Authors Accepted Manuscript

Complications in common general pediatric surgery

procedures

Maria E. Linnaus, Daniel J. Ostlie

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PII: S1055-8586(16)30052-X
DOI: http://dx.doi.org/10.1053/j.sempedsurg.2016.10.002
Reference: YSPSU50649
To appear in: Seminars in Pediatric Surgery
Cite this article as: Maria E. Linnaus and Daniel J. Ostlie, Complications in
common general pediatric surgery procedures, Seminars in Pediatric Surgery,
http://dx.doi.org/10.1053/j.sempedsurg.2016.10.002
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 Complications in Common General Pediatric Surgery Procedures

Maria E. Linnaus, MD & Daniel J. Ostlie, MD

Department of Surgery
Phoenix Children's Hospital

Corresponding Author:
Daniel J Ostlie, MD
Surgeon-in-Chief and Chair of Surgery
Phoenix Childrens Hospital
Professor of Surgery
Mayo Clinic Arizona
1919 E Thomas Road
Phoenix, AZ 85016
602-933-7003
dostlie@phoenixchildrens.com

Abstract

Complications related to general pediatric surgery procedures are a major concern for

pediatric surgeons and their patients. Although infrequent, when they occur the consequences

can lead to significant morbidity and psychosocial stress. The purpose of this article is to discuss

the common complications encountered during several common pediatric general surgery

procedures including inguinal hernia repair (open and laparoscopic), umbilical hernia repair,

laparoscopic pyloromyotomy and laparoscopic appendectomy.

Keywords: Pediatric surgery, complication, laparoscopy, inguinal hernia repair

Introduction

Complications after pediatric surgery are a relatively uncommon occurrence. Several of these

are unique to pediatric patients, and they can differ vastly from complications in the adult

population. Certain complications arise from the increased difficulty of operating on smaller

anatomic structures in infants and young children while others are unique to the pediatric
population simply because of the pathophysiology of the disease or specificity with which the

disease process affects the pediatric patient. This summary attempts to discuss complications of

four of the most commonly encountered pediatric operations.

Inguinal Hernia

Pediatric inguinal hernia is one of the most frequently encountered diagnoses in pediatric

surgery with an overall incidence of 0.8-4%[1] in term infants and children and increasing to nearly

30% in the premature infant[2]. Generally regarded as one of the most common operations a

pediatric surgeon will perform, the pediatric inguinal hernia repair can be particularly challenging

given the small anatomic structures and limited working space. Fortunately, the overall

complication rate for pediatric inguinal hernia repair is low regardless of approach (i.e. open or

laparoscopic) but does appear to increase with prematurity and need for emergent surgery[3,4].

While there appears to be a transition to performing inguinal hernia repair laparoscopically, the

open approach remains in common practice today. Both approaches will be described in this

summary.

Operative and perioperative complications of open repair

There are several technical considerations that merit attention in order to limit intraoperative

complications during inguinal hernia repair. Given that majority of patients with inguinal hernia are

male[2], special attention should be given to protection of the gonadal structures. Injury to the vas

deferens, testis and testicular artery can have long term implications on future fertility and

function - particularly in the case of bilateral inguinal hernia repair. Additionally, injuries to gonadal

structures can leave the surgeon vulnerable to litigation.

Direct insult to the spermatic cord is reported to occur in 0.06% to 0.6% in term infants and

children undergoing open surgery for inguinal hernia repair [2,3]. Premature babies may be at

increased risk of injury but this particular injury does not appear to be elevated during emergency

surgery for incarceration [3,4]. The common mechanisms of injury to the vas deferens include

unintentional cutting or tearing of this delicate structure during repair of the hernia [2]. Direct injury

to the testis may also occur. Although it is rarely reported in the literature the surgeon must be
cautious in handling the testicle during repair. Injury to the testis or the testicular artery/vein may

result in postoperative hematoma formation. Moreover, direct injury to the testicular artery can

occur in both the open and laparoscopic techniques and may result in subsequent testicular

atrophy. Proponents of both approaches cite testicular artery injury as a benefit of their selected

surgical approach. To date no significant difference has been found between techniques [5].

Overall, atrophy occurs in less than 1% of patients and appears to be more directly a result of

incarceration rather than direct injury during elective repair [2]. Several studies have noted that

while a transient decrease in testicular vascularization can occur with surgical manipulation, the

vast majority will return to baseline in the later postoperative period [5,6].

Another commonly encountered problem with pediatric inguinal hernia repair is the presence

of a sliding component to the hernia sac. Sliding hernias occur in approximately 8 to 31% of

pediatric patients with an apparent predilection for female patients and patients under 1 year of

age [2,7,8]. In fact, reports assessing female inguinal hernia repair describe presence of the

fallopian tube or ovary in one-third to three-quarters of patients [7,9]. The pediatric surgeon must

be highly diligent in identifying a sliding hernia component as it may also incorporate a portion of

bladder or intestine. Injury to these organs may occur if the hernia sac is not inspected and

contents not reduced. While the incidence of a sliding hernia may be high, the reported overall

risk of injury to such structures is under 1%. In large retrospective series, no accounts of injury to

the internal organs were documented [2,7]. In these same studies, a few rare cases of ovarian

ischemia were noted as a result of incarceration independent of the sliding hernia. These were

managed with reduction of the ovary into the abdomen [2].

Wound infection after open inguinal hernia repair is reported to be approximately 1% in most

large studies [2,7]. In meta-analysis, this reported risk in open repair has not been found to

significantly differ from laparoscopic repair and remains around 1% [10,11]. However, there exist

several other series that report a 0% incidence of wound infections using the laparoscopic

approach [1214]. Local wound care and antibiotics are sufficient in the treatment of wound

infections after inguinal hernia repair.

Late complications of open inguinal hernia repair

Hernia recurrence is considered the most definitive and most common quoted complication

related to inguinal hernia repair. It is the single most common complication compared between

the open and laparoscopic approaches. After open repair, the recurrence risk reported in

historical retrospective series is approximately 0.4% to 1.2% [2,7], which mirrors the reported

recurrence rates in prospective randomized trials comparing laparoscopic to open techniques of

1.7% to 2.4% [15,16]. Several meta-analyses agree that the risk of recurrence is not significantly

different based on technique and is likely dependent on the comfort and training level of the

operating surgeon [10,17]. There may, however, be an increased predilection for recurrence in

teenagers undergoing open repair [2], in children with malnutrition, increased intraabdominal

pressure (e.g. VP shunt), and connective tissue disorders [18].

One of the most highly debated discussions in the pediatric literature is the management of

the contralateral inguinal region during operative repair of a clinically apparent unilateral hernia.

Although the evaluation itself is not a complication, the decision based on the evaluation can lead

to consequences that should be considered. The incidence of developing a symptomatic

metachronous inguinal hernia is 2% to 11% after open repair in retrospective reports [2,7,1922].

Due to this high rate, many pediatric surgeons have advocated for contralateral exploration using

laparoscopy through the hernia sac during open repair or in highly suspicious cases, initial

laparoscopic evaluation through the umbilicus [1]. In studies employing laparoscopic exploration

of the contralateral groin through the ipsilateral hernia sac, the rate of a non-clinically detected

contralateral patent processus vaginalis (CPPV) is anywhere from 20% to 66% [11]. This rate

appears to be increased in premature patients [23], females greater than 2 years of age [24], and

perhaps even in patients with a left sided inguinal hernia [25]. However, the clinical significance of

this finding and the risk of true hernia development in the setting of CPPV are unknown.

Additionally, even in negative contralateral laparoscopic evaluations, there is still an inherent risk

of inguinal hernia development [26]. Those opposed to contralateral exploration cite increased risk

of injury, postoperative pain, and longer operative time [19,27,28] while those in favor opt to avoid a

second surgery for the development of a symptomatic hernia on the contralateral side. While the
authors mainly utilize laparoscopic hernia repair, in cases of open repair, we perform

laparoscopic evaluation of the contralateral internal ring through the ipsilateral hernia sac in all

patients less than 5 years of age. The reader should understand that this age limit is arbitrary

and chosen based on the decreasing potential of a patent processus becoming clinically

significant after 5 years of age.

Postoperatively, there are a few acquired conditions that may result in parental or patient

distress, increased provider visits or even presentation to the emergency department (ED). In

particular, postoperative hematoma formation can present dramatically. Patients can develop

ecchymosis and swelling of the scrotum and groin which may even track up to the iliac crest. In

large retrospective studies the rate of reported hematoma formation after open inguinal hernia

repair is anywhere from 0.1% to 3.3% [7,29]. If there is no evidence of persistent hemorrhage,

management can be conservative and include comfort measures and reassurance to the patient

and/or family that the hematoma will spontaneously resolve and no intervention is necessary. In

the uncommon scenario where the hematoma becomes infected, drainage and antibiotic therapy

may be required.

Injury to the lymphatic drainage of the testis within the spermatic cord can also result in

postoperative hydrocele formation in up to 2.9% of patients, particularly if the patient had a large

hydrocele preoperatively [3]. Hydrocele formation also occurs more frequently in premature

patients [3]. In general, postoperative hydroceles should be observed for spontaneous regression

which occurs in the majority of cases by one year [3]. Large persistent hydroceles are infrequent

(0.06% in large retrospective reports) [2] and aspiration of the hydrocele may be needed for

resolution. In rare instances operative repair may be required [30].

More concerning to the pediatric surgeon is iatrogenic testicular ascent or secondary

cryptorchidism which can result from failure to return the testis to its anatomic position. Particular

care must be given to ensuring that the testis remains in the scrotum after repair of the hernia has

been performed. Secondary cryptorchidism is rarely reported ( 0.1% to 0.5%) [2,7] in large

retrospective studies assessing open pediatric inguinal hernia repair, but may be as high as 4.5%

when emergent surgery is needed [4]. If its occurrence is clinically detected in the postoperative
period, it can often be resolved with manual testicular traction in the office, however, in the rare

event that the testis cannot be returned to the scrotum, patients may require orchidopexy at a

later date, which can be distressing to the patient or parent.

Inguinal abscess formation is a rare event in the pediatric literature and occurs in less than

0.5% of open repairs [31]. When it is encountered it is generally associated with the suture chosen

for repair (also known as stitch abscess/granuloma). This risk appears to be associated with

utilization of silk suture or other braided nonabsorbable sutures during open repair of inguinal

hernia [32]. Even in the rare cases of paravesicle abscess development described in the literature,

silk suture appears to have been implicated [33]. Antibiotics alone may not resolve the issue and

in most cases aspiration or open incision and drainage along with removal of the foreign material

has been required [3133].

Laparoscopic repair

The initial criticism of laparoscopic inguinal hernia repair in the pediatric population was its

reported higher recurrence rate. However, over the last decade, many pediatric surgeons have

embraced the laparoscopic repair and with changes in surgical technique the recurrence rates

have decreased from an initial recurrence rate of 3-4% to 1% [3436]. Several recent studies

utilizing varying laparoscopic techniques demonstrate recurrence rates from 0.3 to 1.1% [12,3742].

Additionally, recent randomized trials and meta-analyses have shown no difference in recurrence

rates between the laparoscopic and open approaches in term infants and children [15,16,10,17,11,43,44],

and two recent small series have reported a 0% incidence of hernia recurrence [45,46]. There may

be an increased risk of recurrence in certain subsets of patients including premature infants,

patients with incarceration, and children with connective tissue disorders and ventriculoperitoneal

shunts [47,48]. However, laparoscopy is still regarded as an appropriate method of repair for these

patients in experienced hands. Based on these data, cosmesis and surgeon preference have

been driving the technical approach, and no strict recommendations have been made regarding

an optimal repair method since none has been shown to be superior. The authors prefer

laparoscopic hernia repair and hypothesize that the addition of peritoneal suturing around the

internal ring may lead to a more durable repair with decreased recurrence rates [49,50].
 As with the open repair, injury to the spermatic cord is another consideration while performing

laparoscopic repair of inguinal hernia. This can most often be avoided by careful recognition of

the anatomy and meticulous placement of transperitoneal sutures. A distinct difference between

the open and laparoscopic repair is that during laparoscopic repair the spermatic cord is not

directly manipulated as in open repair. However, during intracorporeal suturing, the spermatic

cord lies directly adjacent to the hernia defect. A practiced technique to decrease the risk of

injury to these structures includes hydrodissection with saline or local anesthesia to lift the

peritoneum away from the vas deferens and testicular vessels, thus creating a working space for

passage of the suture to close the internal ring [49].

Umbilical port site hernia is a complication unique to the laparoscopic repair of the inguinal

hernia. Few studies report on the incidence of umbilical port site hernia after laparoscopic inguinal

hernia repair. In one study assessing utility of laparoscopic hernia repair in children under 1 year

of age, the authors noted a 2.6% occurrence rate of umbilical hernia 4 months postoperatively,

however, all closed spontaneously without intervention [42]. Numerous retrospective studies have

reported the rate of port site hernia after laparoscopic hernia repair from 0-1.6% regardless of

age [37, 51-53].

Similar to the open approach to inguinal hernia repair, laparoscopic repair can result in

delayed persistent hydrocele formation. However, this occurrence appears particularly rare in the

laparoscopic literature despite most laparoscopic techniques leaving the distal hernia sac in situ.

Most reports cite early development of a postoperative hydrocele that resolves with aspiration or

observation [39,54]. In the rare circumstance that the hydrocele is recurrent and unresolving,

consideration should be given to repeat laparoscopy to rule out recurrent hernia [36]. Additionally,

for those that are without recurrence and still unresolved, surgical obliteration of the hydrocele

sac should be entertained.

Complication Avoidance during Inguinal Hernia Repair

Complication avoidance during inguinal hernia repair primarily rests on meticulous surgical

technique regardless of approach.

 Spermatic cord injury is essentially limited by careful handling of the cord structures and high

ligation of the hernia sac during open repair, and through precise suture placement around the

internal ring during the laparoscopic repair. Many surgeons will also use hydrodissection of the

peritoneum to elevate it away from the cord structures during the laparoscopic repair to aid in

placement of the suture such that injury can be minimized.

Identification of the presence of a sliding hernia is paramount for avoiding injury to other

organs during its repair. In all female patients, and unless it is clearly evident that there is no

sliding component to the hernia in a boy, the hernia sac should be opened and the internal ring

inspected through the sac to ensure that there is intestinal or ovarian sliding component. If

present, the sliding component should be reduced if possible. If it is not possible to reduce the

sac should be closed with a purse string repair.

Postoperative hydrocele formation can be essentially eliminated by widely opening the distal

hernia sac. In circumstances where the sac is significantly thickened, eversion of the sac with

marsupilazation may be needed.

Umbilical Hernia

Umbilical hernia is another commonly encountered problem in the pediatric population. An

estimated 10-20% of infants are born with a hernia of the umbilicus [55], with increased numbers in

premature infants, but the majority of these resolve spontaneously throughout early childhood.

Operative repair is indicated in patients if the umbilical defect fails to close by 2-5 years of age.

Most surgeons elect to repair umbilical hernia defects through an open approach although

minimally invasive techniques involving injection of polymer into the hernia sac have been

described [56]. For this review we will focus on the open approach to umbilical hernia repair.

The major concern for patients, parents, and surgeons is the risk of recurrence of an

umbilical hernia after operative repair. In a large fifty-year retrospective study comprised of nearly

500 patients, the overall recurrence rate was 2% [57]. However, older reports indicate that rate of

recurrence may be around 1% [58]. Interestingly, no modern studies have assessed the long term
recurrence rate of pediatric umbilical hernia repair. Typically, time to recurrence is less than 1

year [57]. Additionally, the rate of recurrence appears higher with closure using nonabsorbable

suture compared with absorbable suture [57].

Wound infection is another consideration when proceeding with operative repair of umbilical

hernia. It is estimated that less than 1% of umbilical hernia repairs develop postoperative wound

infections [59] and the majority of these can be managed with antibiotics and local wound care.

While there are no modern studies that assess the rates of wound infection after umbilical hernia

most surgeons regard this as a very rare event.

Finally, there has been significant focus on limiting the potential development of hematoma or

seroma after umbilical hernia repair. These two complications are similarly very rare (0.1-

0.5%)[57]. Interestingly, arguments have been made suggesting that dressing type and duration

will decrease this risk. In a prospective randomized trial of 96 patients, there was no difference in

the development of either hematoma or seroma suggesting that dressing type/duration is not a

factor.

Complication Avoidance during Umbilical Hernia Repair

Recurrence is the concerning complication related to umbilical hernia repair. Perhaps most

important in avoiding this complication is timing of surgery. Delaying repair until after 2 years of

age allows for fascial development and potential partial closure of the defect. If either or both of

these occur recurrence is less likely. Additionally, adequate fascial dissection and suture/tissue

approximation is needed to reduce recurrence risk.

Pyloromyotomy

Hypertrophic pyloric stenosis (HPS) was originally recognized as a surgical disease in the

1800s [60]. The initial operative management was invasive and despite success in its treatment,

pyloric stenosis was associated with several complications. Recently, laparoscopic

pyloromyotomy has been shown to be superior to the open approach. Randomized controlled

trials and meta-analyses have shown that laparoscopic pyloromyotomy has decreased length of

hospital stay, and shorter time to full feeds although the effect on overall complications remains

debatable [6163]. It has been suggested that laparoscopic pyloromyotomy may have the potential
for an increase in the risk of incomplete pyloromyotomy [64]. However, numerous reports have

shown no significant difference in mucosal perforation, wound infections, or incisional hernias

[61,65,66]
. Additionally, it has been shown that cosmesis is improved in those undergoing

laparoscopic pyloromyotomy compared to open [67]. It is the view of the authors that laparoscopic

pyloromyotomy should be pursued during this current era of laparoscopy and therefore this

summary on complications will solely focus on laparoscopic pyloromyotomy.

Intraoperative complications

Laparoscopic pyloromyotomy is a short procedure in experienced hands and has been

shown to have decreased operative times compared with the open approach [61,68]. The most

worrisome complication of pyloromyotomy is mucosal injury, especially if it is missed at the time

of initial operation. There have been some reports that indicate this risk may be elevated in

laparoscopy [69] but others show no difference [64,65]. In general, the incidence of mucosal injury is

anywhere between 0.8% to 2.2% [61,64,65,68,70]. This rate appears to be consistent regardless of

trainee or experience of attending surgeon [61,64]. A recent large, multi-institutional observational

study found that there was no difference in risk of mucosal perforation between open and

laparoscopic pyloromyotomy [64]. Similarly, a prospective, double-blind, multi-institutional

randomized controlled trial found no difference in complications between laparoscopic and open

pyloromyotomy including mucosal perforation. In the event of a mucosal perforation, most may be

treated with laparoscopic interventions. In a survey looking at surgeon preferences for repair of

mucosal injury, the majority report preference for primary repair with nearly one-quarter of those

same surgeons utilizing an omental patch which can be done laparoscopically [71]. In these

patients, postoperative management was altered to be more conservative in starting a feeding

regimen and using a nasogastric tube for decompression in the initial postoperative period.

Another relatively uncommon intraoperative complication is injury to the duodenum. During

the laparoscopic repair, the duodenum is often grasped with the laparoscopic grasper, placing the

duodenum at risk of injury. However, the risk of this complication is quite rare. One recent

randomized controlled trial evaluating open versus laparoscopic pyloromyotomy reported a 2%

occurrence [65]. However, this was in a single patient in an overall laparoscopic cohort of 50
patients. Another large cohort study of pyloromyotomy noted an incidence of 0.9% in all

pyloromyotomy procedures but this study didnt specify whether the cases were performed in

open or laparoscopic fashion [72]. There have been retrospective studies that include duodenal

injury as a secondary outcome for laparoscopic pyloromyotomy and some report no injuries

compared to around a 1% rate of duodenal injury in open pyloromyotomy [73]. Finally, in a meta-

analysis performed in 2009, only one reported patient out of 294 (0.3%) had a duodenal serosal

injury [62]. Based on this lack of data, the authors suggest that the operating pediatric surgeon

should be cognizant of this slight risk and utilize caution when grasping the duodenum and

performing the distal myotomy. After complete pyloromyotomy has been performed careful

inspection of the duodenum, gastric serosa and pyloric submucosa should be performed in

addition to insufflation of the stomach utilizing a nasogastric tube despite less than 100%

detection of mucosal injury [74].

Postoperative complications

Fortunately, most patients who have undergone pyloromyotomy do well. Wound infections

will be seen in 1-2.2% of patients [61,65,66,68] and appears to be independent of preoperative

antibiotic usage [75]. While wound infections may become a nuisance the majority can be treated

with oral antibiotics and local wound care.

More concerning in the postoperative period may be the presence of prolonged emesis,

which may be indicative of gastric atony, pyloric edema or a sign of an incomplete

pyloromyotomy. Benign postoperative emesis may occur in as many as 48% to 64% of infants

after pyloromyotomy [66,76]. Due to this phenomenon, varying preferences on postoperative

feeding regimens have emerged with studies reporting no correlation between regimens and

development of postoperative emesis [77]. Additionally, no reliable factors have been identified to

predict risk of postoperative emesis. In the majority of infants, some transient postoperative

emesis is within the range of normal. However, in a small subset of patients it may persist for

several days or weeks which can be concerning to the surgeon for incomplete pyloromyotomy. In

a large randomized trial assessing outcomes between laparoscopic and open pyloromyotomy,

3.4% of patients had significant emesis to warrant evaluation [61]. However, given that many of
these patients may also have concomitant gastroesophageal reflux, determining the etiology of

the prolonged emesis may be difficult. In these cases, swallow studies or upper GI examinations

may be beneficial.

There has been an increased association with the laparoscopic approach and incomplete

pyloromyotomy noted in several randomized controlled trials, large multi-institutional studies, as

well as meta-analyses assessing the outcomes of laparoscopic versus open pyloromyotomy

[61,64,65,70,78]
. Despite this slightly increased risk, the overall rate of incomplete pyloromyotomy in

the laparoscopic group reported in the literature remains low and many have questioned the

clinical relevance of the small difference [61,64,65,70] with some studies reporting no cases of

incomplete pyloromyotomy [66,79]. This trend also appears to be decreasing as more surgeons

become proficient in laparoscopic pyloromyotomy.

Incisional hernia after laparoscopic pyloromyotomy is also a rare event, but appears to be

more related to the open repair than the laparoscopic. In a large randomized controlled trial

assessing open versus laparoscopic pyloromyotomy, zero patients developed an incisional hernia

after laparoscopic intervention compared to a 1% rate in the open group [66]. Similarly, a

prospective randomized trial performed just a year later revealed that they had no incidences of

incisional hernia again with laparoscopic intervention [65]. Another large retrospective study also

noted a zero-event rate of incisional hernia in the laparoscopic group [68]. In a general review of

pediatric laparoscopic surgery the incidence of incisional hernia with 5mm trocar sites was 1.2%
[80]
. In infants undergoing laparoscopic pyloromyotomy, 3mm instruments are used and many

surgeons use trocarless entry for the lateral incisions which again likely decreases the risk of

incisional hernia postoperatively.

Specific to the laparoscopic approach is the development of umbilical port site hernia. No

reports specifically targeting the umbilical port site hernia have been noted in the authors review

of the literature. Since many of the infants undergoing laparoscopic pyloromyotomy already have

a natural orifice at the umbilicus, this risk certainly is less than 1%. Most surgeons close the 5-

mm defect with an absorbable suture which aids in preventing herniation at the umbilical port site.

Complication Avoidance during Pyloromyotomy

 The three most concerning complications of pyloromyotomy are mucosal perforation,

incomplete pyloromyotomy and duodenal injury. All are addressed via appropriate technique.

Careful handling of the distal duodenum should be emphasized to eliminate risk of duodenal

injury. Additionally, the Geiger grasper, which was developed specifically for this operation,

securely fixes the entire duodenum and pylorus while the myotomy is being performed, thus

eliminating the single grasper on the distal duodenum or proximal stomach, depending on the

surgeons preference. We have exclusively used this grasper for the last several years and find it

easy to use and very effective.

Regarding mucosal perforation, careful spreading of the submucosal layers is essential. The

most common site of perforation is at the duodenal margin, and special attention should be taken

while completing the separation of the submucosa at this location.

There have been numerous techniques reported to assure adequate pyloromyotomy,

including the use of length alone (2 cm), the ability to move the superior and inferior

pyloromyotomy edges independently and the ability to bring the superior and inferior edges over

each other. In our experience all of these approaches are effective, and the surgeon should

utilize which ever method they feel most comfortable with.

Laparoscopic Appendectomy

Approximately 30% of pediatric patients will present with perforated appendicitis [81,82] which

may present simultaneously with intraabdominal abscess, free air, feculent peritonitis or, if

advanced, septic shock. Most surgeons perform urgent appendectomy on presentation unless the

symptoms are consistent with development of an organized abscess and the risk of injury to other

structures outweighs need for appendectomy at that time. Traditional open appendectomy has

been replaced in the majority of centers with laparoscopic appendectomy and more recently

single incision laparoscopic surgery. Since its introduction, the rate of laparoscopic

appendectomy has tripled [83] and most pediatric surgeons have adopted laparoscopic

appendectomy after numerous meta-analyses demonstrated decreased incidence of wound

infection, hospital stay, postoperative ileus, and time to normal activity postoperatively [84,85] with

no perceptible difference in intraabdominal abscess formation or operative time in non-perforated

appendicitis. This segment will discuss complications in the context of laparoscopic

appendectomy given its wide acceptance.

Intraoperative complications

Intraoperatively, acute appendicitis has a wide spectrum of complexity and can become a

more challenging operation when perforation has occurred or the appendix is in a retrocecal

position. Iatrogenic bowel injury, while uncommon, can occur during laparoscopic

appendectomy. The appendix may form adhesions with adjacent bowel which may be injured

during adhesiolysis or during dissection of the mesoappendix and in search of the base of the

appendix. Direct manipulation of the friable adjacent bowel may lead to serosal injury or even full-

thickness perforation and use of electrocautery may lead to thermal injury. A large retrospective

study demonstrated a 0.8% risk of iatrogenic bowel injury during laparoscopic appendectomy [86].

