Find best premium and Free Joomla templates at GetJoomlaTemplatesFree.com

Emergency Laparoscopic Appendicectomy in Children: The Results in Trainees Hands

Panteli C, Desai A, Manoharan S, Bouhadiba N, Singh S, Tsang T

Department of Paediatric Surgery, Norfolk and Norwich University Hospital,
Norwich, UK

 

Correspondence:

Mr Thomas Tsang

Department of Paediatric Surgery, Norfolk and Norwich University Hospital ,Colney Lane, Norwich NR47UY

Tel. 0044 1603 286346

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Background: Laparoscopic appendicectomy has been increasingly practiced in children in recent years and is currently a common procedure. The aim of this study was to assess the trainees’ performance in emergency laparoscopic appendicectomy.

Materials and Methods: The hospital records of children who underwent emergency laparoscopic appendicectomy performed by trainees, between 1996 and 2005 were reviewed. Patient demographics, operative findings and duration, usage of antibiotics, duration of hospital stay, complications and follow up were recorded. Surgeons’ data including year of training, previous experience in laparoscopic procedures and the grade and experience of 1st assistant were also noted.

Results: Eighty-six children, 44 boys and 42 girls with median age of 12 years (range 6-16 years) underwent laparoscopic appendicectomy performed by trainees during the above period. Twelve patients were found to have a normal appendix, whereas 44 and 30 had acute and advanced appendicitis respectively. Overall, the mean operative time was 72 minutes and the mean length of hospital stay 3.32 days. Two procedures were converted to open appendicectomy. There were 6 postoperative complications.

Conclusions: Laparoscopic appendicectomy is a safe and effective procedure performed by trainees and it serves a good training opportunity for development of laparoscopic skills. Trainees’ performance, according to the individual experience, followed the anticipated learning curve.

Key words: laparoscopic appendicectomy, children, trainees

 

Introduction

Appendicitis is one of the commonest surgical emergencies and although open appendicectomy has been the standard procedure for junior surgeons to develop basic surgical skills, the same cannot be said for the laparoscopic technique. It has been recommended that laparoscopic appendicectomy is a good training opportunity for surgical trainees [1-4]. However, the experience of trainees in laparoscopic appendicectomy appears to be relatively limited [5].

In paediatric surgery the acceptance of laparoscopic techniques has been relatively slow. There has been a lot of scepticism regarding the advantages of paediatric laparoscopic appendicectomy as children respond well and recovery is not unduly long following open appendicectomy.

Laparoscopic appendicectomy has been reported to be a safe and effective alternative to the open technique in the paediatric population [6-13]. However, data on its application in training for junior paediatric surgeons is limited [8-10]. The aim of this study was to assess the outcome of emergency laparoscopic appendicectomy in children performed by trainees in a single UK centre.

Materials and Methods

The hospital records of all children who underwent emergency laparoscopic appendicectomy carried out by trainees between 1996 and 2005 were reviewed retrospectively. Patients’ and surgeons’ data were collected. Patient data included demographic details and outcome measures such as operative findings and duration, hospital stay and follow up.

Regarding the surgeon, the level of training, previous experience in laparoscopic procedures and the assistant’s grade were noted. Data regarding outcome measures for the cases performed by each trainee were also recorded. All trainees were at Registrar level having performed sufficient open appendicectomies unsupervised and had participated in the department’s training sessions at the laparoscopic skills laboratory. Surgeons were graded as early laparoscopists when they had no previous laparoscopic experience, intermediate when they had limited experience and advanced when they had performed laparoscopic appendicectomies as surgeons prior to the study.

Assignment of patients was based on the on-call rota; there was no selection of cases according to anticipated difficulty.

Laparoscopy was performed using the Hasson technique for insertion of the umbilical port for a 30 degree 5 or 10 mm telescope, according to Consultant’s preference. Pneumoperitoneum was established with the pressure maintained below 12mmHg and subsequently two additional 5-mm ports were inserted in the suprapubic and left iliac fossa positions. The mesoappendix was dissected with hook electrocoagulation. The appendix was ligated with 2 loop ligatures and delivered transumbilically.

Neither advanced appendicitis nor prolongation of the procedure served as indications for conversion to open appendicectomy. A preoperative dose of double antibiotics (Cefuroxime and Metronidazole) was given to all patients and postoperative antibiotic cover was decided upon findings. Time from patient preparation on table to completion of procedure was taken as operative time.Length of stay represents total stay.

Table 1. Results

Diagnosis

Normal

(n=12)

Acute

(n=44)

Advanced

(n=30)

Overall

(n=86)

Operative Time*

69.5

(50.47 -88.52)

69.8

(62.12-77.63)

77.2
(66.91-87.32)

72

(66.4-78.06)

Conversions

 

0 0 2 2
Lenght of stay*

2.81 

(66.4-78.06)

2.46

(2.06-2.87)

4.96

(4.09-5.84)

3.32

(2.86-3.77)

Complications

 

0 1 5 6

* Mean (95% CI)

Results

A total of 86 children were operated on for appendicitis by junior surgeons using the laparoscopic method in the aforementioned period. Forty four were boys and 42 girls. The median age was 12 years (range 6 to 16 years). According to pathology reports, 44 patients had acute appendicitis and 30 patients had advanced appendicitis (gangrenous or perforated). Exploration revealed a normal appendix in 12 patients. Two laparoscopic procedures in patients with advanced appendicitis were converted to open appendicectomy.

The overall mean operative time was 72 minutes. The mean total procedure time was similar for the normal (69.5 min) and acute (69.8 min) group whilst it was longer for the advanced group (77.2 minutes). The mean total hospital stay was 2.18 and 2.46 days for the normal and acute group respectively, while hospitalisation was longer for the advanced group (4.96 days). The mean overall length of stay was 3.32 days.

Six patients presented with postoperative complications, 1 and 5 in the acute and advanced group respectively. In the acute group one umbilical wound abscess required incision and drainage. In the advanced group three patients developed port site infections, one at the umbilical wound and two at the left lower quadrant wound. A residual collection occurred in one patient and was treated effectively with antibiotics. One patient presented with small bowel obstruction 8 months postoperatively and required laparotomy and adhesiolysis.

Results are summarised in table 1.

Five trainees were involved in laparoscopic appendicectomies either early in the study between 1996 and 1998 or after 2004. In the early phase there was one experienced trainee whilst in the late phase there were one experienced, one intermediate and two inexperienced trainees. The outcome measures per trainee are summarised in table 2.

The pattern followed was that trainees initially assisted consultants in laparoscopic appendicectomies, then acted as surgeons assisted by consultants and subsequently carried out the appendicectomies assisted by other trainees who were in the first phase more experienced compared to the surgeons and gradually by trainees of equal or less experience. The distribution of operating times per trainee is shown in Figure 1.

Discussion

Minimally invasive surgery is nowadays being utilised increasingly in paediatric surgery hence adequate exposure of trainees to these procedures becomes more and more important. In terms of technical competence, acquisition of skills in laparoscopic procedures parallels open surgical training. The learning process initially involves studying and observation but the ability improves only through task repetition. Regarding training in laparoscopic surgery there are two trends, one supporting the need of participation in laboratory courses prior to clinical practice and one favouring supervised practice in a clinical setting [3].

Table 2. Outcomes per trainee

TRAINEE

A

(n=14)

 B

(n=10) 

C

(n=13) 

D

(n=17) 

 E

(n=32) 

Operative Time*

90.5

(81.04-99.95) 

 99.0

(80.53-117.46) 

 78.61

(63.15-94.07) 

 66.47

(56.41-76.52) 

 54.0

(46.17-61.82) 

Conversions

 

 0  0  0  0  2
Lenght of stay*

 3.00

(1.66-4.33) 

 3.55

(1.41-5.62) 

 3.30

(1.94-4.66) 

 3.47

(2.04-4.89) 

 3.28

(2.80-3.75) 

Complications

 

 1  1  2  1  1

* Mean (95% CI)

Acute appendicitis accounted for 51.16% of cases in our study while advanced appendicitis accounted for 34.88% of cases. This reflects the fact that cases were not selected as for the easier appendicectomies to be performed by trainees. The negative appendicectomy rate was 13.95%, which is within the acceptable 0 – 21.4% range for children [7,9].

The length of surgery varied significantly depending on surgeon’s experience and pathology encountered. The overall mean operating time was 72 minutes, which is at the upper reported mean times for laparoscopic appendicectomies on children (mean range 34 – 72 minutes) [9-12,14], but within the mean range of 32 – 105 minutes reported in recent studies for either children or adult laparoscopic appendicectomies carried out exclusively by general surgery trainees [1,3,4,8,15].

Two laparoscopic cases, one of gangrenous and one of perforated appendicitis were converted to open appendicectomy; both occurred early in the series. The rate of conversion (2.32%) is within the reported range of 1- 25.9% in paediatric series [11,13,16] and relatively low compared to the figures reported in series performed by trainees (3.7 – 12%) [2,3,15].

emergency lap 1

Figure 1. Distribution of operating times per trainee 

The mean hospital stay for children undergoing laparoscopic appendicectomy is reported to be 1.9 – 7 days depending on findings and postoperative course. The length of hospitalisation reported for cases of perforated appendicitis is 6.5 to 7 days [8,11,12]. In our study the overall mean length of stay was 3.32 days, the mean hospitalisation for advanced appendicitis being 4.96 days. Both figures are within the aforementioned ranges, although not easily comparable as length of stay may refer to either total or postoperative hospitalisation in different studies.

Six postoperative complications (6.97%) were observed, a figure comparable to other studies. All six complications (4 wound infections, 1 residual collection and 1 late bowel obstruction) are considered major since they resulted in increased postoperative morbidity and prolonged hospitalisation. Some paediatric series report a complication rate of 1.5% [14] whereas other studies present complication rates up to 17% [17]. The overall incidence of trocar site infections is reported to be 0.31 to 5% [8,11]. Our rate of wound infections was 4.65%. Increased incidence of intraabdominal abscesses post laparoscopic appendicectomy both in adults and children has long been a major concern. In children an overall 6.4% rate has been reported, with a rate of 27% in particular for perforated appendicitis. [18] However, rates presented in other studies were significantly lower (1.58 – 6.38% overall rates and 6 – 16.3% for the subsets of perforated appendices) [8-11,13]. In this study the overall intraabdominal abscess rate was 1.16% and 3.33% for the advanced appendicitis subgroup.

The overall complication rate (6.97%) is within the range reported in studies on laparoscopic appendicectomies performed exclusively by trainees (2.5 – 13.1%) [1,3,15].

Regarding trainees’ performance, significant variations were observed between operating times. Early laparoscopists showed gradual reduction in operating times throughout the studied period. For the intermediate trainee there was a smaller reduction in procedure duration while for the experienced operators no difference could be identified throughout the study period. These results were expected as each trainee was on a different part of the learning curve. Inexperienced surgeons were on the steep phase where rapid improvement is expected, moderately experienced surgeon was on the slowly changing phase and experienced surgeons were almost at the plateau.

We were concerned about prolonged operating times especially for inexperienced operators, although this difference is expected to decrease as surgeons perform more appendicectomies and thus become more familiar with the technique. [1,4,19] Comparison to other studies is not always easy as there are differences between times taken as operative time. Furthermore in our study prolongation of the procedure did not serve as an indication for conversion [2,4].

Both conversions were carried out by the same experienced trainee, at the early stage of the study and after seeking Consultant’s advice. Surgeon’s level of experience made no difference in the complication rate. Complications were evenly distributed throughout the study period. There were no significant differences in length of stay between operators. The outcome measures per trainee are shown in Table 2.

Our findings suggest that laparoscopic appendicectomy can be performed by trainees with an acceptable outcome. The learning process does not carry a risk of increased conversions, complications or hospital stay. As laparoscopic surgery in children is here to stay, this represents an important issue in training. This study is in agreement with other studies showing that laparoscopic appendicectomy may be the ideal procedure for introducing junior surgeons to laparoscopic techniques as it is common and does not require advanced technical skills. Furthermore it is not associated with high morbidity or mortality rates [2,4].

