Early laparoscopic management of appendicular mass in children: Still a taboo, or time for a change in surgical philosophy?

Abstract

Introduction:
Early appendicectomy has been found to be a safe and better alternative for management of appendicular mass in various studies in adults, while very few studies report such advantages in the paediatric population. We conducted this study to assess the safety, efficacy and need of early laparoscopic appendicectomy (ELA) in child patients with appendicular mass.

Materials and methods:
All patients with appendicular mass who underwent ELA at our institute between September 2011 and August 2014 were retrospectively reviewed. Appendicular mass was defined as a right iliac fossa mass in a case of acute appendicitis, diagnosed by clinical, laboratory and radiological evaluation, and palpation under anaesthesia, the patient being subjected to laparoscopic treatment.

Results:
Forty-eight (48) patients were confirmed to have appendicular mass intraoperatively and were included in the analysis. There were 30 males and 18 females, with ages ranging 7-13 years (mean 9 years). In the present study, appendicular complications included appendicular abscess (62.5%), gangrenous appendicitis (25%), sloughed-out appendix (8.33%) and appendicular perforation (4.16%). The average operative time was 72 min (range 45-93 min). One case (1.92%) required conversion to open procedure due to failure of identification of the appendicular base of a sloughed-out appendix. Post-operative complications were found in 4 (7.69%) patients, of whom 3 (5.76%) had minor wound infection at the umbilical port site and 1 (1.92%) had post-operative pelvic abscess, which was managed with percutaneous aspiration.

Discussion:
ELA avoids misdiagnosis, treats complicated appendicitis at its outset, and avoids complications and/or failure of non-operative treatment of a potentially lethal, diseased appendix. This approach is associated with minimal complications in experienced hands and is a safe and feasible option in children with appendicular mass.

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ISSN 0972-9941
Vol 12 / Issue 2 / April-June 2016
Journal of Minimal Access Surgery
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98
Early laparoscopic management of appendicular
mass in children: Still a taboo, or time for a change
in surgical philosophy?
Vikesh Agrawal, Himanshu Acharya, Roshan Chanchlani, Dhananjaya Sharma1
Departments of Pediatric Surgery and 1Surgery, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur,
Madhya Pradesh, India
Address for Correspondence: Dr. Vikesh Agrawal, 11, Paras Colony, Cherytal, Jabalpur - 482 002, Madhya Pradesh, India.
E-mail: drvikeshagrawal@gmail.com
Abstract
INTRODUCTION: Early appendicectomy has been
found to be a safe and better alternative for management
of appendicular mass in various studies in adults,
while very few studies report such advantages in the
paediatric population. We conducted this study to assess
the safety, efficacy and need of early laparoscopic
appendicectomy (ELA) in child patients with appendicular
mass. MATERIALS AND METHODS: All patients
with appendicular mass who underwent ELA at our
institute between September 2011 and August 2014
were retrospectively reviewed. Appendicular mass was
defi ned as a right iliac fossa mass in a case of acute
appendicitis, diagnosed by clinical, laboratory and
radiological evaluation, and palpation under anaesthesia,
the patient being subjected to laparoscopic treatment.
RESULTS: Forty-eight (48) patients were confi rmed
to have appendicular mass intraoperatively and were
included in the analysis. There were 30 males and
18 females, with ages ranging 7-13 years (mean 9
years). In the present study, appendicular complications
included appendicular abscess (62.5%), gangrenous
appendicitis (25%), sloughed-out appendix (8.33%) and
appendicular perforation (4.16%). The average operative
time was 72 min (range 45-93 min). One case (1.92%)
required conversion to open procedure due to failure of
identifi cation of the appendicular base of a sloughed-out
INTRODUCTION
Initial non-operative regimen with selective interval
appendicectomy is the standard management of appendiceal
mass in children. This approach has recently been
questioned due to its failure in 10-20% cases, leading to
complications such as abscess and perforation peritonitis,
which are more difficult to manage and have higher
morbidity.[1] It is also associated with the need for longer
hospitalisation, increased cost of treatment and loss of
school days in children.[2] These patients may need second
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DOI:
10.4103/0972-9941.178518
Original Article
Cite this article as: Agrawal V, Acharya H, Chanchlani R, Sharma D. Early
laparoscopic management of appendicular mass in children: Still a taboo, or
time for a change in surgical philosophy?. J Min Access Surg 2016;12:98-101.
Date of submission: 07/03/2015, Date of acceptance: 26/07/2015
This is an open access article distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
appendix. Post-operative complications were found in 4 (7.69%)
patients, of whom 3 (5.76%) had minor wound infection at the
umbilical port site and 1 (1.92%) had post-operative pelvic
abscess, which was managed with percutaneous aspiration.
DISCUSSION: ELA avoids misdiagnosis, treats complicated
appendicitis at its outset, and avoids complications and/
or failure of non-operative treatment of a potentially lethal,
diseased appendix. This approach is associated with minimal
complications in experienced hands and is a safe and feasible
option in children with appendicular mass.
Key words: Appendicular mass, children, laparoscopy

