laparoscopic surgery has gained widespread acceptance in a variety of procedures , ranging from gastric fundoplication to cholecystectomy .
although laparoscopic appendectomy ( la ) is more expensive than is open appendectomy ( oa ) due to the costs of the disposable equipment , and can be more technically challenging in children , the overall cost of the operation has been shown to be similar to that of open appendectomy .
the real cost savings of la are due to the shorter postoperative length of hospital stay ( los ) and the infrequent postoperative complications . the ultimate reduction in postoperative hospital costs to make la
most cost - effective would be to perform the procedure as same - day surgery or so - called fast - track surgery . because it has been our observation that many children can be discharged within 24 hours after a laparoscopic appendectomy , we reviewed our records to determine its feasibility .
a retrospective chart review was performed on 79 children who underwent a laparoscopic operation for the suspected diagnosis of acute appendicitis over a 3-year period between july 1997 and july 2000 .
prior to the operation , if the diagnosis of acute appendicitis was unclear , the patients were evaluated with further laboratory and diagnostic testing , which included an abdominal computed tomography scan or ultrasound evaluation , or both of these , in select patients .
laboratory information included white blood count and urinalysis , and depending on the circumstances , might also include a beta human chorionic gonadotropin and rapid streptococcal screen , as well as other tests as indicated .
all patients underwent the operation while under general anesthesia , and all received a single dose of a broad - spectrum antibiotic preoperatively for wound infection prophylaxis .
the standard laparoscopic operative technique was used , with either a 5-mm or 12-mm port introduced at the umbilicus after inducing pneumoperitoneum with carbon dioxide . a 0- or 30-degree laparoscopic telescope
was then introduced through this port , and the abdominal and pelvic cavities were directly visualized with the laparoscope to inspect for other possible pathologies .
next , two 5-mm ports were introduced under direct vision , one in the suprapubic region or the left lower quadrant and another in the right iliac fossa or in the right upper quadrant .
the appendix was identified and grasped by its distal end to fully expose the entire organ and its attached structures .
the appendiceal artery was isolated , ligated , and divided or cauterized . at that point ,
a staple line was fired across the base of the appendix by using an endoscopic stapler , or endoscopic loops were used to isolate the base of the appendix , and it was divided .
if the appendix was particularly enlarged or friable , it was removed from the abdomen through the umbilical incision with the use of an endoscopic bag .
all ports were removed under direct visualization , and the fascia was reapproximated to prevent future incisional hernia occurrences .
if any evidence of localized or generalized peritonitis was visualized during the operation , patients were sent home on oral antibiotics , usually a 5-day course of amoxicillin plus clavulanate .
if the appendix was perforated prior to removal , patients were placed on triple antibiotic coverage intravenously , which included ampicillin , gentamicin , and clindamycin for 5 days while in the hospital .
if any evidence of abscess formation or peritoneal soilage was noted , the abdominal cavity was vigorously lavaged with normal saline .
postoperative analgesia was obtained usually with ketorolac tromethamine and acetaminophen . to be discharged home , patients had to be tolerating oral liquids , be afebrile , and free of nausea and vomiting .
seventy - nine children ( 44 boys and 35 girls ) between 2 to 17 years of age ( mean , 11 years ) underwent la . in 4 ( 5% ) children , all with perforated appendicitis , the la was converted to an open appendectomy , secondary to technical difficulties in completing the operation laparoscopically . at operation , 51 ( 64.5% )
had acute appendicitis , 22 ( 27.8% ) had perforated appendicitis , 4 ( 5% ) had ruptured ovarian cysts , and 2 ( 2.5% ) had no obvious pathology .
total los for all 79 patients was a median of 58 hours , and median postoperative los was 35 hours .
complications included wound infection , 2 ( 2.5% ) ; abdominal abscess , 4 ( 5% ) ; drug rash , 2 ; and epididymoorchitis , 1 .
all but one complication ( drug rash , 1 ) occurred in the perforated group . in the 57 ( 72% ) children without perforated appendicitis , the total los was a median of 42 hours , while median postoperative los was only 28 hours .
thirty - two ( 56% ) of the children without perforated appendicitis went home in 24 hours following la .
no significant morbidity occurred in the nonperforated group ( drug rash , 1 ; fever > 24 hrs , 3 ) ; and no readmissions or reoperations were necessary on follow - up .
although most appendectomies , especially in children , are not done laparoscopically , many studies have shown that laparoscopic appendectomy ( la ) is at least as good as open appendectomy ( oa ) , with several benefits , including less postoperative pain and shorter lengths of stay ( los ) .
the disadvantages of la , which include increased operative time and increased cost of equipment , are easily offset by the decreased postoperative recovery time and the apparent decreased incidence of postoperative complications . additionally , it has been suggested that with increasing operative experience the operative time required for la will decrease significantly .
lastly , it has been suggested that even if patients are not discharged from the hospital soon enough after la to make a significant difference between the cost of la versus oa , la has a much shorter recovery time and returns patients to a productive lifestyle sooner , thus justifying la .
although most children are not working , the care - givers or parents can return to work sooner , when their child goes back to school .
adult series have documented a decreased incidence of postoperative complications and a decreased incidence of wound infection after la .
