Why the Extended Rocky Davis Incision is Not Used in Pediatric Appendectomy
Laparoscopic appendectomy has replaced open techniques, including the Rocky Davis incision, as the standard of care for pediatric appendicitis because it delivers superior outcomes in pain control, infection rates, hospital stay, and quality of life. 1
The Paradigm Shift to Laparoscopy in Pediatric Surgery
The extended Rocky Davis incision—a muscle-splitting open approach through the right lower quadrant—has been largely abandoned in pediatric appendectomy due to the overwhelming evidence favoring laparoscopic techniques:
Superior Clinical Outcomes with Laparoscopy
Laparoscopic appendectomy is strongly recommended over any open approach in children when equipment and expertise are available, based on moderate-to-high quality evidence. 1, 2
Lower surgical site infection rates are consistently demonstrated with laparoscopy compared to open techniques including the Rocky Davis approach. 1, 3, 4
Reduced postoperative pain with shorter duration of intravenous analgesic requirements (0.8 vs. 1.9 days) favors laparoscopy. 5
Shorter hospital stays are achieved with laparoscopic technique (2.2 vs. 3.4 days), allowing faster return to normal activities. 6, 5
Higher quality of life scores post-operatively make laparoscopy the preferred approach for both uncomplicated and complicated appendicitis in children. 1
Specific Advantages Over the Rocky Davis Incision
The Rocky Davis incision requires a 3-4 cm muscle-splitting incision that results in more wound-related complications compared to laparoscopic port sites. 4, 7
Even in developing countries with limited resources, studies comparing the Rocky Davis approach to laparoscopy show superiority of laparoscopy specifically in reducing surgical site infections. 4
Lower incidence of postoperative ileus (0% vs. 2.2%) and bowel obstruction episodes favor laparoscopy over open techniques. 6, 5
When Open Approaches Might Still Be Considered
Resource-limited settings where laparoscopic equipment or expertise is unavailable may necessitate an open approach like the Lanz or Rocky Davis incision. 8
Conversion from laparoscopic to open may require utilizing an open incision when technical difficulties arise, though this occurs infrequently. 8
The Rocky Davis incision is mentioned in contemporary literature only as a comparison group or fallback option, not as a recommended primary approach. 4
Common Pitfalls and Caveats
Do not delay surgery beyond 24 hours from admission regardless of surgical approach chosen; early appendectomy within 8 hours is recommended for complicated cases in children. 1, 2
Younger children under 5 years have higher perforation rates due to atypical presentations and delayed diagnosis, making the minimally invasive benefits of laparoscopy even more valuable. 2
Single-incision laparoscopic techniques should generally be avoided in favor of conventional three-port laparoscopy due to longer operative times, higher wound infection rates, and increased postoperative pain. 1
In complicated appendicitis with abscess or phlegmon, advanced laparoscopic expertise is preferred over open drainage when available. 2
The evidence is clear: the extended Rocky Davis incision has been superseded by laparoscopic appendectomy as the gold standard in pediatric surgery, with open techniques reserved only for settings lacking laparoscopic capabilities or when conversion becomes necessary. 1, 9, 8