LA has become routine for simple appendicitis in children in many centers across the world. However, the role of laparoscopic approach for CA in children is still debatable.[1
] LA in CA has been reported to offer increased safety, shorter length of hospital stay, less pain and quicker return to normal activity with fewer complications.[1
] In contrast, it has also been reported that LA in CA is associated with higher risks of postoperative intra-abdominal abscess formation, bleeding and bowel injuries.[6
] Increased post-operative complications following conversion from LA to OA have also been reported.[9
Our results have indicated the feasibility, safety and efficacy of LA in CA. The benefits of LA in CA were more obvious in the postoperative recovery. The duration of intravenous antibiotics, postoperative resumption of oral feeds and parenteral analgesics requirement were significantly shorter in the LA group when compared to the OA group. The operative time was comparable in both LA and OA groups. The length of hospitalization was shorter in the LA group, which is related to less pain, quicker ambulation, early resumption of oral feeds and fewer complications. This is attributed to less access trauma; the muscle cutting incision in OA is more painful and takes longer time to heal compared to muscle stretching port insertion. The complications encountered in the LA group were significantly less and minor. Postoperative fecal fistula, that occurred in the converted case due to leakage from the friable appendicular stump, inspite of a transfixing ligature of the stump, was more related to pathological condition of the patient, and was possibly unavoidable. Postoperative loose stools were treated with oral antibiotics and probiotics for 5 to 7 days with eventual cure in all the patients. In our study, we did not encounter any case of postoperative intra-abdominal abscess or intestinal obstruction in either group. Superficial wound infection, which was present in 2 patients each of the LA and OA groups, was treated by regular dressing and oral antibiotics as outpatients.
In the hands of an experienced laparoscopic surgeon, LA provides the advantages of panoramic view with increased magnification, ability to visualize the hidden corners and clearance of purulent material as compared to the open technique. It has a steep learning curve, and the results tend to be better once the surgeon acquires necessary experience. In our study, both the conversions were done on the initial 2 cases; later, 24 consecutive cases were operated laparoscopically without any conversion or major complication. In open surgery, atypical localization of the appendix may require an extended or second incision. Laparoscopy avoids this, and it gives an aesthetically acceptable scar and less operative trauma.
Our study has inherent limitations of lack of randomization, shorter follow up and possible observer bias. Nevertheless, our results indicate that LA is safe, effective and beneficial in children with CA. In the presence of relevant expertise, we recommend LA as a favorable alternative for complicated appendicitis in children.