INTRODUCTION
Acute appendicitis is the most common surgical emergency in childhood.Appendicitis may present at any age, although it is uncommon in preschool chil- dren. Approximately one-third of children with acute appendicitis have perforation by the time of opera- tion. Despite advances in improved fluid resuscita- tion and better antibiotics, appendicitis in children, especially in preschool children, is still associated with significant morbidity.
The diagnosis of acute appendicitis in childhood can sometimes be difficult. Definite diagnosis is made in only 50–70% of patients at the time of initial assessment. The rate of negative pediatric appendec- tomy is in the range 10–50% in various reports. The patient’s history and clinical examination are the most important tools for the diagnosis of appendi- citis. Peri-umbilical pain is often the first symptom followed by vomiting and fever. When the inflamma- tion progresses, the pain localizes to the right lower quadrant, and right lower quadrant tenderness de-
velops. Laboratory investigations and plain radio- graphs are neither sensitive nor specific in the diag- nosis of appendicitis. In recent years, graded com- pression ultrasonography of the right lower quad- rant has been shown to be a useful tool in the evalua- tion of patients with clinical findings that are sugges- tive but not diagnostic of appendicitis, having a sen- sitivity of 80–94%, a specificity of 90% and an overall accuracy of 90%. Computed tomography (CT) may be helpful in selected cases but is rarely needed.
In patients with an uncertain diagnosis of acute abdominal pain, a policy of active observation in hospital is usually practised. A repeated structured clinical examination is simple and non-invasive.
Children with perforated appendicitis must be treated pre-operatively to prevent dehydration and generalized sepsis. Antibiotics against aerobic and anaerobic bacteria are essential to reduce complica- tions and to prepare the patient for surgical proce- dure.
Vincenzo Jasonni 322
Figure 29.1, 29.2
A transverse right lower quadrant skin crease inci- sion across McBurney’s point is recommended. The muscular layers are split in the direction of their fi- bres. The peritoneum is opened and fluid sent for culture.
29
Figure 29.2
Vincenzo Jasonni 324
Figure 29.3, 29.4
The mesoappendix is divided and the appendiceal base clamped and ligated. Stump inversion is option- al. Several studies have reported no difference as re- gards wound infection and post-operative fever between one group in which the appendix was ligat- ed and doubly invaginated and another group in which it was simply ligated. If pus is present, the ab-
domen should be irrigated with saline. Drains are not necessary. The abdominal wall is closed in layers. The skin is usually closed by subcuticular absorbable su- tures, even in the case of perforation. Primary wound closure after perforated appendicitis is safe, econom- ical and advantageous in pediatric practice.
29
Figure 29.5
Laparoscopy-assisted removal of the appendix can be performed using two different methods: first, the complete laparoscopic approach and, second, the transumbilical laparoscopic appendectomy (TU- LAP). The complete laparoscopic procedure is per- formed using three ports. The first is inserted through the navel, initially for the telescope and af- terwards for the operating instruments and the sta- pler and to extract the appendix. The second port is positioned in the left iliac region for the telescope and for the operating instruments. The third port is positioned in the right iliac region to grab the appen- dix. A direct transparietal suture is inserted in the right iliac flank to keep the appendix in tension dur- ing the dissection. Before resecting the appendix, an exhaustive evaluation of the entire abdominal cavity must be done.
Figure 29.6
Skeletonizing of the appendix is performed using a bipolar instrument or a monopolar hook; large ves- sels are ligated using clips or regular sutures. Gener- ally, in the case of inflamed tissues and small-sized vessels, clips or sutures are not required. The base of the appendix is closed using staplers or is ligated with two preformed loops.
TULAP is performed using a 10-mm telescope with an operating channel through the umbilicus.
The appendix is grabbed and pulled through the um- bilicus. The procedure is thereafter completed from outside using a conventional approach through the umbilicus. The advantages of TULAP are the limited dimension of the scars and good cosmetic results.
10 mm port
5 mm port 3 mm port
Figure 29.5 Figure 29.6
Vincenzo Jasonni 326
CONCLUSION
Advances in peri-operative care and antibiotics have resulted in a zero mortality rate and low morbidity in children with appendicitis. The long-term outcome of the vast majority of patients who undergo appen-
dectomy in childhood is very good. A small number of patients may develop late adhesive intestinal ob- struction.
29
SELECTED BIBLIOGRAPHY
Emil S, Mikhail P, Laberge JM et al (2001) Clinical versus sono- graphic evaluation of acute appendicitis in children: a com- parison of patient characteristics and outcomes. J Pediatr Surg 36 : 780–783
Gauderer MWL, Crane MM, Green JA et al (2001) Acute appen- dectomy in children: the importance of family history. J Pe- diatr Surg 36 : 1214–1217
Meguerditchian AN, Prasil P, Cloutier R (2002) Laparoscopic appendectomy in children: a favourable alternative in sim- ple and complicated appendicitis. J Pediatr Surg 37 : 695–698
Moir CR (1992) Appendectomy: open and laparoscopic ap- proaches. In: Spitz I, Coran AG (eds) Rob and Smith’s oper- ative surgery. Chapman & Hall, London, pp 402–410 Puri P (1998) Appendicitis. In: Stringer MD, Oldham KT, Mou-
riquand PDE, Howard ER (eds) Pediatric surgery and urol- ogy: long-term Outcomes. WB Saunders, London, pp 321–
328
