Laparoscopic Appendectomy
Indications
Indications for Laparoscopic appendicectomy in children are similar to those in adults. Laparoscopic appendicectomy is performed in various stages of acute and chronic appendicitis.
- In acute cases acutely suppurative, perforated gangrenous appendicitis
- In doubtful cases of appendicitis in young females.
- In obese children or over weight child minimally invasive surgery is more advantages than the conventional procedure.
Contra Indication
- Children with associated Respiratory and cardiac problems and severe renal disease
- In case of coagulatory disorder
- In case of appendicular mass and appendicular abscess.
Establishment of pnemo may disrupt the abscess cavity allowing free spill of Pus to the entire peritoneal cavity and the walls of the abscess cavity can be made up of mesentery and bowel and so dissection is unsafe.
Pre-Operative Preparations
Patients are prepared for laparoscopic appendicectomy in children are some as that of Conventional open surgery. The usual preoperative preparation includes a thorough history and physical examination, routine laboratory, radiological and sonographic investigations are obtained as clinically indicated. The patient should be well hydrated and administered appropriate broad-spectrum antibiotics.
Counselling
A thorough discussion is necessary with the parents and their family members regarding the risk and benefits of laparoscopic verses open appendectomy.
Technique
The principles of laparoscopic appendectomy in children are similar to those in adults.
Special care is required when applying the Technology to children when compared with adults. All the patients are placed under GA with endotrachial intubation and muscle relaxants to allow for controlled ventilation. Stomach and Bladder are decompressed with appropriate cathetrisation in order to prevent trocar injury during cannula insertion and to provide adequate exposure of the operative field. The abdomen is prepared widely.
Place the patient in supine in the operation table with trendelenbergh Position and little tilt to the left. Usually three trocars are placed – sub umbilical 10 mm for telescope and camera. All Secondary trocar are placed under vision. 5 mm supra pubic in the midline and 3 mm secondary trocar on the left iliac region lateral to the rectus muscle. We don’t place the trocar directly over the appendix or in the right iliac region because we feel that makes video endoscopic eye hand co-ordination more difficult. Since the abdominal surface and cavity ratio in children is reduced compared to adults, more attention is required regarding the placement of cannulas. It must be emphasized that an appropriate working angles are maintained by placing the cannulas in proper position.The abdominal wall in these small patients is very pliable compared with adults. So when inserting the cannulas with their accompanying trocars, it is very important to direct the sharp stylette away from the underlying Intra abdominal organs to prevent injury with forceful insertion of the trocars and cannulas.
After locating the appendix separate the appendix from the surrounding adhesions and meso appendix was divided with Electrocautery (we always use monopolar cautery) and base of the appendix ligated with pre-tied Roeder’s Endo knot and appendectomy done. It is our routine to walk through the intestine after the appendicectomy to search for Meckel’s diverticulam.
COMPLICATION
- Conversion to the open procedure should not be regarded as a failure.
- Similar complication to those encountered after open appendicectomy can be expected after laparoscopic appendectomy
- Wound infection less
- Thermal injury due to diathermy.
Advantages of Laparoscopic Approach
- It affords a better view of appendix and pelvic organs resulting greater diagnostic accuracy.
- In infected cases peritoneal cavity can be more thoroughly irrigated and free fluid and purulent collections aspirated under direct vision.
- It requires a small puncture wound rather than the muscle cutting or muscle splitting incision resulting less postoperative pain in Laparoscopic approach.
- Intra abdominal adhesions are lower than the open surgery
- Infertility problems in female patients are also reduced in Laparoscopic approach because of less Intra abdominal adhesions.
Financial Implication
Need of special instruments for laparoscopic surgery resulting in extra costs. Otherwise less hospitalization and early return to full normal activity is the benefit.
Our Experience of 327 Cases
Total No. Of cases for the past 4 years between 1994 to 1997 were 327. Of which we have operated 118 cases of children below 14 years.
Age: More numbers between 10 – 20 years about 174 cases.
- Below 10 Years – 13
- 10-14 Years – 105
- 14- 20 Years – 69
Sex : Male children are slightly higher than the Female
- Male – 62 – 52.5 %
- Female – 56 – 47.5 %
Position: Total No’s. 118
- Retrocaecal – 57
- Pelvic – 24
- Pre-ileal – 20
- Sub-Caecal – 9
- Para-Caecal – 8
Classification: We formed the following classification
- Perforated Appendix – 2 Cases
- Appendicular Mass – 3 Cases
- Acute Appendicitis – 59 Cases
- Chronically Recurring Appendicitis – 31 Cases
- Chronic Appendicitis – 23 Cases
Operating Time:
Initially we needed as average operating time of 65 minutes. After the initial phase the operating time decreases to 25 to 40 minutes and was comparable with the conventional appendicectomy.
Secondary Findings:
Intra operatively we found adhesions to the Rt. tube in One case. Dense adhesions to the small bowel mesentery in 3 cases. Pelvic abscess in 1case.
Conversion:
Among 118 pediatric cases of laparoscopic appendectomies we converted only three Cases (2.5 %) due to pelvic abscess and dense adhesions to the small bowel mesentery in late appendicular mass.
Complication: Nil.
Hospitalization:
Average length of hospitalization was maximum 3 days. Most of the patient discharged on the first postoperative day after the breakfast even though some of the parents wants to stay more of their own.
Summary:
1. Contrary to the initial idea that a Laparoscopic appendectomy can be performed only in the case of chronically inflamed or normal appendix. We successfully Employed this method independent from its Intra operative position and inflammation.
2. We have found from our series that Laparoscopic appendectomy in children is a safe successful and effective method having high cosmetic and less morbidity.
Dr. S. Navaneethakrishnan, MS., FICS. ,
FAIS Professor of Surgery,
Rajah Muthiah Medical College,
Annamalai Nagar, Chidambaram.
