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The IPEG Annual Congress joins with:. II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) VII Congress of the Federation of Pediatric Surgical Associations of the South Cone of America (CIPESUR). Appendicitis: Current Management.

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slide1

The IPEG Annual Congress joins with:

  • II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS)
  • VII Congress of the Federation of Pediatric Surgical
  • Associations of the South Cone of America (CIPESUR)
appendicitis current management

Appendicitis:Current Management

George W. Holcomb, III, M.D., MBA

Children’s Mercy Hospital

Kansas City, MO

appendicitis
Appendicitis

History

Examination

Imaging - Abdominal film?

Ultrasound?

CT scan?

laparoscopic appendectomy
Laparoscopic Appendectomy
  • Since 2002, used exclusively
  • Perforated, non-perforated, abscess
  • Why:
    • Definitely fewer wound problems c/o open operation
    • Less small bowel obstruction
laparoscopic appendectomy port positions
Laparoscopic AppendectomyPort Positions
  • 12 mm umbilical port - working port/stapler
  • 5 mm LLQ - telescope/camera
  • 5 mm L suprapubic region - retraction
laparoscopic appendectomy technique
Laparoscopic AppendectomyTechnique
  • Window in mesoappendix
  • Vascular stapler across mesoappendix
laparoscopic appendectomy technique7
Laparoscopic AppendectomyTechnique
  • Regular stapler across base of appendix
  • Extract through 12 mm umbilical cannula
    • Bag used selectively
acute appendicitis contained perforation
Acute Appendicitis -Contained Perforation
  • Perforated appendicitis (3 - 5 day hx)
    • Evacuation/irrigation
    • Controlled spillage
    • Wound problems minimized
acute appendicitis free perforation hemodynamically stable
Acute Appendicitis - Free Perforation Hemodynamically Stable

Laparoscopic appendectomy

  • reduced discomfort
  • selectively irrigate/evacuate pus
  • lyse adhesions
  • few wound problems
  • often NGT not needed
acute appendicitis free perforation hemodynamically unstable
Acute Appendicitis - Free Perforation Hemodynamically Unstable
  • IVF Resuscitation
  • Antibx/NGT
  • Open appendectomy
    • Lower midline incision
    • RLQ incision
  • Prolonged (10 - 14 days) hospitalization
  • Rare patient
acute appendicitis contained perforation hemodynamically stable
Acute Appendicitis – Contained Perforation Hemodynamically Stable
  • 5 - 7 day history
  • IVF
  • Percutaneous drainage (radiology)
  • PICC line - antibx
  • Discharge day 3-5 if stable
  • Antibx con’t 10 - 14 days at home
  • Return 8-10 wk. for interval appendectomy - overnight hospitalization
postoperative antibiotic regimen for perforated appendicitis
Postoperative Antibiotic Regimen for Perforated Appendicitis
  • Prospective, randomized trial
  • AGC vs CM
  • 50 pts each arm
  • Definition of perforation
    • Hole in appendix
    • Stool in abdomen

AAP, 2007

postoperative antibiotic regimen for perforated appendicitis15
Postoperative Antibiotic Regimen for Perforated Appendicitis
  • No difference b/w groups re: weight, gender, days of symptoms, temperature, WBC count on admission

AAP, 2007

postoperative antibiotic regimen for perforated appendicitis16
Postoperative Antibiotic Regimen for Perforated Appendicitis

Conclusion:

Ceftriaxone and metronidazole offers a more efficient, cost-effective antibiotic regimen than ampicillin, gentamicin, clindamycin for children with perforated appendicitis. Also, it may allow earlier resolution of symptomatic peritoneal irritation as reflected by lower narcotic needs.

slide17
Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess
  • Retrospective study
  • June 00 – Dec 06
  • 52 pts
  • Attempted percutaneous drainage, interval appendectomy

AAP, 2007

slide18
Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess

AAP, 2007

slide19
Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess

AAP, 2007

slide20
Adhesive Small Bowel Obstruction After Appendectomy in Children: Comparison Between the Laparoscopic and Open Approach

AAP 2006

J Pediatr Surg 42:939-942, 2007

laparoscopic versus open appendectomy
Laparoscopic versus Open Appendectomy

AAP 2006

J Pediatr Surg 42:939-942, 2007

sbo after perforated appendicitis
SBO After Perforated Appendicitis

AAP 2006

J Pediatr Surg 42:939-942, 2007

prospective randomized trial
Prospective Randomized Trial
  • Patients presenting with an abscess
  • IR drainage with IV antibiotics followed by laparoscopic interval appendectomy vs laparoscopic appendectomy and evacuation of abscess on admission
  • Pilot study: 30 patients
conclusions
Conclusions
  • Lap appendectomy is our preferred approach for all forms of appendicitis
  • Lap appendectomy can be performed for perforated appendicitis and for patients presenting with an abscess
  • Lap appendectomy results in fewer wound problems and less SBO