
f, presence of; -, absence of.
ated abscess) or in whom the appendix was frankly perforated and an abscess was present), 16 of 50 patients (32%) in the OA group had complicated appendicitis compared with 5 of 14 (36%) in the LA group. Although there were a few cases of gangrene in the OA group, all of the 5 patients in the LA group classified as “complicated” had ruptured appendicitis with abscess. An analysis of variance of the differences between groups accounted for by the presence of complicated appendicitis is presented in Table 3. Patients with complicated appendicitis stayed longer in the hospital than did patients with acute disease regardless of the technique used. However, patients who underwent LA for acute appendicitis spent significantly fewer days in the hospital than those in the OA group. Patients who underwent LA were able to return to unrestricted activity sooner than patients who underwent OA when considering both acute and complicated appendicitis. Although LA cost approximately $1,000 more than OA, there were no cost differences noted when comparing acute versus complicated appendicitis. However, when considering operative time, LA for complicated (ruptured) appendicitis took nearly twice as long as the open procedure for the same disease. However, there was no difference between groups noted comparing the operative time required to perform surgery for acute appendicitis. There were no missed diagnoses in this series; all patients had appendicitis. In the OA group there were 10 complications (20%). These included 1 case of pneumonia in a patient with ruptured appendicitis, a wound infection in a patient with acute appendicitis, 7 postoperative fevers that lasted longer than 48 hours, and 1 pelvic abscess in a patient with ruptured appendicitis. Among the 16 patients with complicated appendicitis, the complication rate was 56%. In the LA group, there were 2 complications, both
RESULTS
There were no significant differences between the OA and LA groups regarding the severity of disease (Table 1). Age, weight, and total hospital cost were comparable in both groups (Table 2). Patients in the LA group spent significantly fewer days (P < .Ol) in the hospital and returned to unrestricted activity (P < .Ol) sooner than patients who underwent OA. LA was approximately $1,000 more expensive than OA and took slightly longer to perform. Regarding complicated appendicitis (eg, those patients in whom gangrene was present (without associ-
Table 2. Comparison of Patients Having Open or Laparoscopic Appendectomy
Age Group
w
Weight
Operative Time
Hospital Cost
Inpatient
Weeks to
Operative
(kg)
(min)
(5)
Days
Full Activity
(5)
Cost
OA
9.7 1.5)
36 (2.4)
54 (3)
5,515 (377)
5.4 1.4)
4(.1)
1,371 (62)
LA
9.8 (.8)
36 (4.0)
71 (12)
5,935 (1618)
2.9 (.7)
1.6 (.2)
2,255 (249)
NS
NS
.0422
NS
,008
.OOOl
.OOOl
P value
NOTE. Data given as mean (SEM). Abbreviations: OA, open appendectomy;
LA, laparoscopic appendectomy;
NS, not significant.
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LAPAROSCOPIC APPENDECTOMY
Table 3. Comparison of the Open and Laparoscopic Appendectomy
Techniques
Open Appendectomy Acute
Complicated
Age W)
10.1
Weight
35.7
(kg)
Operative Hospital Inpatient Weeks
time (min) cost ($)
53.4 5,364
days
Acute
38.2 55.7
34.4 56.1 6,736
8.6t
Complicated
9.9
8.8
5,835 3.9
Laparoscopic Appendectomy
9.8 39 98.8* t 4,600
1.2+
6t
to
unrestricted Operative
activity
cost ($)
3.8 1,322
4.3 1,475
*Significant
P < .05 LA v OA.
tsignificant
P < .05 acute v complicated.
1.2* 2,340”
2.2s 2,307*
of which occurred in patients with ruptured appendicitis. One patient developed pneumonia, which was treated successfully with antibiotics. Another patient was demonstrated to have a retained fecalith and he developed a pelvic abscess that required operative drainage. DISCUSSION
Laparoscopy was born of urologic innovation and otolaryngologic equipment. Human endoscopy was first done by Bozzani in 1805 when he examined the urethra of a patient using a tube and candlelight.13 Ott, in 1901, inspected the abdominal cavity by focusing a head mirror onto a speculum introduced through a small incision.14 Peritoneal endoscopy as practiced today was first described in 1902 by Kelling, who reported his technique of pneumoperitoneum followed by introduction of a Nitze cystoscope to examine the peritoneal cavity,15 and Gans was instrumental in the late 1960s and early 1970s in developing the tools and techniques now used for children.9-” Today, because of experimentation, innovation, and improvisation by both researchers and clinicians, laparoscopy has become a major component of many specialities in surgery. This minimally invasive procedure has been enhanced greatly in the last decade by the development of miniature, high-resolution TV cameras that can be sterilized and mounted on the laparoscope.‘” Recognizing the impact that laparoscopy has had on gynecology, urology, and now general surgery in this country, we asked: “Is there a role for laparoscopic surgery both therapeutically and diagnostically in a general pediatric surgical practice?” We chose to evaluate the most common pediatric surgical abdominal emergency: appendicitis, and learned that the impact of laparoscopic surgery on postoperative return to unrestricted activity (including athletics) may be profound.
