Seminars in Pediatric Surgery 25 (2016) 208–211

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Seminars in Pediatric Surgery

journal homepage: www.elsevier.com/locate/sempedsurg

Operative management of appendicitis

Shawn D. St. Peter, MDn, Charles L. Snyder, MD
Department of Surgery, Center for Prospective Clinical Trials, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108

a r t i c l e i n f o abstract

Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of
Keywords: the most common operations performed in children. The advent of data-driven medicine has led to
Appendicitis questions about every aspect of the operation—whether appendectomy is even necessary, when it should
Appendectomy be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation
Interval appendectomy versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review
Intra-abdominal abscess the current status of, and available data regarding, the surgical management of appendicitis in children.
Laparoscopy & 2016 Elsevier Inc. All rights reserved.
Children
Pediatric

The operative management of appendicitis varies with the
extent of disease at presentation. The three general categories of
disease are those with appendicitis with no evidence of perfora-
tion, those with perforated appendicitis, and those who present
with a well-defined abscess. This article will review the definition
and application of this classification schema and the available data
on the various operative approaches and technical factors asso-
ciated with the surgical procedures in use currently.
Acute appendicitis
Acute non-perforated appendicitis is definitively cured with
prompt appendectomy, and this is the rationale for early operation
as the traditional standard of care. We now understand that acute
appendicitis can be treated effectively to the point of disease
resolution and hospital discharge with antibiotics alone.1–3 This
concept is discussed at length in another section of this edition.
However, emerging data demonstrating the ability to treat appen-
dicitis with antibiotics lends insight to a long debated topic, the
timing of appendectomy relative to presentation. If antibiotics
alone can treat the disease, it would be rational to assume that
once antibiotics are started, the operation is not emergent or
perhaps even necessary, in the immediate setting. The primary
concern around which any argument regarding the timing of
appendectomy is centered, is the possibility that patients with
non-perforated appendicitis will progress to perforation if there is
a delay in performing appendectomy. A retrospective study sug-
gested that a longer in-hospital wait for operation was associated
n
Corresponding author.
E-mail address: sspeter@cmh.edu (S.D. St. Peter).
with a higher-perforation rate in children. However, the patients
appear to have been highly selected, since no one who underwent
appendectomy within 9 h had a perforation,4 implying that no one
in the early operative group had a perforation at admission. Given
the known data regarding the percentage of children with perfo-
ration or complicated disease, this is quite atypical and suggests
selection bias. This study also focused only on time from presen-
tation to operation. A more recent study investigating time to
appendectomy relative to onset of symptoms found no association
between a longer time to appendectomy and worse outcomes.5
Both of these studies involved relatively small cohorts. A recent
multicenter study including over 1300 patients demonstrated that
delay in appendectomy did not impact the incidence of surgical
site infections.6 The only variables correlating with surgical site
infections were the duration of symptoms, shock or sepsis at
presentation, and the presence of complicated appendicitis. Since
the most robust data available suggest timing of appendectomy
does not impact adverse event rates, appendectomy in the middle of
the night is no longer justified. National health care trends toward
maximizing system efficiency and delivery of care, combined with
data suggesting overnight appendectomy places undue stress on the
surgeon, surgical team, family, and hospital staff7–9 argue for
approaching appendectomy as an elective procedure once antibiotic
therapy has been initiated. This information may be useful during
the initial consultation, to ease patient and family anxiety.
Perforated appendicitis
The best management strategy for perforated appendicitis is
still a topic of debate. The three options consist of antibiotics only,
antibiotics followed by interval appendectomy, and appendectomy
at presentation.

