The IPEG Annual Congress joins with:

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

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

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

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

Laparoscopic AppendectomyPort Positions • 12 mm umbilical port - working port/stapler • 5 mm LLQ - telescope/camera • 5 mm L suprapubic region - retraction

Laparoscopic AppendectomyTechnique • Window in mesoappendix • Vascular stapler across mesoappendix

Laparoscopic AppendectomyTechnique • Regular stapler across base of appendix • Extract through 12 mm umbilical cannula • Bag used selectively

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

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

Acute Appendicitis - Free Perforation Hemodynamically Unstable • IVF Resuscitation • Antibx/NGT • Open appendectomy • Lower midline incision • RLQ incision • Prolonged (10 - 14 days) hospitalization • Rare patient

Acute Appendicitis – Contained Perforation Hemodynamically Stable • 5 - 7 day history • IVF • Percutaneous drainage (radiology) • PICC line - antibx • Discharge day 3-5 if stable • Antibx con’t 10 - 14 days at home • Return 8-10 wk. for interval appendectomy - overnight hospitalization

Interval Appendectomy Why?

Appendectomy Studies at Children’s Mercy

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

Postoperative Antibiotic Regimen for Perforated Appendicitis • No difference b/w groups re: weight, gender, days of symptoms, temperature, WBC count on admission AAP, 2007

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

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

Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess AAP, 2007

Adhesive Small Bowel Obstruction After Appendectomy in Children: Comparison Between the Laparoscopic and Open Approach AAP 2006 J Pediatr Surg 42:939-942, 2007

Laparoscopic versus Open Appendectomy AAP 2006 J Pediatr Surg 42:939-942, 2007

SBO After Perforated Appendicitis AAP 2006 J Pediatr Surg 42:939-942, 2007

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

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

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The IPEG Annual Congress joins with: