Conventional single-port laparoscopic appendectomy for complicated appendicitis in children: Efficient and cost-effective

Abstract

BACKGROUND:

Laparoscopic appendectomy (LA) is gradually gaining popularity among paediatric surgeons for complicated appendicitis. A retrospective study was conducted to compare conventional single port LA, multiport LA and open appendectomy (OA) for complicated appendicitis in children.

PATIENTS AND METHODS:

From January 1995 from December 2014, 1,408 patients (604 girls, 804 boys) underwent surgery for uncomplicated and complicated appendicitis. The patient characteristics, operation times, duration of hospitalization, operative costs, and postoperative complications were recorded. A 10-mm 0^° scope with a parallel eye piece and an integrated 6 mm working channel were inserted through an 11-mm “conventional umbilical port” for single port LA.

RESULTS:

A total of 314 patients with complicated appendicitis (128 girls, 186 boys) underwent appendectomy. Among these, 102 patients (32.4%) underwent single port LA, 17 patients (5.4%) underwent multiport LA and 195 patients (62.1%) underwent OA. The hospital stay of the single port LA group was significantly less (3.88 ± 1.1) compared with multiport LA (5.41 ± 1.2) and OA groups (6.14 ± 1.1) (P < 0.001). Drain usage, wound infection and adhesive intestinal obstruction rates were significantly high in the OA group. There was no significant difference between the groups in postoperative intraabdominal abscess formation. Single-port LA performed for complicated appendicitis was cheaper compared with the other groups.

CONCLUSIONS:

The present study has shown that single-port LA for complicated appendicitis can be conducted in a reasonable operative time; it shortens the hospitalization period, markedly reduces postoperative wound infection and adhesive intestinal obstruction rates and does not increase the operative cost.

INTRODUCTION

Laparoscopic appendectomy (LA) became the preferred operative method for uncomplicated appendicitis.[1,2] On the other hand, LA has been increasingly used for the treatment of complicated appendicitis in the last decade[2,3,4,5,6] although LA for complicated appendicitis has been accused for resulting in higher operative cost and increased rates of postoperative complications.[7,8,9] Postoperative complication rates of LA have been shown to be decreased by standardization of the operative technique[9,10,11,12] However, higher operative cost of LA is the main concern during operative method selection.[9,13] Usage of a conventional single port in conjunction with conventional re-use instruments can reduce the operative cost of LA.

Several modifications have been described for LA; thus, the number of working instruments and ports have been decreased.[14,15,16] Recent interest in endoscopic surgery has turned towards single-site access surgery.[17,18] Non-conventional ports for single-site surgery are disposable and expensive. Therefore, we devised a single-port intracorporeal LA technique utilizing a conventional single-port and conventional re-use instruments.[19,20]

A retrospective study was conducted to compare conventional single port LA, multiport LA and open appendectomy (OA) for complicated appendicitis in children.

PATIENTS AND METHODS

This study was approved by the Local Clinical Ethical Committee (no.1256-GOA.2013/45-12).

Operative technique

LA has been conducted since 1996 in our clinic. We began with the classic 3-port LA technique.[21] Three-port LA technique was performed in a standardized manner using two 6-mm working ports inserted at the lower abdominal quadrants bilaterally and one 11-mm port through the umbilicus for the scope. Disposable laparoscopic instruments were used during the 3-port LA period.

We reduced the number of ports to one and started performing LA through a single conventional port with the aid of a transabdominal sling suture in 2005.[19] For this purpose, an 11-mm “conventional umbilical port” was inserted and a 10 mm 0° scope with a parallel eyepiece and an integrated 6-mm working channel was used (Storz, Tuttlingen, Baden-Württemberg, Germany). Mesoappendix was divided using monopolar electrocautery and the base of the appendix was ligated with an extracorporeally created fishermen knot (2/0 polyglactin).[22] The appendix was divided over the ligature with scissors or monopolar electrocautery. Intraabdominal collection was either aspirated only or locally irrigated/aspirated. The appendix was grasped and extracted through or together with the umbilical cannula.

In 2008, we developed the so-called transabdominal “swing” suture for LA replacing sling suture.[20] As the swing suture does not pass through mesoappendix, the position of the appendix can be changed by releasing the swing suture and repositioning the appendix as required during LA.

Patients

The records of all patients who were operated for uncomplicated and complicated appendicitis between January 1995 and December 2014 were evaluated retrospectively. The patients were divided into three groups:

1. Single-port LA group,

2. Multiport LA group,

3. OA group.

The demographic characteristics, type of operation, the number of ports used, actual operation time, drain usage, occurrence of wound infection, postoperative intraabdominal abscess formation and adhesive intestinal obstruction rates were recorded.

The choice of the operative method for appendectomy was based on the physical examination findings. Late-presenting patients with signs of generalized peritonitis plus abdominal obstruction with massive abdominal distention were treated by OA. All other cases of appendicitis were selected for LA. In the presence of appendiceal mass, if the mass could be separated by external manipulation under general anaesthesia the patient underwent LA; otherwise, OA was preferred.