Very few other studies even comment on the incidence of bowel injury during appendectomy

likely secondary to low incidence. In the case of superficial thermal injury or serosal tear, an

imbricating stitch on the site is satisfactory in preventing a postoperative leak. In the case of a full-

thickness perforation, an intracorporeal two-layered repair may be necessary.

Bleeding is another consideration during laparoscopic appendectomy. The most common

location of bleeding is the appendiceal artery. Techniques for ligation of the appendiceal blood

supply vary (e.g. staple device versus electrocautery, versus suture ligation/loop) and inadequate

ligation can lead to oozing or even hemorrhage. Most slow venous oozing ceases with brief

electrocautery to the site or even without intervention in a patient with normal coagulation.

However, steady or pulsatile bleeding indicates that repeat intervention is necessary. The

incidence of this complication is not well documented but in a large retrospective study bleeding

from the mesoappendix was reported in 1.2% of laparoscopic cases [86]. The authors did not

attempt to stratify based on technique for ligation of the artery nor did they describe the

management of the bleeding. However, most often use of electrocautery or a suture ligation/loop

is satisfactory in controlling this bleed.

Bleeding may also be encountered during instrument and trocar insertion during laparoscopic

surgery. Caution must be maintained to avoid the epigastric arteries which may be encountered
upon left lower quadrant trocar entry in a classic three-port appendectomy. While this

complication is generally not reported, the authors estimate the incidence to be low, certainly less

than 1%. Frequently, this can be managed laparoscopically by tying off the epigastric artery with

a suture passer. This complication, when recognized intraoperatively, is often with minimal

sequelae, most commonly pain and hematoma formation near the trocar site. In a large

retrospective series of pediatric appendectomy, the incidence of parietal bleeding (unspecified)

was 2.4% in the laparoscopic group [86] but this is likely not specific to the epigastric artery and

may indicate simple peritoneal oozing or muscular bleeding. Finally, even less frequent is injury to

a major blood vessel such as the aorta, inferior vena cava or iliac artery or vein. Again, this is

most likely to occur during trocar insertion and has been reported with use of the Veress,

disposable and reusable trocars [87]. Also, it is likely correlated with children who are obese with a

thickened abdominal wall leading to difficulty with pneumoperitoneum or need for excessive force

to be applied during trocar insertion [87]. Very rarely, device malfunction may contribute to these

types of injuries but in the large series of major vascular injuries from trocar insertion the majority

of trocars reported were functionally normal [87]. There are no pediatric studies that describe this

complication in the setting of laparoscopic appendectomy and in fact, most of the literature is from

adult gynecologic surgery. However, extreme caution must be given to Veress entry, optical entry

or blind trocar insertion to avoid such a morbid complication.

Postoperative complications

After appendectomy, there are several infectious complications that must be considered.

Postoperative abscess rates vary within studies and are dependent on the status of the appendix

at the time of surgery. In a nonperforated appendix, the risk of developing an intra-abdominal

abscess is extraordinarily low, 0-0.7%. In a large study utilizing the Nationwide Inpatient Sample,

the rates of intraabdominal abscess formation after laparoscopic appendectomy for nonperforated

appendicitis was around 0.1% [81]. This risk increases with perforation of the appendix and may

be anywhere from 5.7 to 20% [8992]. Management of the postoperative abscess includes

drainage with administration of antibiotics in the vast majority of cases. Occasionally, the

abscess may not be amenable to interventional guided drainage and in these cases antibiotics
alone should be utilized reserving repeat operative intervention for the rare case in which this

strategy is not successful.

Superficial wound infection is another relatively common complication after appendectomy.

The overall rate of wound infection appears to be less than 2.0% in both retrospective reports and

randomized controlled trials or meta-analyses assessing complications after laparoscopic

appendectomy [83,84,9395]. However, this risk is increased in perforated appendicitis where rates

reach as high as 5.7% after laparoscopic appendectomy [83]. As in most cases of wound infection,

a short course of antibiotics and local wound care are often satisfactory in management; less

frequently, open drainage of the wound may be necessary.