, in our series , 2 patients had wound infection and 4 patients developed abscesses , which is a similar complication rate to that in other series . in all instances , these complications arose in the perforated group .
although perforation was at first considered a contraindication for la , it has now been utilized successfully in the management of acute appendicitis as well as perforated appendicitis .
it has been suggested that thorough lavage of the abdominal cavity after appendectomy can help to decrease the incidence of abscess formation , and this is a practice that we utilize and is facilitated by the use of laparoscopy .
certainly , the laparoscopic approach facilitates the complete irrigation of the abdominal cavity and identification of all loculated collections .
an additional benefit of laparoscopic surgery is that it leads to greater accuracy of diagnosis , especially in teenage female patients with suspected appendicitis . in cases such as obesity and mental retardation , the diagnosis of appendicitis
laparoscopy can be used to delineate the source of abdominal pain when the diagnosis of appendicitis is suspected but not certain . in 4 of our patients with the presumed diagnosis of appendicitis ,
intraoperative visualization revealed normal appendices , and ruptured ovarian cysts were identified as the source of their pain . obviously , all four patients were female .
others have also found an increased preponderance of unclear diagnoses in the female population . in our patients ,
the appendix was always removed at the time of operation , despite the fact that occasionally ( in 4 patients ) the gross appearance of the appendix was normal . in the past
, it has been unclear whether it would be of any benefit to the patient to remove a healthy organ , but it has been argued that with advances in laparoscopy and its proven benefit , there is no justification for leaving a visually normal appendix in place . additionally , microscopic evidence of early appendicitis is occasionally seen . in our study , it was noted that 2 visually normal appendices were found to have microscopic evidence of appendicitis .
outpatient surgery has been widely accepted in a variety of procedures , and many are done laparoscopically . the idea that an appendectomy can be done in the pediatric patient as outpatient surgery is not a new one . in 1993 ,
ramesh and gallard suggested early discharge after open appendectomy , even within 24 hours . in another study ,
velhote et al also found that most children could be sent home within 24 hours after appendectomy . in that study
, the appendectomy was performed through a standard gridiron incision of 2 cm or less .
brosseuk and bathe suggested laparoscopic appendectomy as outpatient surgery in 1999 , and they advocated early discharge in both perforated and simple appendicitis .
the fact that all major complications in our study occurred in perforated cases would argue against these cases being performed as same - day surgery , although others have disputed this approach . in our treatment protocol
, perforated appendicitis would not be placed on a fast - track surgery list because these patients usually receive inpatient intravenous antibiotic therapy for 72 hours .
we suggest that laparoscopic appendectomy is a safe and effective treatment in the pediatric population , and that in cases of nonperforated appendicitis this may be performed as a fast - track or short - stay procedure .
we believe that this not only is more convenient for patients and their families , but it also adds to the overall cost - effectiveness of laparoscopic appendectomy .
our findings are based on a retrospective review of our charts over the past 3 years , and this is an obvious criticism of the study . in no instance was it prospectively decided that the child would be discharged within 24 hours .
in fact , a small number of children met exclusion criteria due to delays in discharge not related to their medical condition .
we made our best attempt to identify when the order was given for the child to be released rather than the actual time that the child left the hospital .
however , the documentation was occasionally unclear , and these children were excluded if it could not be ascertained exactly when the order was given or when they left the hospital .
we believe that in cases of simple appendicitis , there is no reason not to dismiss a child within 24 hours if the above - mentioned discharge criteria are met .
we anticipate that in the future , a greater percentage of our pediatric patients will be discharged within 24 hours , and we feel that in cases of simple appendicitis , laparoscopic appendectomy can be done as fast - track or short - stay surgery .
it may be safely performed as fast - track or same - day surgery , in select children without perforated appendicitis , with a postoperative stay of 24 hours in the majority of such patients .
 background : laparoscopic surgery has reduced the length of hospital stay for common operations like cholecystectomy , gastric fundoplication , and appendectomy . 
 we have noticed a reduction in length of hospital stay for children undergoing laparoscopic appendectomy . 
 we , therefore , looked at our data to assess whether laparoscopic appendectomy in children could be performed as fast - track or same - day surgery ( 24-hour postoperative stay).methods : we performed a retrospective review of the records of all children who underwent laparoscopic appendectomy for suspected appendicitis during a 3-year period ( 7/97 to 7/00).results : laparoscopic appendectomy was performed in 79 children ( 44 boys and 35 girls ) , between 2 to 17 years of age ( mean , 11 years ) . in 4 ( 5% ) children with perforated appendicitis 
 , the laparoscopic appendectomy was converted to an open appendectomy . at operation , 51 ( 64.5% ) had acute appendicitis , 22 ( 27.8% ) had perforated appendicitis , 4 ( 5% ) had ruptured ovarian cysts , and 2 ( 2.5% ) had no pathology . 
 the median operative time was 54 minutes . 
 total length of stay for all 79 patients was a median of 58 hours , and median postoperative los was 35 hours . 
 complications included wound infection ( 2 ) , abdominal abscess ( 4 ) , drug rash ( 2 ) , and epididymo - orchitis ( 1 ) . in 57 ( 72% ) children without perforated appendicitis , the total length of hospital stay was a median of 42 hours , while median postoperative length of stay was only 28 hours . 
 thirty - two ( 56% ) children went home in < 24 hours following laparoscopic appendectomy . 
 no significant morbidity was noted in the nonperforated group ( drug rash,1 ; fever > 24 hrs , 3 ) ; and no readmissions or reoperations were necessary on follow-up.conclusion:laparoscopic appendectomy is safe and effective for treating children with appendicitis . 
 laparoscopic appendectomy may be safely performed as fast - track or same - day surgery , in select children without perforated appendicitis , with a postoperative stay of 24 hours . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION