What is the recommended incision approach for a pediatric patient undergoing an appendectomy?

Recommended Incision Approach for Pediatric Appendectomy

Laparoscopic appendectomy using the conventional three-port technique is the recommended approach for pediatric patients undergoing appendectomy, as it provides superior outcomes compared to open surgery and single-incision techniques. 1

Primary Surgical Approach

Conventional three-port laparoscopic appendectomy should be performed over open appendectomy in all pediatric patients when laparoscopic equipment and expertise are available. 1 This approach offers:

• Lower postoperative pain 1, 2
• Reduced surgical site infection rates 1, 2
• Shorter hospital stays 1, 2
• Higher quality of life scores 1
• Earlier return to normal activities and diet 2

The evidence supporting laparoscopic appendectomy in children is strong, with moderate quality evidence demonstrating consistent benefits across both uncomplicated and complicated appendicitis. 1

Port Placement Technique

For the conventional three-port approach, use the following configuration: 3

• 10-12 mm umbilical port for the laparoscopic camera 3
• 5 mm suprapubic port for traction instruments 3
• 5 mm left iliac fossa port for dissection and cutting instruments 3

Position the patient supine with Trendelenburg inclination and establish pneumoperitoneum using either open or closed technique based on surgeon preference. 3

Single-Incision Technique: When to Consider

In pediatric patients with favorable anatomy, single-incision/transumbilical extracorporeal laparoscopic-assisted appendectomy may be performed based on local expertise. 1 However, this recommendation comes with important caveats:

Advantages of single-incision approach:

• Comparable safety profile to three-port technique in children 1
• Superior cosmetic results with single umbilical scar 4, 5
• Cost-effective when using standard equipment 5
• Successful in 83% of pediatric cases 4

Disadvantages requiring consideration:

• Longer operative times compared to three-port technique 1
• Higher wound infection rates in some studies 1
• Increased postoperative pain in certain analyses 1
• Higher conversion rates to multi-trocar surgery (approximately 17%) 4

The single-incision technique is particularly challenging in cases of severe intraabdominal inflammation, where conversion to conventional laparoscopy or open surgery may be necessary. 4

Open Appendectomy: Limited Role

Open appendectomy should be reserved only for situations where laparoscopic equipment or expertise is unavailable. 1 The open approach is associated with:

• Higher surgical site infection rates 1, 2
• Increased postoperative pain requiring more analgesics 2
• Longer hospital stays 2
• Delayed return to normal activities 2

Timing Considerations

Appendectomy should be performed within 24 hours of admission to minimize complications. 1, 6 For complicated appendicitis in pediatric patients, early appendectomy within 8 hours is recommended. 1, 7 Delaying surgery beyond 24 hours increases the risk of adverse outcomes. 1, 6

Special Pediatric Considerations

Age-Related Factors:

• Preschool children under 5 years have atypical presentations leading to delayed diagnosis and higher perforation rates 3
• Younger children have higher perforation rates due to delayed presentation 3

Intraoperative Management:

• Use monopolar or bipolar electrocautery for mesoappendix dissection (cost-effective) 3, 7
• Use endoloop/suture ligation or polymer clips for stump closure 3, 7
• Perform aspiration only without peritoneal irrigation for intra-abdominal collections 3, 7
• Do not place abdominal drains after appendectomy for complicated appendicitis 3, 6

Common Pitfalls to Avoid

• Avoid delaying surgery beyond 24 hours from admission, as this increases complication rates 1, 6, 7
• Do not choose single-incision technique if the surgeon lacks specific expertise or if severe inflammation is anticipated 1, 4
• Always remove the appendix even if it appears normal during surgery in symptomatic patients 6, 7
• Perform routine histopathological examination to identify unexpected findings 3, 7

Algorithm for Approach Selection

1. First choice: Conventional three-port laparoscopic appendectomy (if equipment and expertise available) 1
2. Alternative in favorable anatomy: Single-incision transumbilical technique (if surgeon experienced) 1, 4
3. Last resort: Open appendectomy (only if laparoscopic unavailable) 1

The conventional three-port laparoscopic technique remains the gold standard, providing the optimal balance of safety, efficacy, operative time, and patient outcomes in the pediatric population. 1, 3