Journal of Minimal Access Surgery | April-June 2016 | Volume 12 | Issue 2 99
Agrawal,
et al
.: Early laparoscopic management of appendicular mass in children
admission for interval appendicectomy, and often tend
to delay their surgery and need readmission for another
acute episode. Another disadvantage of non-operative
management is the increased chance of misdiagnosis,
such as intussusceptions, typhoid perforation or Meckel’s
diverticulum, which may be inappropriately treated, adding
considerable morbidity.[3]
Early surgical intervention has been known to be an effective
alternative to conservative therapy for a long time, as it
considerably reduces the morbidity and total hospital stay,
and obviates the need for a second admission.[4]
Thus early surgery has an advantage of being curative in
the index admission and ensuring early return to school,
providing higher compliance at a lower expense. Early
appendicectomy has been found to be a safe and better
alternative for management of appendicular mass in
various studies in adults, while very few studies report such
advantages in the paediatric population.[5] This controversy
is not only confined to the management approach, but also
extends to the technique, that is, laparoscopy versus open,
with regard to their feasibility and safety. While laparoscopy
has become the standard mode of intervention for simple
appendicitis in children, its role in complicated appendicitis
is still controversial.[6] We conducted this study to assess the
safety, efficacy and need of early laparoscopic appendicectomy
(ELA) in child patients with appendicular mass.
MATERIALS AND METHODS
All the patients with appendicular mass who underwent ELA at
our institute between September 2011 and August 2014 were
retrospectively reviewed. Appendicular mass was defined
as a right iliac fossa mass in a case of acute appendicitis,
diagnosed by clinical, laboratory and radiological evaluation,
and palpation under anaesthesia. All the cases of appendicular
mass were initially treated with hydration, nasogastric
aspiration, intravenous antibiotics and analgesic before
ELA. Laboratory evaluation included complete hemogram,
erythrocyte sedimentation rate (ESR) and C-reactive protein
(CRP) level. Routine radiological evaluation included a scout
film of the abdomen and ultrasound examination with a
10 MHz transducer in all the patients. All the operations were
performed using the three-trocar technique. An optical port
(5 mm, 30°) was placed at the umbilicus by open technique,
along with two 5- or 3-mm working ports according to the
size of the patient, in the suprapubic and right paraumbilical
regions. The appendiceal stump was left unburied after
transfixation by intracorporeal endosuturing with 3-0
polyglactin 910 suture. In patients who were found to have
evidence of pus, the areas of intra-abdominal collection were
sucked out and rinsed with normal saline along with tube
drainage. Data pertaining to sex, age, duration of symptoms,
operative time, operative findings, gross appendiceal finding,
difficulties encountered during surgery, complications, length
of hospital stay, and pathological results were reviewed.
Appendicular complication was defined as laparoscopic gross
identification of gangrenous, perforated or sloughed-out
appendix, and appendicular abscess.
RESULTS
During the study period, 52 patients were diagnosed with
appendicular mass, of whom 4 had had misdiagnosis. These
included singular cases of ileal perforation, tubercular
lymphadenitis, ileocolic intussusception, and gangrenous
Meckel’s diverticulum, which were managed with laparoscopic
repair, laparoscopic biopsy, open reduction with resection,
and open resection anastomosis, respectively. The remaining
48 patients were confirmed to have appendicular mass
intraoperatively and were included in the analysis. There
were 30 males and 18 females, with ages ranging 7-13 years
(mean 9 years). The duration of treatment received elsewhere,
before admission to our institute, ranged 3-7 days (mean
4 days). Forty-seven patients (97.91%) had leukocytosis of
greater than 11,000 per mm3, while 42 (87.5%) had raised
ESR (mean 60) and CRP (>3 mg/L). Clinically palpable mass in
right iliac fossa was identified preoperatively in 41 (85.41%)
patients and confirmed on ultrasound, while the rest were
diagnosed under anaesthesia.
The average operative time was 72 min (range 45-93 min).
The post-operative analgesia requirement was not more than
three doses per day of rectal acetaminophen for the initial
2 days. The average time to ambulation, time to resumption
of diet and length of hospital stay were 10 (range 6-11) h;
2 (range 1-3) days and 3 (range 1-6) days, respectively. There
were no major intraoperative complications [Table 1]. The
findings at surgery are listed in Table 1. In the present
study, gross appendicular findings included appendicular
abscess (62.5%), gangrenous appendicitis (25%), sloughed-out
appendix (8.33%) and appendicular perforation (4.16%),
as depicted in Table 1. Forty-eight (48) patients (92.30%)
underwent ELA and 1 (1.92%) required conversion to open
procedure due to failure in identification of appendicular base
of a sloughed-out appendix. In 3 (5.76%) patients, there was
difficulty in localisation of the appendix due to retro-cecal
gangrenous appendix in 1 and sloughed-out appendix in
2 patients. Four (4) patients (7.69%) had dense adhesions
and all had history of more than two attacks of acute
appendicitis (AA) in the past. Post-operative complications

Journal of Minimal Access Surgery | April-June 2016 | Volume 12 | Issue 2
100
Agrawal,
et al
.: Early laparoscopic management of appendicular mass in children
were found in 4 (7.69%) patients, of whom 3 (5.76%) had
minor wound infection at the umbilical port site and 1 (1.92%)
had post-operative pelvic abscess, which was managed with
percutaneous aspiration. This latter patient had appendicular
perforation as a complication and went on to develop
adhesive intestinal obstruction, which was successfully
managed non-operatively. All patients are healthy, at the time
of writing, on the minimum 6-month follow-up.
DISCUSSION
The management of an appendiceal mass in children
is surrounded by controversy amongst two schools of
thoughts: That advocating early surgical intervention
versus that advocating non-operative management with
or without interval appendicectomy.[7] Advocates of
operative initial appendicectomy report the advantages
of immediately excluding other masquerading conditions,
as well as providing a definitive treatment at the initial
admission. More traditional surgeons propose initial
conservative management, reporting that the majority of
a patient’s symptoms will resolve spontaneously, thereby
avoiding an operation during the initial admission which
is considered hazardous. Of those initially managing
appendiceal mass conservatively, some propose elective
interval appendicectomy once the mass has resolved. This
is supposed to have the advantages of a less hazardous
appendicectomy, prevention of any future recurrence
of appendicitis and ruling out other conditions. Others
manage appendiceal mass conservatively and do not
perform interval appendicectomy, following up patients
at the outpatient clinic to exclude other conditions and
the recurrence of symptoms.[8] The need for interval
appendicectomy after successful conservative treatment
is still under debate. Indications for early surgery in
appendiceal mass have been failure of conservative
management or features of generalised peritonitis or
obstruction.[9] A recent questionnaire study of 67 surgeons
in the Mid-Trent region of England showed no agreed
consensus on the management of appendiceal mass.[10]
In the past, ELA in all cases of appendicular mass was
considered an overenthusiastic approach by critics.
There are limitations of non-operative management, such as
leading to failure in up to 10% of cases, frequent misdiagnosis,
need for prolonged index admission along with additional
hospitalisation for interval surgery, dropout, and delays in
surgery by the parents. This leads to increased morbidity
and cost of treatment along with loss of school days for
children.[2] The literature mentions that recurrent attacks
after non-operative treatment of AA usually have a milder
course.[11] In the present study, 18 patients (37.5%) had
evidence of more than two attacks of AA in the past, which
was managed non-operatively and later on presented with
appendicular mass. This reflects the reluctance of Indian
parents to opt for interval surgery; it is also our unit policy,
once the acute attack has been resolved with medical
treatment. Misdiagnosis in 4 out of 48 patients preoperatively,
which included singular cases of ileal perforation, tubercular
lymphadenitis, ileocolic intussusception and gangrenous
Meckel’s diverticulum, also supports the necessity of early
intervention on the index admission. In the present study,
patients developed appendicular complications along with
appendicular mass, which included appendicular abscess
(62.5%), gangrenous appendicitis (25%), sloughed-out
appendix (8.33%) and appendicular perforation (4.16%), as
depicted in Table 1. These hidden complications are promptly
detected and appropriately managed if ELA is opted for as
the preferred treatment of appendicular mass, which would
otherwise predispose patients to treatment failure and
higher morbidity if managed non-operatively. Hence, the
role of laparoscopic appendicectomy (LA) as an emergency
intervention procedure for appendiceal mass is further
substantiated by this study.
The percentage of infectious complications secondary to
laparoscopic appendicectomy in complicated appendicitis
varies widely in the literature: 19-28%, and doubts therefore
remain about the safety of this procedure. In both open
and laparoscopic types of appendicectomy, it is accepted
that the greater the degree of evolution of AA, the worse
the short-term results and the higher the rate of infectious
complications.[12] Initially there were conflicting reports of
increased complications such as pyoperitoneum and faecal
fistula by using this approach, but most of them have been
Table 1: Table showing laparoscopy fi ndings, operative diffi culties and complications
Gross appendiceal
fi nding (n = 48)
nProcedure Operative diffi culties Complications
Diffi culty in localisation
of appendix
Dense
adhesions
Umbilical wound
infection
Pelvic
abscess
Adhesive intestinal
obstruction
Appendicular abscess 30 ELA 0 2 1 0 0
Gangrenous appendix 12 ELA 1 0 2 0 0
Appendicular perforation 2 ELA 0 0 0 1 1
Sloughed-out appendix 4 1 ELA, 1 Open 2 2 0 0 0
ELA: Early laparoscopic appendicectomy

Journal of Minimal Access Surgery | April-June 2016 | Volume 12 | Issue 2 101
Agrawal,
et al
.: Early laparoscopic management of appendicular mass in children
recently dismissed.[13] The recent comparative studies have tried
to solve these controversies and have identified comparable
results for laparoscopy in complicated appendicitis.[14] In the
present study, post-operative complications were found in
4 (8.33%) patients; among these, major complication was
observed in only 1 patient (2.08%) in the form of pelvic abscess
and adhesive obstruction, which was managed non-operatively.
The rate of conversion to open procedure, increased duration
of procedure, and prolonged duration of stay were the initial
concerns in ELA for complicated appendicitis, which in the
present study was 2.08% (1/48), 72 min, and 3 days respectively.
These data are comparable to the results of LA performed for
non-mass-forming appendicitis.[15] This supports the statement
that ELA is a safe option for management of appendicular
mass in children.
The question of “golden hours” for emergency LA for “hot”
appendix masses, similar to that identified for emergency
laparoscopic cholecystectomy for acute cholecystitis,
needs to be answered. Nevertheless, the proper timing
for emergency surgery needs further substantiation. At
our institute, we follow the policy of ELA for all children
presenting with appendicular mass on an emergency basis.
But at the same time, one has to be experienced enough to
manage complicated appendicitis laparoscopically and if not,
it is always safer to follow the traditional regimen.
Due to the lack of sufficient Level I evidence for this common
problem, no clear guidelines have been made so far. With the
advancements in minimal access surgery, as seen with other
surgical diseases, the management of appendicular mass
needs change. More multicentre randomised controlled trials
and systematic reviews are required to reach a consensus on
management.
CONCLUSION
ELA avoids misdiagnosis, treats complicated appendicitis at
its outset, and avoids complications and/or failure of non-
operative treatment of a potentially lethal, diseased appendix.
This approach is associated with minimal complications in
experienced hands and is a safe and feasible option in
children with appendicular mass.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
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