Laparoscopic treament of acute appendicitis in children

The treatment of acute appendicitis remains discussed although the first laparoscopic appendectomy was performed almost 30-years ago and great series was presented at the National Academy of Surgery in 1993 by JS Valla.Since 1990, we performed about 2000 laparoscopic appendectomies in our department of pediatric surgery, technique become systematic since 2001 for all surgeons and all types of appendicitis.We used three techniques for appendectomy – in, mixed and out - and we preferred the two first for residents learning. The antibiotics were given during the procedure and prolonged during 10 days in case of perforated appendicitis with three antibiotics. The sequence laparoscopic drainage – antibiotics – interval appendectomy was rarely used, as the nonoperative management of intra-abdominal abscess. The rate of conversion in laparotomy was about 2%, only for a few intra-abdominal abscess or old generalized peritonitis.For perforated appendicitis, we compared the postoperative complications after laparotomy (91 cases) and laparoscopy (173 cases) between 1995 and 2007 with the same antibiotics: the rate of wound abscess was respectively 7.7% vs. 1.2% (p<0.01) and the rate of intra-abdominal abscess was 5.5% vs. 2.9% (NS). The rate of postoperative bowel obstruction was 9.9% vs. 0.6% (p<0.001). In the literature, the results are the same for wound abscess and postoperative bowel obstruction, and these laparoscopic advantages are now well recognized. For the postoperative intra-abdominal abscesses, this is more discussed and the rate of this complication is very different according to the series. But it is difficult to conclude because the exact treatment is not always known.For us, the ‘McBurney’ approach has to be left now, even if this procedure was very useful during one century. The laparoscopic approach is better: the appendix is well seen, the abdominal cavity can be explored and washed entirely, the treatment of an ectopic appendix or peritonitis is easy, without wound enlargement, and wound abscess and postoperative bowel obstruction are significantly diminished.