http://dx.doi.org/10.1053/j.sempedsurg.2016.05.003
1055-8586/& 2016 Elsevier Inc. All rights reserved.
 S.D. St. Peter, C.L. Snyder / Seminars in Pediatric Surgery 25 (2016) 208–211
The rationale for treating initially with antibiotics is to avoid a
difficult operation in the setting of peritonitis. Once the infection is
controlled with antibiotics and operative difficulty is decreased,
then the decision is whether to even perform the appendectomy
or not. Foregoing the appendectomy assumes a low risk of
recurrent appendicitis; short-term data suggest the risk is approx-
imately 8–14%.10,11 It is currently impossible to estimate the
lifetime risk of leaving the offending organ in place. There are no
longitudinal population-based studies of these children as they
mature through adulthood and old age; therefore, recurrence
curves are unknown quantity. However, assuming the current
series are accurate in estimating the short-term risk of recurrent
appendicitis at 1–3% per year, and that the rate remains stable,
appendectomy may be indicated in a child with 60–80 years of life
expectancy. We found only 16% of patients had luminal obliter-
ation at the time of interval appendectomy, implying the remain-
ing appendices would remain at risk for recurrent appendicitis.
Additionally, some authors have noted a high rate of pathologic
findings in interval appendectomy specimens.12–14 Although rare
in children, missed appendiceal neoplasms are a potential unde-
sirable side effect of the non-operative approach. A survey of the
American Pediatric Surgical Association (APSA) in 2005 found that
86% of the responders perform interval appendectomy routinely
after non-operative management of perforated appendicitis.15
Initial management with antibiotics followed by elective
appendectomy depends on the patient responding to medical
management and becoming asymptomatic. Several groups have
attempted to evaluate which patients are more likely to fail and
require an early appendectomy prior to the scheduled interval
operation. A study found a high-failure rate in patients with more
than 15% band forms in the differential white cell count on
presentation.16 The presence of an appendicolith on imaging has
also been associated with failure of medical management.17 Others
have found that evidence of disease or contamination beyond the
right lower quadrant on imaging was a predictor of failure.18
The management pathway of initial antibiotic therapy followed
by interval appendectomy includes a de facto assumption that the
clinician can distinguish perforated from non-perforated appendi-
citis based on the preoperative presentation (clinical, laboratory,
and radiographic studies). A blinded review of CT scans at our
institution found that radiologists and surgeons (of all levels of
experience) were unable to diagnose perforation with greater than
80% accuracy.19 Treating a child with non-perforated appendicitis
with a protracted course of antibiotics and interval appendectomy
is gross overtreatment. These patients do not require post-
operative antibiotics after appendectomy and currently are usually
discharged from the hospital on the day of operation.20
While the goal of “antibiotic therapy first” is to avoid a difficult
and potentially dangerous operation, this has been documented to
be an operation that most experienced surgeons can perform
safely, and with a minimally invasive approach. Laparoscopic
appendectomy has been shown to be reliably feasible and safe in
both children and adults who present with a phlegmonous right
lower quadrant mass.21,22
Several studies have compared early versus delayed appendec-
tomy for perforated appendicitis, culminating in a meta-analysis
published in 2010. This report reviewed 17 studies, 16 of which
were retrospective and non-randomized; the other was prospec-
tive but non-randomized.23 This review compared 847 patients
who underwent delayed appendectomy and 725 who underwent
early appendectomy. The delayed operation was associated with
significantly less overall complications, wound infections, abdomi-
nal/pelvic abscesses, ileus/bowel obstructions, and reoperations.
No significant difference was found in the duration of first
hospitalization, the overall duration of hospital stay, and the
duration of intravenous antibiotics. Overall complications
209
remained significantly less in the conservative treatment group
during sensitivity analysis of studies including only pediatric
patients. Due to the poor-quality data, the authors suggested that
high-quality studies were necessary for a definitive conclusion.
Higher-quality data now exists with the completion of a
prospective, randomized trial comparing appendectomy on pre-
sentation to initial antibiotic therapy and appendectomy 6–8
weeks later.24 Children with a presumed preoperative diagnosis