In this series, hospitalization was reduced by 40%, with several of the patients with acute disease leaving the hospital within hours of surgery. The advantages of early discharge include early return to school with full, unrestricted activity 24 to 48 hours after the procedure. The cost of LA was higher than OA in this series. Presently, the cost of the specialized equipment and the amount of time needed in the operating room for surgeons to learn the laparoscopic techniques mitigate against it being inexpensive. Operating room time can be costly. As operating room nurses and other personnel become more familiar with setting up the equipment, time in the operating room will decrease. And, as surgeons become more adept at laparoscopic techniques and decrease their operating room time, LA will probably become less expensive. The increased cost of LA in this study was partially due to the use of lasers. The one-time cost of a laser is approximately $75,000 to $100.000, depending on the type of instrument purchased. This outlay is ultimately paid for by the patient, but laser use is not paramount. Although we agree with McKernan and Saye” and Berlein et al” and believe that laser provides the safest dissection of visceral organs through a laparoscope, there is no strong argument in favor of lasers over the use of the much less expensive electrocautery equipment. In addition to the cost of the laser, there is also the cost of the video equipment and instruments required for laparoscopy. However, these one-time purchases ($25,000 to $35,000) can be used for other types of endoscopy. We also used disposable instruments for our procedures, but these are not essential if one is willing to use nondisposable items. However, the advantages of disposable instruments are that these devices are always sharp, clean, uncontaminated, all parts are in working order, and they are conveniently packaged. We believe this justifies their added cost. If one were to use the electrocautery unit in conjunction with reusable laparoscopy trocars and instruments, the cost of the laparoscopic procedure would be no greater than that for conventional appendectomy. There is a hidden economic advantage to LA. When the patient can return to school more quickly, working couples may be freed from reliance on day care costs and baby-sitters. And parents who stay home with their children are able to return to work more quickly without a loss of pay. These considerations may well turn out to be the biggest economic advantage of laparoscopic surgery in children. Of those patients who underwent LA for perforated appendicitis, the complication rate was slightly less than that of those who underwent laparotomy for
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ruptured appendicitis by 16%. However, the small numbers at this time do not justify a conclusion favoring the use of laparoscopic surgery for perforated appendicitis. Advantages of laparoscopic treatment of ruptured appendicitis include the fact that one can see and evacuate localized pockets of pus better under laparoscopic vision than one can at laparotomy; and that, while hospitalization is no shorter for laparoscopically treated ruptured appendicitis, these patients still return to unrestricted physical activity and athletics more quickly than those treated conventionally. The single disadvantage of treating ruptured appendicitis laparoscopically is that it takes longer to complete the procedure. This prospective study confirms that laparoscopic appendectomy in children is safe and effective. It confirms what Semm” and Gotz et all9 taught regarding LA in adults: all stages of appendicitis can be treated through the laparoscope. One must become familiar with the equipment, the technical aspects of the instruments, and how to use them. There is also
an aspect of learning that involves the development of a eye-hand coordination that may at times be seemingly counterintuitive to surgeons unaccustomed to laparoscopic intervention. In childhood, LA and other laparoscopic procedures will become less expensive as surgeons shorten their operative time, and procedures such as LA can be learned at the resident level.“” The present study suggests a promising future for these procedures, but continuing evaluation and analysis will be in order as more cases are performed. However, it is evident now that there are some clear advantages of laparoscopy over conventional techniques: less hospitalization, earlier return to unrestricted physical activity, earlier return to school, and, for the parents, fewer days away from work. We believe that LA offers advantages over OA for appendicitis and that these advantages warrant the expense and time required of the surgeon to learn the procedure. LA deserves a place in general pediatric surgical practice.
REFERENCES 1. Lewis A, Archer TJ: Laparoscopy in general surgery. Br J Surg 68:778-780,198l 2. Perty CP, Upchurch JC: Pelviscopic adnexectomy. Am J Obstet Gynecol162:79-81,199O 3. Iberti TJ, Salky BA, Onofrey D: Use of bedside laparoscopy to identify intestinal ischemia in postoperative cases of aortic reconstruction. Surgery 105:686-689,1989 4. Watt I, Stewart I, Anderson D, et al: Laparoscopy, ultrasound, and computed tomography in cancer of the oesophagus and gastric cardia: A prospective comparison for detecting intraabdominal metastases. Br J Surg 76:1036-1039,1989 5. Teisala K, Heinonen PK, Punnonen R: Laparoscopic diagnosis and treatment of acute pyosalpinx. J Reprod Med 3519-21, 1990 6. Caldironi MW, Roman0 M, Bozza F, et al: Progressive pneumoperitoneum in the management of giant incision hernias: A study of 41 patients. Br J Surg 77:306-308, 1990 7. Deutsch AA, Zelikovsky A, Reiss R: Laparoscopy in the prevention of unnecessary appendectomies: A prospective study. Br J Surg 69:336-337, 1982 8. Foster, HMc: Laparoscopy . . a useful technique for the general surgeon. N Z J Surg 58:47-50, 1988 9. Gans SL: A new look at pediatric endoscopy. Postgrad Med 61:91-loo,1977
10. Gans SL, Berci G: Peritoneoscopy in infants and children. J Pediatr Surg 8:399-405,1973 11. Gans SL, Berci G: Advances in endoscopy of infants and children. J Pediatr Surg 6:199-233,197l 12. Semm K: Operationslehre fur Endosckopische Abdominalchirurgie. Stuttgart, Germany, Schattauer, 1984 13. Gunning JE: History of laparoscopy, in Phillips JM, Corson SL (eds): Laparoscopy. Baltimore, MD, Williams & Wilkins, 1977. pp 6-16 14. Ruddock JC: Peritoneoscopy. Surg Gynecol Obstet 65:623639,1937 15. Kelling G: Ueber oesophagoskopie, gastroskopie und kolioskopie. Muenchn Med Wochenschr 49:21,1902 16. Das S, Amar A: The impact of laparoscopy on modern urologic practice. Urol Clin North Am 15:537-540, 1988 17. McKernan JB, Saye WB: Laparoscopic technique in appendectomy with argon laser. South Med J 83:1019-1020,199O 18. Berlien HP, Muller G, Waldschmidt J: Lasers in pediatric surgery. Prog Pediatr Surg 25:5-22,199O 19. Gotz F, Pier A, Bather C: Modified laparoscopic appendectomy in surgery. Surg Endosc 4:6-9,199O 20. Meyers WE, Branum GD, Farouk M, et al: A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 324:1074-1078, 1991
Discussion A.I. Philippart (Detroit, MI): The first step in offering any alternative to a time-honored procedure is to prove that your results are no worse than that prior procedure. Dr Gilchrist and Dr Lobe have provided evidence to suggest that. I have had the opportunity to read their manuscript and they provide some data on comparable distribution between the two groups
between what they call complicated, which includes gangrenous or perforated appendicitis, and nongangrenous or nonperforated. I would ask if they can separate these groups because we think of it in terms of differentiation between perforated and nonperforated because of the emphasis on cost and length of stay. Length of stay has in large part two determi-
LAPAROSCOPIC
APPENDECTOMY
nants. One is the length of antibiotic course that is required. The second and very important one is the motivation of the surgeon. We studied our own group a couple of years ago, and found significant variation in length of stay in perforated and nonperforated appendicitis. Simple identification of that fact dropped length of stay significantly and length of stay particularly for uncomplicated appendicitis can be comfortably less than 2 days and in some hands has been done on 23-hour programs. How much do you believe, and I’m looking across the room on purpose, surgeon motivation has to do with those changes in length of stay figures? I look forward to the rest of the discussion of this paper and to more data from what is an interesting small series to start. G. W: Holcomb (Nashville, TN): At Vanderbilt, we have also been interested in laparoscopic procedures in the pediatric patient and have performed seven laparoscopic cholecystectomies and eight laparoscopic appendectomies. I applaud the group from Memphis and their results. As regards to the experience with laparoscopic appendectomy, how many cases were converted from the laparoscopic technique to the open technique especially in the complicated cases? Were drains placed at the time of laparoscopic appendectomy in the complicated cases? Do you have any experience with the laparoscopic gastrointestinal stapling device, which should decrease the time necessary for this procedure? And in your experience, at this time at your hospital, how do you differentiate between who gets a laparoscopic appendectomy and who gets an open appendectomy? R.E. Sonnino (Cleveland, OH): I have questions about your indications. Was it the surgeon who was the indication for a laparoscopic procedure? Did you take all comers, including a patient you expected to have a ruptured retrocecal appendix, or did you try to differentiate ahead of time? We found the best candidates to be those whom we weren’t sure had appendicitis. Was this true in your experience? D.R. King (Columbus, OH): There are a couple of internal inconsistencies in the data that I would like to see addressed that relate to the duration of hospitalization. Since the incidence of complicated appendicitis in both groups was the same, then our only conclusion is that the 2.3 days of the hospitalization is related to the wound in the right lower quadrant. This seems to be a modest hospital stay for an incision. I think this is unreasonable. How many of these cases were gangrenous and how many were frankly perforated? What were the complications? I presume for the open group that they are complications of the disease. In the laparoscopic group, were they complications of disease or were they complica-
213
tions of technique ? How many of each group had positive cultures? We can talk about gangrenous appendicitis and ruptured appendicitis but how many of those were confirmed by culture? How many normals were in each group? What are contraindications to initiating a laparoscopic appendectomy and what are the indications to abort the procedure? J.M. Warden (Anaheim, CA): How are we going to credential pediatric surgeons to do endoscopic surgery? In adult surgery, this has now become an established practice but people do have to take courses and demonstrate some proficiency. I wonder what pediatric surgery is going to do and I wonder if the author has an answer? K. Georgeson (Birmingham, AL): Last summer, I spent a few days in Germany watching Dr Gotz who has done about 700 appendectomies in both adults and children. In the first 56, he had to open 15. In the next 500, he opened none. They were all laparoscopitally done. That included about a 30% perforation rate so that there seems to be a learning curve and it’s fairly significant in that you have to open quite a few when you first start and you open fewer later on. The other thing I would caution is that I know there are many people who are satisfied with what we are doing at the present time. It’s time-honored, but if you will recall what happened with gastrointestinal endoscopy, surgery and surgeons just ho-hummed that right out of their own armenentarium and the gastroenterologists lapped it up. So I think we should take a lesson from that, that shouldn’t push us into something prematurely. The credentialing issue is important, but it certainly should spur us into looking at it as an alternative. K. Ashcraji (Kansas Cit)i MO): I am going to go kicking and screaming into the future, hanging on to the old operation techniques. One of the things I would like to hear you discuss is the economic impact on the surgeon. I had a discussion with a number of general surgical colleagues the other day who were doing laparoscopic cholecystectomies, which take hours more than the open method, particularly early on. What do you do with the rest of your schedule while you diddle around all that time with this gimmick? A. Kosloske (Baltimore, MD): I think from the discussion it is abundantly clear that until you do a clinical trial with randomization, no one will be convinced that one procedure is superior or that the procedures are equivalent. This is a very important question. I urge the authors to go ahead and design and carry out such a clinical trial. S. Rothenbeg (Houston, TX): 1 have two technical questions. We have also recently embarked on trying
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to do laparoscopic appendectomies, although we are being somewhat selective at this time. The first question is on the patient whose incision you showed the picture of, you showed a right lower quadrant incision and a left lower quadrant incision. I wonder if you have had problems with the point of your trocar introducer in the right lower quadrant getting adequate tension on the appendix to be able to adequately move it around and take down the mesentery? The second question is in taking out perforated appendix. Have you had problems with wound infection at the site of the trocar and are you using some kind of sleeve or something to cover up the appendix? T. Lobe (Memphis, TN): I would like to make one comment about credentialing because I think it is important. Right now there are no valid credentialing bodies for laparoscopic procedures in adults or children. I hate to sound like an advertisement but we are preparing a series of laparoscopy courses specified for pediatric surgeons, which will be given in Memphis. I will be sending out appropriate brochures to those who may be interested. B.F. Gilchrist (response): To begin with Dr Holcomb’s questions first, before we began this study we converted several cases to open procedures. This study was started after we were comfortable with the procedure and we did not have to convert to open appendectomy any of the cases presented to you today. We did not use drains, although their placement with the trocar would be easily accomplished if that is your practice. We have not used the endoscopic GIA stapler device for abdominal operations yet. However, we have found this device useful for thorascopic lung resections. Dr Ring, as far as the
GILCHRIST ET AL
length of hospitalization and your perceived discrepancy, when ruptured appendectomy patients are ambulating and eating, but require parenteral antibiotics, we use home antibiotic therapy and follow the patients in the office; thus, the average stay for ruptured appendicitis is rarely more than 7 days. Regarding complications, these are discussed in the manuscript and were comparable in both groups. None of the complications in the laparoscopic group were due to the procedures with the exception of a retained fecalith which I may have dropped into the field. We always perform a thorough inspection and lavage, in cases of ruptured appendectomy, before removing the trocars. As far as cultures are concerned, I don’t have that data. And, all of the complicated appendectomy cases in the laparoscopic group were ruptured with abscesses. Dr Ashcraft, many of these cases are performed at night and on weekends and are not disruptive of the operating schedule. When one of these procedures becomes long and tedious we open another room and get another surgeon to do the other case. Regarding patient selection: when the laparoscopically trained surgeon was available, we offered laparoscopy to all patients. The technique is discussed in the manuscript. We use three incisions: 5 mm in the umbilicus, 5 mm in the left lower quadrant, and 10 mm in the right lower quadrant. We are able to use new more miniaturized equipment for these pediatric cases without very much difficulty. I think when Dr Gans was first discussing these concepts, back in the late 1960s and 1970s the equipment didn’t exist and I realize that Dr Gans met with the manufacturers back then and really had a great impetus in so far as getting the equipment to be what it is today.