Postoperative bowel obstruction and ileus are relatively uncommon in nonperforated

appendicitis treated with laparoscopic surgery. In large national database studies, the risk of true

bowel obstruction appears to be less than 0.1% for nonperforated appendicitis [81]. Overall,

treatment of nonperforated appendicitis is a technically less challenging operation compared to

perforated appendicitis and often requires less manipulation of adjacent structures which results

in decreased adhesion formation. The risk of ileus, however, is around 1.2% to 1.3% [81,84]. The

increased risk of postoperative bowel obstruction and ileus results from the presence of

perforation. Reported rates of postoperative bowel obstruction range from 0.2 to 1.2 in large

retrospective studies of perforated appendicitis treated with laparoscopic appendectomy [81,96,97].

The risk of prolonged ileus after perforated appendicitis is much higher than true bowel

obstruction but is less frequently reported in the literature. A large discharge database study

noted a 12.4% incidence of prolonged ileus in laparoscopic appendectomy for perforated

appendicitis [81]. However, the rate of abdominal distention and vomiting with or without paralytic

ileus may be as high as 40 to 75% in patients undergoing laparoscopic appendectomy for

perforated appendicitis or appendicitis with abscess [98]. In patients with prolonged paralytic ileus,

management should be conservative with bowel rest and total parenteral nutrition (TPN) if

necessary. Paralytic ileus may be prolonged for several weeks in rare instances.

Venous thromboembolism (VTE) is a rare complication in the pediatric general surgery

population. The risk of VTE after laparoscopic appendectomy is less than 0.1% [81]. This risk may
be slightly increased in perforated appendicitis. Additionally, while patient factors such as obesity

and postoperative activity level may affect this rate, it is more likely that this rare rate of VTE is

related to a previously undiagnosed coagulopathy such as Factor V leiden or Protein C/S

deficiency. For the typical pediatric patient requiring laparoscopy for appendicitis the risk is so

small that no additional precautions are necessary.

Even rarer in the pediatric literature is the occurrence of portal vein or splenic vein thrombosis

either at presentation of appendicitis or after appendectomy. In these cases, the inflammatory

state related to appendicitis or another intraabdominal infection incites thrombophlebitis of the

portal venous system known as pylephlebitis. Historically, this condition had a <0.4% incidence
[99]
and now is reported in a few case reports only [100103]. One review noted that in all cases

reported since 1971 nearly one-quarter are in the pediatric population [104]. Other reports indicate

that this risk may be higher in perforated appendicitis as well [100] although there are no large

scale studies to prove this since the incidence is so rare. This condition can be fatal if left

undiagnosed or untreated. Initial presentation may include fevers, often nausea and diarrhea with

or without vague abdominal pain and longer history of appendicitis-like symptoms. Sometimes

weight loss and poor appetite may accompany these symptoms as well. Diagnosis is often made

with either ultrasound or CT demonstrating thrombus formation in the portomesenteric system

and may extend into the splenic vein or mesenteric veins. In the event of thrombophlebitis of the

portal system or splenic vein, broad spectrum antibiotics targeting gram-negative bacteria and

anaerobes are a staple in management and therapeutic anticoagulation should be utilized if the

thrombus is extensive [105]. Sequelae of pylephlebitis may include the development of hepatic

abscesses which may require percutaneous drainage if antibiotics alone do not treat.

Anticoagulation is indicated in these cases to limit extension of the thrombus and to allow natural

fibrinolysis to occur.

Complication Avoidance during Appendectomy

Infectious complications are difficult to avoid in perforated appendicitis and suggestions for

limiting these include removal of as much of the contaminated material as possible and careful

removal of the perforated appendix to limit potential wound infection.

 Two areas of special note are limiting bowel injury and trocar complications. Bowel injury is

generally related to intense adhesions secondary to perforation. Two timeframes during the

procedure are at greatest risk, entering the abdomen and dissection of the inflammatory mass.

Our technique of entering the abdomen is via an open cutdown and insertion of a blunt cannula.

Once the abdomen has been insufflated the working space can be developed through gentle

dissection with the laparoscope until adequate exposure has be obtained to allow insertion of the

additional operating instruments to be placed. Regarding the dissection of the inflammatory

mass, the mobilization of the cecum from the right lower quadrant will greatly aid in identification

of normal distal colon and proximal bowel. Often, once the cecum/ascending colon is mobilized,

the abscess is encountered, and the appendix and its base can be identified and divided without

significant manipulation of the proximal ileum, thus limiting potential small bowel injury.

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