of perforated appendicitis were included. They randomized 131
children with or without abscess; 64 children in the initial
appendectomy group and 67 in the initial antibiotic followed by
interval appendectomy group. The length of hospitalization was
2 days longer with initial antibiotics followed by interval appen-
dectomy (P ¼ 0.03). The overall adverse event rate substantially
favored early appendectomy with a relative risk of 1.86 associated
with initial antibiotic therapy and delayed appendectomy (95% CI:
1.21–2.87, P ¼ 0.003). Importantly, children who had delayed
appendectomy had higher costs and were more likely to receive a
central line. The results of this trial firmly demonstrate patient
benefits from early laparoscopic appendectomy in children with a
preoperative diagnosis of perforated appendicitis.
Role of irrigation
An abundance of data from several decades failed to demon-
strate a clinical role for irrigation in the face of peritoneal
contamination.25 Despite this lack of compelling data in all the
previous studies investigating the role of irrigation, in a survey of
North American pediatric surgeons published in 2004 only 7% of
the respondents reported using no irrigation.26 Two retrospective
studies comparing irrigation to no irrigation during appendectomy
(mostly laparoscopic) both demonstrated an increase in abscesses
resulting from the use of irrigation, leading both to recommend no
irrigation.27,28
We completed a prospective, randomized trial comparing
normal saline irrigation to suction alone during laparoscopic
appendectomy for perforated appendicitis in children.29 Perfora-
tion was defined as a hole in the appendix or a fecalith in the
abdomen. We had previously shown that using these criteria as
the definition of perforation separated those with post-operative
risk of abscess of approximately 20% (perforated) to children with
an abscess risk under 1% (non-perforated).30
In the irrigation arm, a 1-L bag of sterile normal saline was
attached to the irrigation device. A minimum of 500 mL of saline
was required, with no maximum volume limit. There were 220
patients randomized. At presentation, there were no differences
between the two groups in age, weight, body mass index percen-
tile, gender distribution, duration of symptoms, presenting leuko-
cyte count, or temperature.
The primary outcome variable was the development of an
abdominal abscess, and there was no difference between groups
—19.1% with suction only and 18.3% with irrigation (P ¼ 1.0)
developed an abscess. There was no difference in time to starting
clear liquids, advancement to a regular diet, or discharge. Hospital
charges were the same. There was also no difference in mean
maximum daily temperatures. Additionally, there was no differ-
ence in any aspect of their management, hospital course, or
outcomes. The study demonstrated miniscule effect sizes in either
direction, suggesting that irrigation is unlikely to have an impact
on clinical course during laparoscopic appendectomy.
Abscess on presentation
Patients presenting with a well-defined abscess on imaging
studies are another focus of controversy. An option is initial
210 S.D. St. Peter, C.L. Snyder / Seminars in Pediatric Surgery 25 (2016) 208–211
treatment of the abscess with percutaneous drainage with or
without drain placement, followed by interval appendectomy
when the inflammation has resolved. This algorithm was initially
described over 25 years ago,20 and became an important part of
contemporary practice.31–33 However, as previously mentioned,
improvement in laparoscopic skills and instruments allow the
operation to be done with minimal morbidity. Percutaneous
drainage with interval appendectomy also carries the risk of
complications and employs considerable medical resources. We
randomized 40 patients who presented with a well-formed
abscess to drainage and interval appendectomy versus early
laparoscopic appendectomy at presentation.34 Hospital charges
and overall outcomes were similar in our patients, but we did
not capture outpatient charges. These would of course be higher
for those in the interval appendectomy group receiving home
health care. Quality of life assessment favored early operation,
since patients and families report ongoing stress due to continued
health care needs until the appendix is finally removed.35 Cur-
rently, we approach most abscesses with early primary laparo-
scopic appendectomy, with the possible exception of the patient
who is clinically doing well (e.g., capable of eating and with
minimal discomfort) at presentation. These children are perhaps
more likely to become ill from the operation (“poking the skunk”)
than from drainage.
Operative approach
Traditional open appendectomy is done through a muscle-
