Laparoscopic versus open appendectomy in complicated appendicitis in children: a single center study

Acute complicated appendicitis is a common abdominal emergency in children. Unlike simple appendicitis, laparoscopic appendectomy has not been considered yet the first choice in management of complicated appendicitis. This prospective randomized controlled clinical trial was conducted at Pediatric Surgery Department, Zagazig University Hospitals, Egypt, during the period from December 2018 to August 2019. The aim of the study was to evaluate the role of laparoscopic appendectomy in such cases compared to open appendectomy. Sixty patients were included in the study, divided randomly into 2 equal groups: laparoscopic and open appendectomy groups. The mean operative time was significantly longer with laparoscopic appendectomy than open appendectomy, 85 vs. 61 min, respectively (p < 0.001**). The time taken to start oral intake was significantly shorter with laparoscopic appendectomy than open appendectomy, 1.9 vs. 2.73 days, respectively (p = 0.025*). The mean hospital stay was significantly lower with laparoscopic appendectomy than open appendectomy, 4.23 vs. 5.13, respectively (p = 0.044*). There were no statistical differences between the two groups regarding wound infection, occurrence of postoperative ileus, intraperitoneal collection, or readmission. Laparoscopic appendectomy is safe, feasible, and effective procedure in the management of complicated appendicitis in children, with no evidence of any increase in the postoperative complications.

Our work aims to compare the intraoperative and postoperative outcomes of LA versus OA in complicated appendicitis in children in our center.

Methods
After approval of the Institutional Review Board (ZU-IRB #4787/5-8-2018), registered 5 August 2018, a prospective randomized controlled clinical trial was conducted at Pediatric Surgery Department in our hospital during the period from December 2018 to August 2019. During the period of study, 60 patients were diagnosed and operated for complicated appendicitis based on history, clinical examination, laboratory findings, and ultrasonography. Patients with simple appendicitis or more than 12 years old were excluded.
Complicated appendicitis in this study was defined as acute appendicitis in which perforation with purulence or fecalith in the abdominal cavity or gangrenous appendicitis with or without intra-abdominal abscess.
LA was performed to 30 of the included patients, and OA was performed to the other 30.
Data was collected regarding demographics, preoperative assessment, intraoperative findings, operative time, length of hospital stay, time taken to start oral intake, and occurrence of postoperative complications, including wound infection, intraperitoneal collection, ileus, and readmission.
All patients had general endotracheal anesthesia and muscle relaxant. A Foley's catheter and a nasogastric tube were used when indicated. OA was performed conventionally through McBurney's or Lanz's incisions.
The operative time in this study was measured as the real time of operation, from the first skin incision to the last skin closure with exclusion of the time of anesthesia and preparation.
LA was performed using a two-handed, three trocar technique. After pneumoperitoneum had been performed, a 5-mm port was introduced for a laparoscopic camera through a semicircular incision to the upper edge of the umbilicus, and then inspection of abdomen was done. Two working ports were introduced under direct vision, one to the suprapupic region at the midline (5 mm) and the other to the left lower quadrant at the level of the iliac spine (5 mm or 10 mm if endoclips would be used). After finding the appendix, hook diathermy was used to divide the mesoappendix carefully from the distal end of the artery towards the cecal base. According to the surgeon preference, the base of appendix was ligated with intracorporial sutures, a laparoscopic pre-tied loop sutures in small children, or endoclips via clip applier 10 mm in older children, and then the appendix was sharply divided between them and removed through the port.
Suction/irrigation was carried out if needed using sufficient saline solution till the aspirate become clear. Intra-abdominal drains were placed only on necessary when there were multiple pockets of collection.
All patients received intravenous antibiotics (cefotaxime, a third generation cephalosporin, 100 mg/kg/day), metronidazole (7.5 mg/kg/q 8 h), and analgesia (Paracetamol, 15 mg/kg/q 6 h). When the bowel function was restored, oral intake was started as soon as patients could tolerate it. Drain was removed usually after 48-72 h if there was no discharge and the abdomen of patient was lax and not distended. Patients were discharged after remaining afebrile for 24 h and after they can tolerate normal diet and exhibited a decrease in the white blood cell count to the normal level. The patients were followed up in the outpatient clinic at 1 week, 2 weeks, and at 1 month intervals for 3 months.
The collected data was analyzed using the software SPSS version 20. Quantitative variables were described using their means and standard deviations. Categorical variables were described using their absolute frequencies and were compared using Chi square test and Fisher exact test when appropriate. Independent sample t test (used with normally distributed data) was used to compare means of two groups. The level statistical significance was set at 5% (p < 0.05). Highly significant difference was present if p ≤ 0.001.

Results
A total of 60 patients were included in the study, 30 of them were managed with OA, and the other 30 were managed with LA. Demographic data showed no significant difference between the two groups (Table 1).
According to the latest update of definition of sepsis (sepsis-3), which is a life-threatening organ dysfunction caused by a dysregulated host response to infection [15], there were no cases of sepsis regarding both groups. No cases were presented with intestinal obstruction in both groups.
There were 12 cases of perforated appendix, 10 suppurative appendicitis, and 8 gangrenous appendicitis in OA group, and 11 cases of perforated appendix, 12 suppurative appendicitis, and 7 gangrenous appendicitis in LA group. Operative time was significantly longer in with LA; its mean was 85.17 ± 27.02 min vs. 61.33 ± 20.08 min with OA (p < 0.001**). Intraperitoneal drain was inserted in 33.3% of LA cases vs. 76.6% of OA cases, which was statistically significant. There were 2 cases that had not been completed laparoscopically and converted to open approach. Patients could tolerate oral intake after (2.37 ± 0.85 days) OA group vs. (1.9 ± 0.71 days) in LA group, which was significantly faster with LA (p = 0.025*). Hospital stay was significantly shorter with LA (4.23 ± 1.57 days) vs. (5.13 ± 1.81 days) in OA group ( Table 2).
The rate of wound infection was lower in LA group than OA group, but the difference was not significant (20% vs. 26.7% respectively, p = 0.542). There was no significant difference between the LA and OA groups regarding occurrence of postoperative intraperitoneal collection (6.3% vs. 10% respectively) or ileus (3.3% vs. 6.3% respectively). There was also non-significant difference between the two groups regarding readmission (3.3% in LA group vs. 6.3% in OA group) (Fig. 1).