While pathological identification of the patients was performed, complicated appendicitis was defined as the presence of perforation and/or intraabdominal abscess. Perforated appendicitis was described as presence of a hole at the wall of appendix or a fecalith.[23] Patients with gangrenous appendicitis and/or intraabdominal turbid fluid were considered as uncomplicated appendicitis.

Antibiotic regimen for appendicitis comprised {cefuroxim [100 mg/kg/day ter in die or three times a day (t.i.d.)] plus metronidazole [30 mg/kg/day bis in die or two times a day (b.i.d.)]} single dose for uncomplicated appendicitis and 7 days for complicated appendicitis.

Postoperative pain control was managed with peroperative or postoperative infiltration of bupivacaine (1 mg/kg/dose) at port site(s) and intravenous paracetamol (10 mg/kg/dose). Additionally, non-steroid anti-inflammatory agent (diclofenac sodium, 1 mg/kg) was used in adolescent patients.

Single-port LA was performed using a special standardized laparoscopy set comprising an 11-mm conventional metal port, a dissector, a grasper, a scissors, a L-shaped monopolar electrocautery and a 10-mm 0° operating scope placed in a special container [Figure 1a-c].

Figure 1.

(a) Single-port laparoscopic appendectomy set, base tray: Cannula, parallel eye-piece scope and light cable (b) Upper tray: Working instruments (c) With transparent cover

Operative costs were calculated using the invoice prepared by the hospital administration that were presented to the social security providers and are presented as US dollars ($). To calculate the cost of re-use instruments, the following equation was used: TC₁₀₀ = AC (100/x) + R (100 - 100/x) where TC₁₀₀ = total cost for 100 uses, AC = acquisition cost of a single instrument, R = reprocessing cost for a single instrument and x = the number of uses per instrument.[24] The reprocessing cost was defined as the cost of materials plus the labour for reprocessing. The cost of re-use instruments were calculated on the basis of each usage during the study period as they were used in all cases of appendicitis, both uncomplicated and complicated. Reprocessing cost of the instruments used for single-port LA was calculated as the whole standardized set.

The data were expressed as mean ± 1 standard deviation (SD). Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 15. Analysis of variance (ANOVA) followed by Tukey's test was used to compare results between the groups. Chi-square test was used to compare proportions of complications. P value of less than 0.05 was considered significant.

RESULTS

The records of 1,408 patients who were operated for appendicitis (uncomplicated plus complicated) were evaluated (604 girls, 804 boys). The mean age of boys and girls were 10.9 ± 4.1 (3-17 years) and 10.4 ± 5.3 (4-17 years), respectively.

A total of 314 patients with complicated appendicitis (128 girls, 186 boys) underwent appendectomy during the study period. The mean age of boys and girls were 11.2 ± 5.4 (3-17 years) and 10.4 ± 6.4 (4-17 years), respectively. There was no significant difference regarding age among the gender groups. Among complicated appendicitis cases, 102 patients (32.4%) underwent single-port LA, 17 patients (5.4%) underwent multiport LA and 195 patients (62.1%) underwent OA. The mean operation time of the single-port LA group was significantly less compared with the multiport LA and OA groups [Table 1]. Conversion from LA to OA was required in six patients (5.0%) and all conversions occurred in the multiport LA group. Technical difficulties were the reasons for conversion. The mean operation time of the conversion cases was 96 ± 27.8 min (range: 78-145 minutes).

Table 1.

The effects of operative method on operation time (minutes) (mean ± 1 SD^‡)

The duration of hospitalization was significantly less in the single-port LA group compared with the multiport LA and OA groups (P = 0.011) for uncomplicated cases [Table 2]. The duration of hospitalization of the complicated appendectomies was also significantly less in the single-port LA group compared with the multiport LA and OA groups (P < 0.001) [Table 2].

Table 2.

The effects of operative methods on hospitalization time (days) (mean ± 1 SD^‡)

Drain usage, wound infection and adhesive intestinal obstruction rates of the complicated appendectomies were significantly high in the OA group [Table 3]. After 2011, drain usage was abandoned for LA.

Table 3.

The effects of operative methods on drain usage and postoperative complications in complicated appendicitis

Postoperative intraabdominal abscess occurred in nine complicated appendicitis cases (4.6%) in the OA group and two complicated appendicitis cases (1.9%) in the LA groups. There was no significant difference among the groups in terms of postoperative intraabdominal abscess formation.

Postoperative intraabdominal abscess patients were re-admitted to the hospital 12.2 days after discharge (range 3-30 days). In the OA group, six postoperative intraabdominal abscess patients underwent re-operation for postoperative intraabdominal abscess drainage and three patients were treated only with antibiotics. In the LA groups, one patient with postoperative intraabdominal abscess was treated by laparoscopic abscess drainage and the other one was treated only with antibiotics.

