 laparoscopic appendectomy , first performed by semm in 1983 , has become increasingly popular .
the surgical management of complicated pediatric appendicitis ( gangrenous or perforated ) has been more controversial , and the role of laparoscopy in its treatment has not yet been established .
intraabdominal abscess ( iaa ) can form after laparoscopic appendectomy ( la ) , especially in complicated cases and is associated with significant morbidity .
the aim of our study was to establish the incidence of iaa formation in complicated pediatric appendicitis ( cpa ) treated with laparoscopy .
pediatric patients presenting with acute appendicitis were identified from our prospectively collected database . between march 1996 and october 2001 ,
a standard 3-trocar technique is used with two 5-mm trocars and one 12-mm trocar for the introduction of the stapling device ( endogia , united states surgical corporation , norwalk , ct ) .
the appendix is freed , and the mesoappendix is divided between applied clips or staples .
the appendiceal base is divided with the stapling device ; the freed appendix is placed in an endoretrieval bag and removed .
when present , a special effort is made to debride the fibrin peel from the peritoneum .
patients with cpa have a jackson - pratt drain placed in the pelvis and right lower quadrant after completion of the appendectomy ; the drain exits through the suprapubic port site .
after removal of the trocars , the fascia and the skin edges are approximated with absorbable sutures .
postoperative analgesia and perioperative intravenous antibiotics are administered in the same fashion as in open appendectomy . noncomplicated cases received antibiotics only perioperatively , but patients with cpa received antibiotics during their entire hospital stay . an oral diet was resumed usually within 24 hours after admission .
the diagnosis of acute appendicitis in all patients was based on clinical and computed tomography ( ct ) scan findings .
patients with a positive ct scan underwent laparoscopy , and all of them had appendicitis . patients with vague symptoms and negative ct imaging were observed and did not undergo laparoscopy .
thirty - five ( 67% ) male and 17 ( 33% ) female patients underwent surgery .
five of the 52 patients ( 10% ) had cpa . among the patients with cpa were 2 female ( 40% ) and 3 ( 60% ) male patients ( table 1 ) .
one of the 5 ( 20% ) patients with cpa developed postoperative intraabdominal abscess and underwent laparoscopic drainage during the same admission .
the single postoperative abscess occurred early during our initial experience with laparoscopic appendectomy , and it was the first case of cpa performed laparoscopically .
the average operative time for laparoscopic appendectomy has been 60 minutes ( range , 30 to 120 minutes ) and recently 40 minutes . in cases of cpa , the average operative time was 130 minutes ( range , 120 to 200 minutes ) .
at the same time , the average length of stay after laparoscopy in noncomplicated acute appendicitis was one day .
the cost of the laparoscopic surgery was difficult to calculate because of the retrospective nature of our study . in recent cases ,
the specifics of the equipment used were not always available except for the standard stapling device .
all these patients underwent laparoscopic appendectomy plus drainage if the appendix was gangrenous or perforated .
all patients with noncomplicated appendicitis were effectively and definitively treated with laparoscopy , and almost all of them were discharged home within 24 hours .
our findings corroborate previously established knowledge that appendicitis can be safely and effectively treated in children through laparoscopy .
up to 21% of patients presenting with acute appendicitis can have a perforated appendix . in our series , 5 ( 10% ) of the 52 patients presenting with acute appendicitis
all of these 5 patients with cpa were treated with laparoscopy without conversion to open technique .
although the patient underwent an extra laparoscopic procedure , it was well tolerated , and he was discharged home without other complications .
this single complication occurred during the initial learning curve of laparoscopic appendectomy , was the first case of laparoscopic appendectomy performed for cpa at our institution , and was associated with a long operative time . since then , as experience has accumulated , no more complications have occurred after laparoscopic appendectomy for cpa .
. a high degree of suspicion and liberal use of imaging helps in the diagnosis and early treatment of postoperative iaa . in a recent study
, it was suggested that the placement of drains in the right lower quadrant might be beneficial in patients with perforated appendicitis and localized abscess cavities . in that study ,
it has been suggested in the past that laparoscopic appendectomy for cpa in children is not a safe procedure and should be avoided .
our recent findings suggest that laparoscopy can be a reasonable therapeutic alternative to open appendicitis in these complicated cases .
the incidence of postoperative iaa formation after laparoscopy in children with cpa varies anywhere between 5.8% and 41% .
some of these abscesses are treated with antibiotics , but most of them require drainage . in another recent study , comparing laparoscopy to open appendectomy for cpa , no iaa occurred after la .
it has been suggested that visualization of the abdominal cavity seems to be improved with laparoscopy .
the pelvis and the abdominal cavity can be thoroughly irrigated , debrided , and drained .
the surgery is less traumatic , and most patients return to their regular activities sooner . on the other hand , in cases of perforated appendicitis , anatomy can be obscure , and the operative time can be significantly prolonged .
laparoscopy in complicated cases of acute appendicitis can be a challenging and technically demanding procedure that requires more than basic laparoscopic skills .
there is limited tactile sensation , manipulation of inflamed tissues is difficult , and inadvertent injury to adjacent organs is possible .
one should attempt laparoscopy in these complicated cases only after performance of many routine laparoscopic appendectomies .
it can not be overemphasized that one should be prepared to convert early to an open appendectomy should a difficult case of cpa be encountered .
that is especially true when the surgeon is on the initial part of the learning curve .
our data were retrospectively collected , and the numbers are too small to draw safe conclusions . our findings and those of others suggest that laparoscopy might be a safe alternative even for cpa , but properly randomized , prospective studies will answer this question .
complicated appendicitis in children can be effectively treated with laparoscopy by experienced laparoscopic pediatric surgeons .
complicated appendicitis should not be considered a contraindication for laparoscopy , but more solid evidence is necessary before it becomes the standard treatment .
close postoperative follow - up and a high index of suspicion for development of complications is essential .
prospective randomized trials will be necessary to establish the role of laparoscopy in complicated appendicitis in the pediatric population .
 background : complicated appendicitis ( gangrenous or perforated ) has been associated with increased risk for postoperative complications , especially intraabdominal abscess . 
 caution has been advised when attempting laparoscopic appendectomy for complicated appendicitis in children . 
 the objective of our study was to assess the incidence of intraabdominal abscess formation after laparoscopic appendectomy in pediatric patients presenting with complicated appendicitis.methods:this is a retrospective review of 52 pediatric patients presenting with acute appendicitis at a single teaching institution who underwent laparoscopic appendectomy by a single surgeon . 
 all laparoscopic procedures were completed without conversion . 
 treatment complications and outcomes were recorded for all cases.results:five of the 52 patients ( 10% ) had complicated appendicitis . 
 one of the 5 patients ( 20% ) developed intraabdominal abscess postoperatively and underwent laparoscopic drainage during the same admission . 
 no other complications were noted . 
 none of these patients was readmitted for wound infections or intraabdominal abscesses . 
 the single postoperative abscess occurred early during our initial experience with laparoscopic appendectomy.conclusion:laparoscopic appendectomy seems to be a safe alternative for the treatment of complicated appendicitis in children . 
 caution is recommended during the initial experience of surgeons with this procedure , because the complication rate seems to be higher during the learning curve . 
 close postoperative follow - up and a high index of suspicion for development of complications is recommended . 
 as surgeons ' experience accumulates , the safety of the procedure seems to increase . a prospective , randomized trial is recommended to establish the role of laparoscopy in complicated appendicitis in the pediatric population . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION