Page 151 - Read Online

Aziz et al. Laparoscopicsuction in paediatrics post-appendectomy

INTRODUCTION administration of standard antibiotics (and additional
antibiotics if any) and days to discharge. We also
Laparoscopic appendectomy (LA) for perforated documented clinical evaluation of these patients
appendicitis had shown favorable outcomes in terms during follow-up, specifically looking for symptoms
of length of hospital stay, antibiotic usage, return of oral to suggest adhesive intestinal obstruction. We also
intake and rate of wound infection in comparison with included in this series, cases referred to our centre for
open appendectomy (OA). With regards to infection management of IAA. Parental consent was taken prior
rate, Lin et al. in 2006 showed that the rate of wound to DLS procedure.
[1]
infection was lower than the OA group i.e. 15.2% vs.
30.7%. However, there was no mention of the more The laparoscopic approach to appendectomy was
dreaded complication of intra-abdominal abscess (IAA) the 3-port technique using 11 mm Hasson trocar
especially after LA for perforated appendicitis. This for camera insertion and 2-6 mm working ports.
issue was later addressed in subsequent literature and The antibiotics of choice were intravenous second
it became a major concern when deciding to perform generation cephalosporin group and metronidazole.
LA for perforated appendicitis for many surgeons. The The surgical technique was standardised for all
European guideline recommends thorough peritoneal patients. All appendiceal stumps were ligated using
lavage (6-8 L of warm saline) and aspiration to minimize loop polypropylene suture. All perforated cases would
the IAA rate in complicated appendicitis. However, have suction and irrigation with unspecified amount
this practice was controversial as it was postulated of warm saline till the effluent was clear. Patients who
that lavage itself might help to spread the infectious have persistent fever at day 3 of post-surgery with or
materials. [2-4] without symptoms of abdominal distension, pain or poor
appetite would be subjected to ultrasound assessment
There are many published articles on the role of LA and to look for presence of IAA, its complexity and size.
lavage and OA and peritoneal washout in the formation Intraabdominal abscess of less than 5 cm × 5 cm
of IAA, however there has not been any discussion were treated conservatively by adding intravenous
on the management of these patients with IAA post- gentamycin (aminoglycoside). For cases with IAA of
surgery except for placement of drains and antibiotics more than 5 cm × 5 cm, we documented the procedures
in some series. [5-9] The aim of this study is to document chosen to manage the IAA i.e. either percutaneous
feasibility and effectiveness of delayed laparoscopic drainage or DLS and the clinical progress based on
suction (DLS) at tackling IAA. The hypothesis is that factors mentioned earlier.
DLS is a feasible and effective technique for treatment
of IAA post perforated appendectomy in children. RESULTS

METHODS Out of the 49 cases of LA at our institution, 20 cases
were for perforated appendicitis and 29 were for
This study was based on a comprehensive review suppurative appendicitis. None of the cases underwent
of audit on paediatric patients who underwent conversion to open surgery. Intraoperatively, all
laparoscopic appendectomy at our institution for acute cases with perforated appendicitis had laparoscopic
and perforated appendicitis for the recent three and peritoneal lavage with unspecified amount of warm
a half years; we looked at the occurrence of IAA and saline and suction. Out of 20 patients, 9 developed IAA.
the management strategy to resolve this problem i.e.
percutaneous drainage or DLS. All patients with acute All 9 patients with suspected IAA were febrile at post-
or perforated appendicitis at our institution would operative day 3 with temperature of more than 38 °C.
undergo laparoscopic appendectomy unless there was They were subjected to ultrasound abdomen for
presence of distended abdomen from a dilated bowel confirmation of IAA. Ultrasound showed 8 patients
i.e. suggestive of intestinal obstruction secondary to had IAA larger than 5 cm × 5 cm at the right iliac
the pathological appendix. Suggestion of intestinal fossa and in the pelvis region. Two patients underwent
obstruction would be evident clinically and supported percutaneous drainage under ultrasound guidance
radiologically (AXR and/or ultrasound abdomen). We and a pigtail catheter insertion, the tip of the catheter
documented the type of appendicitis (suppurative or was placed in the pelvic cavity to drain the residual
perforated), whether irrigation and suction was done IAA into a sterile bag. The aspirated pus was sent for
intraoperatively, days of persistent and cessation of culture and sensitivity and the bacterial involved was
fever, presence of abdominal pain and poor appetite confirmed to be Escherichia coli. In these 2 patients,
and disappearance of these symptoms, ultrasound intravenous antibiotic gentamycin was added. Both
findings of the measurement of the IAA, days of patients remained febrile till over a week post-surgery.
144 Mini-invasive Surgery ¦ Volume 1 ¦ September 30