Adhesive intestinal obstruction occurred in 16 complicated appendicitis patients (8.2%) who underwent OA and none among complicated appendicitis in the LA groups. These patients presented median 30 days (range 7 days-24 months) after discharge. Ten of these patients were treated conservatively and the other six patients underwent operation. Postoperative follow-up was 3.51 ± 4.48 months (range 30 days-24 months).

The operative cost of single-port surgery set was calculated as $41.55 for each use. Acquisition cost of a single set was $7,978 and single reprocessing cost was $14.48. LA performed by re-use instruments was significantly cheaper compared with other groups (P < 0.001) [Table 4].

Table 4.

Operative cost analysis according to operative method. (US$) (mean ± 1 SD^‡)

DISCUSSION

Pediatric conventional 3-port LA was first reported in 1992.[25] The first series of paediatric single-port laparoscopy-assisted appendectomy was published in 1998.[14] Intraabdominally conducted conventional single-port LA utilizing conventional working instruments was devised in 2005.[19] However, LA was not preferred for complicated appendicitis regarding technical difficulties, longer operation times, higher operative costs, increased rates of postoperative wound infection and intraabdominal abscess formation.[1,9,26] Standardized operative techniques for LA have been shown to reduce the complication rates in children with uncomplicated as well as complicated appendicitis.[9,10]

There is still a debate as to whether the advantages of LA are similar in uncomplicated and complicated appendicitis. LA has been reported to result in increased risk of postoperative intraabdominal abscesses formation in complicated appendicitis compared to OA.[27] On the contrary, postoperative intraabdominal abscess formation rates of LA in complicated appendicitis have not been found to be increased compared to OA.[1,9,28] Moreover, LA for complicated appendicitis has been shown to reduce the incidence of infectious complications such as wound infection and postoperative intraabdominal abscess formation.[11] The ability to explore the entire abdomen and sufficient irrigation of the contaminated peritoneal cavity has been suggested as technical advantages of LA.[9] Thus, LA is favoured in generalized peritonitis resulting from complicated appendicitis regarding the aforementioned technical usefulness.[18] The present study has shown that LA markedly reduced postoperative wound infection and adhesive intestinal obstruction rates but did not decrease postoperative intraabdominal abscess formation rate.

The operation time in LA has been found to be longer than OA in complicated appendicitis[11,26] but this observation may have resulted from tedious dissection of the inflamed viscera.[11,29] Other reports did not find significant difference regarding conduction time between LA and OA in complicated appendicitis.[30] Single-port LA in uncomplicated appendicitis is feasible in paediatric patients with reasonable operation times.[19] The present study showed that the operation time for single-port LA in complicated appendicitis was less than multiport LA while there was no difference between multiport LA and OA. We think that reduction of the number of ports and the experience gained with conventional single-port LA have resulted in shorter operation times in single-port LA in the current series. Nevertheless, conversion from single-port LA to multiport LA obviously requires longer operation time. Multiport LA patients were hospitalized longer than single-port cases. We think that while drains were not placed in single-port cases, drain usage in multiport LA cases resulted in longer hospitalization as patients were hospitalized till the removal of drains.

The overall treatment cost of LA has been determined to be 26% higher compared with OA and this difference has been attributed to the high operative cost.[9] On the other hand, the higher operative cost of LA is solely attributable to the purchase price of the disposable supplies such as stapler, clip, endoloop and LigaSure.[13] Another report has mentioned that single-site umbilical LA leads to longer operative times resulting in greater charges.[3,29] The present study has showed that operative cost of single-port LA is cheap compared with multiport LA and OA in complicated appendectomies while there was no significant difference of the operative cost between LA and OA in the uncomplicated cases. Although the usage of disposable instruments during multiport LA is the primary reason for high operative cost, we think that the longer hospitalization and longer operation times are also other significant contributors to increased costs. The mean operative cost of single-port LA is 1.6-3.3 (the bigger figure relates to usage of vessel sealing devices) times lower than multiport LA. These decreases of cost in single port LA were attributed to the usage of re-use conventional laparoscopic working instruments and elimination of the usage of vessel sealing devices. Therefore, both the usage of disposable instruments and the number of the port should be reduced to decrease the operative costs.

The present study has shown that single-port LA for complicated appendicitis can be conducted in a reasonable operative time; it shortens the hospitalization period, markedly reduces postoperative wound infection and adhesive intestinal obstruction rates and does not increase operative cost. Thus, conventional single-port laparoscopy should be the preferred efficient and cost-effective modality for appendectomy in complicated appendicitis.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

Dr. Osman Z Karakuş, Dr. Oktay Ulusoy, Dr. Oğuz Ateş, Dr. Gülce Hakgüder, Dr. Mustafa Olguner and Dr. Feza M Akgür have no conflicts of interest or financial ties to disclose.