The next step, proficiency in laparoscopic appendicectomy, cannot be objectively assessed [20]. Apart from the numbers being small in paediatric surgery, the process of becoming proficient in a procedure is highly individualised.

However, the increased interest in minimally invasive surgery in children and the tendency towards a wider application of laparoscopic techniques demands more intensive training in that field, provided that safety and feasibility criteria are fulfilled.

We feel strongly that trainees should be encouraged to learn and carry out laparoscopic appendicectomy and also to share their experience and assist colleagues in this operation.

 

 

REFERENCES

1. Baker A. Laparoscopic appendicectomy--a trainee’s experience. N Z Med J 1999;112:208-211

2. Botha AJ, Elton C, Moore EE, Sauven P. Laparoscopic appendicectomy: a trainee’s perspective. Ann R Coll Surg Engl 1995;77:259-262

3. Carrasco-Prats M, Soria Aledo V, Lujan-Mompean JA, et al. Role of appendectomy in training for laparoscopic surgery. Surg Endosc 2003;17:111-114

4. Sweeney KJ, Dillon M, Johnston SM, Keane FB, Conlon KC. Training in laparoscopic appendectomy. World J Surg 2006;30:358-363

5. Noble H, Gallagher P, Campbell WB. Who is doing laparoscopic appendicectomies and who taught them? Ann R Coll Surg Engl 2003;85:331-333

6. Davenport M. Laparoscopic surgery in children. Ann R Coll Surg Engl 2003;85:324-330

7. Newman K, Ponsky T, Kittle K, et al. Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg 2003;38:372-379; discussion 372-379

8. Little DC, Custer MD, May BH, Blalock SE, Cooney DR. Laparoscopic appendectomy: An unnecessary and expensive procedure in children? J Pediatr Surg 2002;37:310-317

9. Meguerditchian AN, Prasil P, Cloutier R, et al. Laparoscopic appendectomy in children: A favorable alternative in simple and complicated appendicitis. J Pediatr Surg 2002;37:695-698

10. Oka T, Kurkchubasche AG, Bussey JG, et al. Open and laparoscopic appendectomy are equally safe and acceptable in children. Surg Endosc 2004;18:242-245

11. Canty TG, Sr., Collins D, Losasso B, Lynch F, Brown C. Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice? J Pediatr Surg 2000;35:1582-1585

12. Lintula H, Kokki H, Vanamo K. Single-blind randomized clinical trial of laparoscopic versus open appendicectomy in children. Br J Surg 2001;88:510-514

13. Aziz O, Athanasiou T, Tekkis PP, et al. Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg 2006;243:17-27

14. Varlet F, Tardieu D, Limonne B, Metafiot H, Chavrier Y. Laparoscopic versus open appendectomy in children--comparative study of 403 cases. Eur J Pediatr Surg 1994;4:333-337

15. Wong K, Duncan T, Pearson A. Unsupervised laparoscopic appendicectomy by surgical trainees is safe and time-effective. Asian J Surg 2007;30:161-166

16. Stringel G, Zitsman JL, Shehadi I, Kithir S. Laparoscopic appendectomy in children. Jsls 1997;1:37-39

17. Vegunta RK, Ali A, Wallace LJ, Switzer DM, Pearl RH. Laparoscopic appendectomy in children: technically feasible and safe in all stages of acute appendicitis. Am Surg 2004;70:198-201; discussion 201-192

18. Krisher SL, Browne A, Dibbins A, Tkacz N, Curci M. Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis. Arch Surg 2001;136:438-441

19. Jaffer U, Cameron AE. Laparoscopic appendectomy: a junior trainee’s learning curve. JSLS 2008;12:288-291

20. Dagash H, Chowdhury M, Pierro A. When can I be proficient in laparoscopic surgery? A systematic review of the evidence. J Pediatr Surg 2003;38:720-724