What are the techniques and management strategies for open appendectomy in pediatric patients?

Open Appendectomy Technique in Pediatric Patients

Primary Recommendation

Open appendectomy should be reserved only for situations where laparoscopic equipment or expertise is unavailable in pediatric patients, as it is associated with higher surgical site infection rates, increased postoperative pain, longer hospital stays, and delayed return to normal activities. 1

When Open Appendectomy is Indicated

• Perform open appendectomy when laparoscopic equipment is not available 1
• Consider open approach when laparoscopic expertise is lacking 1
• May be appropriate for clinically typical acute appendicitis in resource-limited settings 2

Surgical Technique Components

Incision and Access

• Use a McBurney or Rocky-Davis incision in the right lower quadrant 3
• Employ wound ring protectors during open appendectomy to decrease the risk of surgical site infections, especially in complicated appendicitis with contaminated/dirty wounds 3

Appendiceal Stump Management

• Perform simple ligation over stump inversion, as both techniques have similar major morbidity and infectious complications, but simple ligation is associated with shorter operative times, less postoperative ileus, and quicker recovery 3
• Use endoloops/suture ligation or polymeric clips for stump closure in both uncomplicated and complicated appendicitis 3
• Polymeric clips are the cheapest and easiest method with shorter operative times for uncomplicated appendicitis 3

Wound Closure

• Perform primary skin closure with a single absorbable intradermal (subcuticular) suture for open appendectomy wounds 3
• Avoid delayed primary skin closure, as it increases hospital stay and overall costs without reducing surgical site infection risk 3

Intraoperative Management Considerations

Drainage Decisions

• Do not place abdominal drains after appendectomy for complicated appendicitis in pediatric patients 3, 4
• Prophylactic drainage does not prevent postoperative complications and may be associated with negative outcomes including increased antibiotic requirements, longer fasting times, and longer hospital stays 4

Mesenteric Dissection

• Use monopolar or bipolar electrocautery for mesoappendix dissection due to cost-effectiveness 4, 5
• No significant clinical difference exists between various dissection techniques (endoclips, endoloop, electrocoagulation, Harmonic Scalpel, LigaSure) 4

Perioperative Antibiotic Management

Preoperative Prophylaxis

• Administer single dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 4
• Recommended regimens: amoxicillin/clavulanate 1.2-2.2 g every 6 hours or ceftriaxone 2 g every 24 hours + metronidazole 500 mg every 6 hours 4
• For beta-lactam allergy: ciprofloxacin 400 mg every 8 hours + metronidazole 500 mg every 6 hours 4

Postoperative Antibiotics

• For uncomplicated appendicitis: do not administer postoperative antibiotics 4
• For complicated appendicitis: administer broad-spectrum antibiotics with early switch to oral antibiotics after 48 hours and total duration less than 7 days 4

Critical Pitfalls to Avoid

Technical Errors

• Never invert the appendiceal stump, as this increases operative time and postoperative ileus without improving outcomes 3
• Avoid placing drains in pediatric patients with complicated appendicitis, as this worsens outcomes 3, 4
• Do not perform delayed primary closure, as it increases costs and hospital stay without benefit 3

Special Pediatric Considerations

• Recognize that preschool children under 5 years have atypical presentations leading to delayed diagnosis and higher perforation rates 4, 1
• Younger children have higher perforation rates due to delayed presentation 4, 1
• Always perform routine histopathological examination of the appendix to identify unexpected findings, as intra-operative diagnosis alone is insufficient 3

Timing Considerations

• Perform appendectomy within 24 hours of admission to minimize complications 1, 5
• Early appendectomy within 8 hours is recommended for complicated appendicitis in pediatric patients 1, 5

Quality Outcomes Comparison

While open appendectomy remains a safe procedure, the evidence demonstrates that laparoscopic approach provides superior outcomes with lower postoperative pain, reduced surgical site infection rates, shorter hospital stays, and higher quality of life scores when equipment and expertise are available 1, 6. The overall complication rate is lower with laparoscopic approach, particularly in perforated appendicitis 7.