Discussion
Introduction of minimal invasive surgery made a revolution in the surgical practice as it provides many advantages over conventional surgeries. LA has been reported as the best choice for managing uncomplicated pediatric appendicitis for many benefits such as early return to physical activity, reduced postoperative pain, and decreased postoperative complications. But, as regards complicated appendicitis, it shows controversy to take the decision of performing laparoscopy as distorted anatomy and severe inflammation are challenging [9,16,17].
Many studies reported the superiority of laparoscopy regarding surgical site infection, regaining of oral intake, length of hospital stay, and cosmesis. On the other hand, slight higher rates of intra-abdominal infection, increased costs, and increased operative time are also recorded, but with more experience, laparoscopic surgery could become faster than open one [18,19].
The operative time was significantly longer with LA than OA by 23.48 min that was nearly similar to many published literature [7,9,[20][21][22]. These results could be explained as laparoscopic approach needs more experience, skills, and training. Also dealing with complicated appendicitis needs meticulous dissection which needs furthermore skills and training.
The need for intraperitoneal drain insertion was significantly lower with LA than OA (p = 0.001). This significance was also reported by Horvath et al. [23]; we explained that the laparoscopic technique offers a good vision to the entire abdomen and that enables the surgeon to achieve a careful suction from every quadrant having collections.
Conversion from laparoscopic to OA occurred with 2 cases included in this study (6.7%); one of them, the appendix was inaccessible due to extensive adhesions, and the other was perforated closely to the cecum, and it was difficult to ligate the appendix. This rate of conversion was nearly the same with that published by Thomson et al. [24] which occurred with 5% of their cases. Other publications reported fewer rate of conversion from laparoscopic to open, such as Kassem et al. [25] who reported the conversion to open in 2.4% of cases. This rate may differ according to the severity of the individual case. Additionally, using "Ligasure®, Covidien,  USA" was reported to decrease the rate of conversion to open, especially in case of gangrenous tissue [16].
The time taken to start oral intake was significantly shorter after LA than OA by 0.47 days, which was comparable to other published studies [9,25]. This could be explained by the advantages of the laparoscopic technique which is less traumatic to the abdominal wall and peritoneal cavity, associated with lower chance for introducing foreign bodies, provides better ability for hemostasis and associated with quicker return of bowel motility.
The present study showed that the hospital stay was significantly shorter after LA than OA by (0.9 day), which was nearly similar to that reported by Xuan et al. in their meta-analysis [17] and also the recent Cochrane systemic review which was (0.8 day) in favor of LA [18]. These results could be explained as LA is associated with less surgical stress, early mobilization, early oral intake, and less postoperative pain.
Most of recent studies have reported the benefits of LA over OA regarding wound infection [7]. However, in this study, the rate of postoperative wound infection was not significantly different between the two groups (p = 0.542), but incidence rate was still lower after LA than OA (20% vs. 26% respectively), which was comparable to Lin et al. [26] and Khirallah et al. [20]. On the other hand, some studies reported a significant decrease in the incidence of wound infection with LA, such as Xuan et al. [17]. These results could be explained that they protect the extraction site of the appendix during LA by using retrieval bag, which was not used in our study.
Formation of postoperative intraperitoneal collection is one of the issues that had shown controversy. Many earlier studies mentioned a major concern about increasing rate of incidence after LA, such as Horwitz et al. [27] who reported the occurrence of postoperative intraperitoneal collection after 9% of OA cases vs. 41% of LA cases. Also Krisher et al [28] and Thomson et al [24] reported nearly similar results. With increasing the experience in using LA in pediatric complicated appendicitis, many recent studies such as Vahdad et al [29] and a meta-analysis performed by Xuan et al [17] proved that there was no significant difference between the two techniques in formation of postoperative intraperitoneal collection, which was aligning with our results. On the other hand, Khirallah et al. reported a significant increasing rate of postoperative intraperitoneal collection after OA (28.4%) and LA (7%) [20]. This controversy could not be explained only as a result of the operative technique, but there were other external factors that could influence the results, such as the level of experience of the surgeon, the severity of inflammation, the degree of intraperitoneal contamination, the time of diagnosis, and the time of intervention [17].
The incidence of postoperative ileus was higher after OA than LA (6.3% vs. 3.3% respectively); however, this difference was not statistically significant. This was comparable to other published studies [17,30]. The reduced incidence of postoperative ileus after LA could be explained due to reduced manipulation of the bowel with hands, minor abdominal trauma, and less postoperative pain.
There were 3 cases of readmission in this study, 2 of them occurred after OA (6.3%); one was due to ileus, and the other was due to intraperitoneal collection. The third case occurred after LA (3.3%) due to intraperitoneal collection. All these cases were managed conservatively. There was no significant difference between the two groups regarding readmission (p > 0.999) and that was nearly similar to other publications [7,12,17].

Conclusions
Our study demonstrates that laparoscopic appendectomy is safe, feasible, and effective in the management of complicated appendicitis in children. Furthermore, it provides many advantages, including faster recovery, less need for drain insertion, less hospital stay, and less wound infection, with no evidence of any increase in the postoperative intraperitoneal infection, ileus, or readmission.