Laparoscopy in Infants and Children: What’s New?

1. Laparoscopy in Infants and Children:What’s New? George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO

2. Pediatric Laparoscopy

3. Appendicitis

4. Do We Need to Operate?Adult Studies • Park HC, Kim BS, Lee BH: Efficacy of short-term antibiotic therapy for consecutive patients with mild appendicitis. Am Surg 2011; 77:752-755. • Lien WC, Lee WC, Wang HP, Chen YC, Liu KL, Chen CJ. Male gender is a risk factor for recurrent appendicitis following nonoperative treatment. World J Surg 2011; 35:1636-1642 • Turhan AN, Kapan S, Kütükcü E, Yiğitbas H, Hatipoğlu S, Aygün E. Comparison of operative and non operative management of acute appendicitis. Ulus Travma Acil Cerrahi Derg 2009; 15:459-462. • Hansson J, Körner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg. 2009; 96:473-481. • Vons C, Barry C, Maitre S, et al . Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 2011; 377:1573-1579.

5. Do We Need to Operate? • In the adult literature, non-operative management with antibiotics for both acute and perforated appendicitis is successful as primary definitive therapy in up to 70% of patients. • About 20-30% will fail antibiotic management and will need an operation.

6. Appendicitis

7. Operation at Presentation Versus The Following Day Yardeni D, Hirschl RB, Drongowski RA, et al: Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J Pediatr Surg 39:464-469, 2004. • Retrospective comparison in children (Level 3 study) between operation < 6 hrs after presentation or the following day • 126 patients (38 early vs 88 late) • No differences in operating time, perforation rate, or complications

8. When to Operate?Current Practice at CMH • Patients identified with appendicitis are booked for laparoscopic appendectomy • All receive a dose of rocephin (50mg/kg) and flagyl (30mg/kg) • This antibiotic regimen was shown to be most cost effective in a PRT • If the patient presents at night, the operation is scheduled for the ‘surgeon of the week’ the next day (8 am or 1 pm start) • Appendectomies rarely occur after 10 PM at night

9. How do we manage the child presenting with an abscess due to perforated appendicitis?

10. Appendicitis with Abscess • 5 - 7 day history • Dehydrated – needs IVF • Percutaneous drainage (interventional radiology) • PICC line - antibiotics • Discharge day 3-5 if stable • Antibiotics con’t 10 - 14 days at home • Return 8-10 wk. for interval appendectomy (to prevent recurrent appendicitis) - overnight hospitalization

11. Abscess StudyProspective Trial • Drainable abscess • OR for laparoscopic appendectomy vs percutaneous drainage as initial management • Drain groups undergo laparoscopic appendectomy at 10 weeks. • Quality of life surveys at admission, at 2 weeks and at 12 weeks • Pilot study – 40 patients APSA 2009 J Pediatr Surg 45:236-240, 2010

12. Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting with an Abscess Values are expressed as mean ± SD APSA 2009 J Pediatr Surg 45:236-240, 2010

13. Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting with an Abscess Values are expressed as mean ± SD, unless otherwise indicated APSA 2009 J Pediatr Surg 45:236-240, 2010

14. Prospective Randomized Trial • Conclusion – There is no difference b/w initial laparoscopic operation vs initial non-operative management followed by laparoscopic interval appendectomy • Management can be determined by the surgeon’s preference and experience APSA 2009 J Pediatr Surg 45:236-240, 2010

15. Should we irrigate and suction the abdominal cavity for perforated appendicitis?

16. Introduction • The debate over irrigation of the peritoneal cavity has persisted over the past century • Comparative data in patients with perforated appendicitis are limited and confined to the era of open surgical approaches • Therefore, our group conducted a prospective, randomized trial comparing irrigation to no irrigation during laparoscopic appendectomy for perforated appendicitis

17. Study Population Inclusion Criteria • Under 18 years of age • Perforated appendicitis at the time of appendectomy • Stool in the abdomen • Hole in the appendix Exclusion Criteria • Severe concomitant process ASA 2012 Ann Surg 256:581-585, 2012

18. Methods Sample Size • Primary outcome variable – post-operative abscess • Sample size calculation utilized the known and stable abscess rate from our previous trials for perforated appendicitis (20%) • Power = 0.80 and α = 0.05 • 110 patients in each arm ASA 2012 Ann Surg 256:581-585, 2012

19. Operations • Operations were performed by 8 pediatric surgeons at a single institution • The on call surgeon staffed the operation • Allotment had no influence on operating surgeon ASA 2012 Ann Surg 256:581-585, 2012

20. Interventions Irrigation • 1 Liter bag of normal saline attached to the suction/irrigator • Minimum irrigation volume of 500cc Suction Only • No bag attached to the suction/irrigator Battery Powered Suction Irrigator Used in All Cases ASA 2012 Ann Surg 256:581-585, 2012

21. ResultsPatient Demographics Age (years) Weight (kg) BMI (%tile) Gender (% male) 9.7 +/- 3.6 41.2 +/- 19.8 65.0 +/- 32.3 59.1% 10.4 +/- 3.8 41.5 +/- 18.8 60.7 +/- 31.9 52.7% 0.17 0.92 0.36 0.89 Irrigation (n = 110) No Irrigation (n = 110) P Value ASA 2012 Ann Surg 256:581-585, 2012