splitting right lower quadrant incision. Standard laparoscopic
appendectomy typically involves a camera site at the umbilicus
with two additional working ports in the lower abdomen. The
primary change in the operative approach to appendicitis has been
away from open operation and toward a minimally invasive
approach. Recent changes involve permutations of the minimally
invasive approach, particularly regarding the number of
access sites.
A statewide analysis in California demonstrated a 33% increase
in laparoscopic appendectomies over 3 years prior to 2010.36 We
examined the PHISs database over a 12-year period, from 1999 to
2010, and found an increase in laparoscopic appendectomy from
22% to 91% (P o 0.0001).37 This change in approach was
associated with decrease in complications during this time. The
rapidly changing utility of laparoscopy implies that the traditional
open approach will become a largely historical operation within
the not too distant future.
During the initial experience with laparoscopy for perforated
appendicitis, some authors found a higher post-operative abscess
rate than was reported for open appendectomy.38,39 However, the
more recent experience, including multiple prospective trials,
meta-analyses and large multi-institutional comparative series
clearly documents no difference in abscess risk between the open
and laparoscopic approach.40–46 Laparoscopy has been repeatedly
shown to decrease wound infections. 44,45,47–51 Further, the clinical
importance of port site infections is relatively small. Also, the
laparoscopic operation has been found to reduce the risk of post-
operative adhesive small bowel obstruction.37,52
The most recent debate about the operative approach to
appendicitis involves the use of single incision laparoscopy, where
instruments are placed through the same incision used for the
camera port. There are many variations of the technique including
using stab incisions for instrument placement, using multi-
lumen ports, and dividing the appendix intracorporeally or
extracorporeally.
We randomized 360 patients to either single site or standard
three-port laparoscopic appendectomy for non-perforated appen-
dicitis.53 Our approach for single site generally involved one or two
stab incisions along the side of a 5-mm transumbilical port. Once
the appendix is mobilized, it was exteriorized through the umbil-
icus for resection. The primary outcome variable was surgical site
infection, and no difference was found between groups. The
single-site approach took longer on average. Although the differ-
ence was highly significant, the effect size was only 5 min. There
was no difference in length of stay and both groups were dis-
charged within 24 h. There was no difference in convalesce either.
There have subsequently been many other randomized trials
involving all the described versions of the single-site technique.
The most recent meta-analysis confirms our findings with no
major differences in outcomes, and across the board, the effect
sizes are very small.54 The authors concluded that single incision
laparoscopic appendectomy may not be a better approach for
pediatric patients.
While it seems intuitive that removing the appendix utilizing
three separate small sites or one slightly larger, central site would
not result in major outcome differences, the major purported
advantage to single-site laparoscopic surgery driving its use is
cosmesis. Although almost every report on single-site approaches
document outstanding subjective cosmesis, this is rarely sup-
ported by objective data. After our randomized trial, we recorded
the cosmetic outcomes at a short-term and long-term follow-up
using the Patient Scar Assessment Questionnaire (PSAQ) that has
been validated in adults.55,56 The PSAQ has five subscales, four of
which are validated and used in the scoring. The validated
subscales include appearance, consciousness, satisfaction with
appearance, and satisfaction with symptoms. The single-site
approach produced superior scores at early follow-up (about
6 weeks after the operation). However at 18 months, this differ-
ence largely disappeared and the cosmetic scores approached the
best possible score in both groups. Since the only potential
advantage for the single-site approach is cosmetic, and the long-
term cosmetic outcome is very similar to the three-port approach,
it appears there is little to no objective advantage to single incision
appendectomy. This is not to say the single-site approach is
inferior, but no meaningful comparative data suggest that it should
be offered over three-port appendectomy. Our group now utilizes
the single-site approach selectively in non-obese patients with
non-perforated appendicitis, with a low threshold for additional
port sites.
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