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Aziz et al. Laparoscopicsuction in paediatrics post-appendectomy

it showed that it was not the type of approach (LA vs. intraoperative irrigation. They concluded that routine
OA) that determined the rate of IAA formation post use of intraoperative irrigation for appendectomies
appendectomy, but some other factors that yet to be does not prevent intra-abdominal abscess formation.
determined. In this study, all the patients with infected This paper did not mention specifically the subsequent
wound underwent open surgery to obtain optimal management of postoperative IAA among their
drainage followed by lavage with a water shower. Drain patients. [7]
was then placed in most of the cases. It did prolong
the healing time but was comparable in both groups. [5] A prospective randomised trial study conducted by
St Peter et al. in 2012, concluded that there is no
[8]
In 2015, Cho et al. conducted a study with the aim advantage to irrigation of the peritoneal cavity over
[6]
to identify the risk factors for IAA formation in patients suction alone during laparoscopic appendectomy for
receiving LA; 1,817 patients were enrolled in this study. perforated appendicitis; 220 patients with perforated
During the LA, when the surgical findings revealed appendicitis were enrolled in this study. They were
generalized peritonitis or pus, or if faecolith were randomised to irrigation (minimum of 500 mL of saline
spilled during the procedure, the operative surgeon with no maximum limit), or to suction only group (no
would routinely perform cleansing procedure using irrigation). There were 110 patients treated in each arm
laparoscopic gauze and suction; no irrigation water was of this study. There were no differences in age, weight,
involved. However, if the routine cleansing procedure body mass index percentile, gender distribution,
was incomplete, peritoneal irrigation using sterile duration of symptoms, presenting leukocyte count,
isotonic saline with minimum volume of 200 mL would or temperature between the 2 groups. All patients
be carried out. Result showed that 27 patients (1.5%) were managed with the same antibiotic regiment
developed IAA formation; 21 of them had received and protocol. The primary outcome variable was the
peritoneal irrigation intra-operatively and this was the development of a postoperative abdominal abscess.
only factor that was statistically significant to raise the The result showed no difference in abscess rate,
incident of IAA formation in this study. Not even the which was 19.1% with suction only group and 18.3%
type of appendicitis (suppurative vs. complicated) or in irrigation group (P = 1.0). From these data, it’s
metabolic factor (diabetes vs. non-diabetes) or use of clearly demonstrated that the outcome in patients with
antibiotics could significantly contribute to the higher perforated appendicitis will not be affected by the use
incidence of IAA formation. IAA was suspected when of a moderate amount of irrigation during laparoscopic
patient developed fever and abdominal pain post appendectomy. The authors did not mention regarding
operatively. Computed tomography scan abdomen the management of postoperative IAA among their
was performed to confirm the IAA formation. Among patients. [8]
the 27 patients who developed IAA postoperatively,
only 1 patient received a re-operation. However, the Similar result was found in recent randomised,
type of operation (laparoscopic or open) and procedure controlled equivalence trial done by Snow et al. that
[9]
done was not explained in this paper. The remaining was published in 2016. Eighty-two patients with
26 cases of IAA, 12 of them underwent percutaneous suppurative or perforated appendicitis were enrolled
drainage, and the rest received antibiotic treatment in this study; 41 patients were randomised to the
only, no mortality was reported. [6] suction only (SO) group and 40 patients to irrigation
and suction (IS) group. Procedure was performed
A comparative study done by Moore et al. published using standard laparoscopic technique. Primary end
[7]
in 2011, documented a higher abscess rate when point was the rate of IAA formation. A median volume
irrigation was used during appendectomy for perforated of 675 mL of irrigation was used in the IS group. Result
appendicitis including LA. In this study, the data of 176 showed equal number of patient who developed IAA in
patients who underwent appendectomy (39% open both groups (5% in IS group and 4.9% in SO group).
and 61% laparoscopic) were reviewed retrospectively. From the 4 patients with IAA, 3 required re-operation,
More than 50% of patients in both groups received in which 2 were laparoscopic (1 SO, 1 IS) and 1 by
intra-operative irrigation. The amount of irrigation was laparotomy (SO). Another patient (IS) was planned for
not quantified in this study due to inconsistent amount percutaneous drainage but this was cancelled due to
of irrigation used between surgeons. Perforation was decreasing size of the collection. The rate of IAA in this
observed in 28% (50/176), of which 86% (43/50) of study was lower than other studies, which had shown
patients received intraoperative irrigation. Eleven closer to 20%. The reason being is most likely due to
patients (9.6%) with irrigation developed postoperative the case definition for enrollment. This study included
abscess compared with 2 (3.3%) patients without suppurative appendicitis as their subjects while other
irrigation (P = 0.22). The result showed no decrease studies focused more on perforated appendicitis. [9]
in postoperative intra-abdominal abscess with use of In our series, persistent fever was the most

146 Mini-invasive Surgery ¦ Volume 1 ¦ September 30