22. ResultsInitial Presentation Days Symptoms Admit Temp (ºC) WBC 3.1 +/- 2.1 37.8 +/- 1.0 17.1 +/- 5.9 3.1 +/- 2.0 37.8 +/- 0.9 17.3 +/- 5.0 0.99 0.90 0.79 P Value No Irrigation (n = 110) Irrigation (n = 110) ASA 2012 Ann Surg 256:581-585, 2012

23. ResultsOutcomes P Value No Irrigation (n = 110) Irrigation (n = 110) Abscess (%) Op Time (mins) Initial PO’s (days) Reg Diet (hrs) Narcotic Doses Days of Stay Charges ($K) 19.1% 38.7 +/- 14.9 2.6 +/- 1.5 3.4 +/- 1.7 11.4 +/- 5.4 5.5 +/- 3.0 48.1 +/- 20.1 18.3% 42.8 +/- 16.7 2.5 +/- 1.3 3.5 +/- 1.5 11.6 +/- 6.3 5.4 +/- 2.7 48.1 +/- 18.2 1.0 0.06 0.70 0.63 0.76 0.93 0.97 ASA 2012 Ann Surg 256:581-585, 2012

24. Location Of Postoperative Abscesses 14.3 14.6 4.8 1.8 31.0 29.1 4.8 7.3 47.3 45.3 No Irrigation Irrigation ASA 2012 Ann Surg 256:581-585, 2012

25. Conclusions There is no advantage to irrigation of the peritoneal cavity over suction alone during laparoscopic appendectomy for perforated appendicitis ASA 2012 Ann Surg 256:581-585, 2012

26. Is there a clinical advantage to performing the laparoscopic appendectomy through a single umbilical incision?

27. SSULS Appendectomy

28. Postoperative Appearance

29. Prospective Randomized Trial Single Umbilical Incision vs 3-PortLaparoscopic Appendectomy • 360 total patients • Acute non-perforated appendicitis • August 09 – November 10 • Primary outcome variable – postoperative wound infection • Standardized pre and postoperative management • Quality of life surveys at 6 weeks and 18-24 months ASA 2011 Ann Surg 254:586-590, 2012

30. Patient Characteristics at Operation ASA 2011 Ann Surg 254:586-590, 2012

31. Outcome Data ASA 2011 Ann Surg 254:586-590, 2012

32. Other Outcomes ASA 2011 Ann Surg 254:586-590, 2012

33. Convalescence Following Discharge ASA 2011 Ann Surg 254:586-590, 2012

34. Subset Analysis • BMI% for age & gender: overweight 85-95%, obese >95% • Compared normal to overweight and normal to obese within each group • Compared single site to 3 port within each body habitus classification IPEG 2012 JLAST 22:404-407, 2012

35. Technique Comparison For Overweight IPEG 2012 JLAST 22:404-407, 2012

36. Technique Comparison For Obese IPEG 2012 JLAST 22:404-407, 2012

37. Conclusions • Obesity increases operating time, postoperative length of stay, doses of narcotics, and hospital charges with single site lap appendectomy • Obesity has no impact in 3 port appendectomy • Clinically significant increase in wound infection in overweight and obese patient undergoing single site lap appendectomy • We do not recommend single site laparoscopic appendectomy in obese patients IPEG 2012 JLAST 22:404-407, 2012

38. Is there a cosmetic advantage to performing the laparoscopic appendectomy through a single umbilical incision?

39. Postoperative Appearance3 Port Laparoscopic Appendectomy

40. Methods APSA 2013 • Patients enrolled in the trial completed the PSAQ (Patient Scar Assessment Questionnaire) • Survey was obtained from: • Patients 12 years or older • Parents of patients less than 12 years old • PSAQ completed in early and late follow up • Early - 6 weeks post-op clinic visit • Late - after at least 18 months post-op by phone call

41. Methods • PSAQ - 4 validated subscales • Appearance • Consciousness • Satisfaction with Appearance • Satisfaction with Symptoms • Each question has 4 point response from least to most favorable • Sum of the scores within each subscale was used for comparison between groups APSA 2013

42. Results APSA 2013

43. Results PSAQ Scores: Early Follow Up (6 weeks) APSA 2013

44. Results PSAQ Scores: Late Follow Up (18-32 months) APSA 2013

45. Conclusions The short-term results demonstrate significantly more favorable perception of scar scores with the single-incision approach At two years, these differences largely vanish Long term follow-up responses approach best possible scores in both groups Our group now utilizes the single site approach in non-overweight/obese children with non-perforated appendicitis, and we have a low threshold for additional ports if needed APSA 2013

46. AppendicitisSummary • There have been significant changes in the surgical management of appendicitis • These changes have revolved around timing of surgery and the almost exclusive use of the laparoscopic approach • Long-term, there is no cosmetic advantage for the single-incision approach c/w the three-port operation • Unclear if appendicitis will be a surgical disease in the future

47. Gallbladder Disease

48. Biliary Dyskinesia • Symptomatic biliary colic w/o stones • Reduced GBEF and pain with CCK stimulation • Has become the most common reason for cholecystectomy in many U.S. centers • IU study – 37 pts – 71% resolution of symptoms • GBEF < 15% successful resolution of symptoms (O.R. – 8.00) (J Pediatr Surg 39:813-816, 2004) • Chronic cholecystitis seen on histological examination of many specimens

50. Laparoscopic Cholecystectomy • 2006 – 2011 - CHA • 82 children • Chronic cholecystitis – 60% • Long-term symptom relief: 44% • EF < 15%: symptom resolution