George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

1. Laparoscopy for Acute Abdominal Conditions50th Meeting of the Brazilian Association of Pediatric Surgeons George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

2. Acute Abdominal Conditions • Abdominal trauma • Small bowel obstruction • Intestinal perforation – free air • Ovarian torsion • Volvulus • Intussusception and . . . .

3. Acute Appendicitis

4. Laparoscopy -TraumaBackground • Most intra-abdominal (and intra-thoracic) injuries can be managed non-operatively • Absolute indications for operation: • Shock from intra-abdominal bleeding • Pneumoperitoneum • Contrast extravasation • Selective indications for operation • Thickened bowel loops • Mesenteric infiltration • Unexplained free fluid • Violation peritoneum on local exploration for penetrating trauma

5. Laparoscopy - TraumaBackground • FAST & DPL not as helpful in deciding management in children • Equivocal findings for an injury are sometimes found on CT scan

6. When To Use Laparoscopy in Trauma • Hemodynamically stable patient • Blunt trauma • Free fluid not from solid organ injury • Persistent abdominal pain/tenderness • Penetrating trauma • Peritoneal violation?

7. Algorithm Gaines BA, et al: The role of laparoscopy in pediatric trauma. SemPediatrSurg 19:300-303, 2010

8. Minimally Invasive Surgery for Pediatric Trauma – A Multi-Center Review Hanna Alemayehu, MD1 Matthew Clifton, MD2; Matthew Santore, MD2; Diana Diesen, MD3; Timothy Kane, MD4; MikaelPetrosyan, MD4; Ashanti Franklin, MD4; Dave Lal, MD, MPH5; Todd Ponsky, MD6; Margaret Nalugo, MPH6; George W. Holcomb III, MD, MBA1; Shawn D. St. Peter, MD1 • 1. The Children’s Mercy Hospital, Kansas City, MO • 2. Emory University, Children’s Healthcare of Atlanta at Egleston, Atlanta, GA • 3. Children’s Medical Center, Dallas, TX • 4. Children’s National Medical Center, Washington, DC • 5. Children’s Hospital of Wisconsin, Milwaukee, WI • 6. Akron Children’s Hospital, Akron, OH 2014 IPEG/BAPS Meeting

9. Operative Interventions • 205 total MIS procedures • 187 patients (94%) – laparoscopy • 8 patients (4%) – thoracoscopy • 5 patients (2%) – both • 36% converted to open

10. Indications for Laparoscopy

11. Conclusion • Overall MIS was successful in excluding or diagnosing injury, and completing therapeutic intervention in 65% of cases • Laparoscopy and thoracoscopy can be performed safely and effectively for both diagnostic and therapeutic purposes in stable pediatric trauma patients

12. Pediatr Surg Int. 2014 Sep 21 (epub ahead of print)

13. Laparoscopic Pancreatic Resection forTrauma • 2000 – 2012 • 13 US pediatric trauma centers • 167 patients • 95 managed nonoperatively • 57 underwent resection • 80% laparoscopically since 2008 Pediatr Surg Int. 2014 Sep 21 (epub ahead of print)

14. Laparoscopic TraumaticDiaphragmatic Hernia Repair

15. Laparoscopic TraumaticDiaphragmatic Hernia Repair

16. Laparoscopy forPossible Traumatic Bowel Injury

17. Laparoscopy for Possible Traumatic Bowel Injury

18. Laparoscopy forPenetrating Traumatic Injury

19. Conclusions • Laparoscopy can be a useful tool for diagnosis of a traumatic injury when the diagnosis is not clear • Some traumatic injuries can be managed entirely laparoscopically or with the use of a small umbilical incision • Patient must be hemodynamically stable if the laparoscopic approach is utilized

21. Laparoscopy for Small Bowel Obstruction • Jan 01 – Dec 08 • 34 patients • Mean age 8.1 yrs ± 5.9 • Adhesions – 74% • Conversion – 11 pts • Inadeq working space • Volvulus • Could not identify source • Enterotomy • Our protocol: Initial laparoscopic management unless contraindications present

22. Laparoscopy for Small Bowel Obstruction

23. Intestinal Perforation – Free Air • Patient hemodynamically stable • Reason for perforation unclear • Allows directed open incision (if necessary)

24. Laparoscopy for Ovarian Torsion

25. Emphasis Now On Conservation Of Ovarian Tissue • Long-term results of conservative management of adnexal torsion in children • J. Pediatric Surgery (2005) 40: 704– 708 • Ovarian torsion in children: Management and outcomes • J. Pediatric Surgery (2013) 48: 1946–1953 • Predominant etiology of adnexal torsion and ovarian outcome after detorsion in premenarchal girls • Eur. J. Pediatric Surgery (2010) 20: 298 – 301

26. Laparoscopy for Malrotation - Volvulus • Hemodynamically stable patient • Difficult to reduce volvulus in an infant (not enough working space) • Laparoscopy very good for pt with malrotation but no volvulus

27. 1996 – 2009 • 284 Ladd procedures • Open – 241 • Laparoscopic - 43 • Laparoscopic – • 33% conversion – almost all due to volvulus • Recurrent volvulus – 6 pts (2.4%) - all s/p open Ladd procedure

28. Laparoscopy for Intussusception • Hemodynamically stable infant • Our usual initial approach • Convert if unsuccessful • 5 mm atraumatic clamps position across width of bowel

29. 1998 – 2008 • 22 pts (2.9 yrs, mean) • 19 ileocolic • 3 small bowel • 20 pts successfully managed laparoscopically or via extending umbilical incision ( 9 pts 7 bowel resections) • 2 required RLQ laparotomy

30. Acute Appendicitis • When do we operate? • How do we define perforation? • What is the incidence of a postoperative abscess? • Should we irrigate the abdomen? • Is there an advantage to a single umbilical laparoscopic approach?

31. 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 PRT • If patients present at night, the operations are scheduled for the ‘surgeon of the week’ the next day (8 am or 1 pm start) • Appendectomies rarely occur after 10 PM at night

32. Non-Operative Mgmt • Non-operative management with antibiotics for both acute and perforated appendicitis in adults is successful as primary, definitive therapy in up to 70% of patients. • About 20-30% will fail antibiotic management and will need an operation • Appendectomy is now probably considered the gold standard of treatment options, but unclear if this will change in the next 10 years.

33. 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 PediatrSurg 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

34. How do we define perforated appendicitis? • The literature is replete with retrospective studies regarding perforated appendicitis • All of these studies fail to strictly define perforation • Dependent on surgeon’s definition • “Gangrenous”, “suppurative”, “perforated” • Therefore, the conclusions from these retrospective reports must be approached cautiously

35. J Pediatr Surg 43:2242-2245, 2008

36. Definition of Perforation Used in Prospective Randomized Trial Visible appendicolith Hole in appendix

37. What is the incidence of postoperative abscess? • Acute, non-perforated appendicitis • 609 pts (Apr 03 – Nov 06) • 3 postop abscesses (0.49%) • Perforated appendictis • 20%

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

39. Perforated appendicitis: hole in appendix or fecalith in abdomen • Minimum irrigation 500 cc saline

40. 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

41. 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

42. 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

43. Is a single umbilical laparoscopic approach advantageous?

44. 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 6 months ASA 2011 Ann Surg 254:586-590, 2012

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

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

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

49. QUESTIONS www.cmhclinicaltrials.com www.cmhmis.com