Laparoscopy for Acute Abdominal Conditions

50th Meeting of the Brazilian Association of Pediatric Surgeons

George W. Holcomb, III, M.D., MBA

Surgeon-in-Chief

Children’s Mercy Hospital

Kansas City, Missouri

Acute Abdominal Conditions• Abdominal trauma

• Small bowel obstruction

• Intestinal perforation – free air

• Ovarian torsion

• Volvulus

• Intussusception

and . . . .

Acute Appendicitis

Laparoscopy -TraumaBackground

• Most intra-abdominal (and intra-thoracic) injuries can be managed non-operatively

• Absolute indications for operation: Shock from intra-abdominal bleeding Pneumoperitoneum Contrast extravasation

• Selective indications for operation Thickened bowel loops Mesenteric infiltration Unexplained free fluid Violation peritoneum on local exploration for penetrating trauma

Laparoscopy - TraumaBackground

• FAST & DPL not as helpful in deciding management in children

• Equivocal findings for an injury are sometimes found on CT scan

When To Use Laparoscopy in Trauma

• Hemodynamically stable patient

• Blunt trauma Free fluid not from solid

organ injury Persistent abdominal

pain/tenderness

• Penetrating trauma Peritoneal violation?

Algorithm

Gaines BA, et al: The role of laparoscopy in pediatric trauma. Sem Pediatr Surg 19:300-303, 2010

Minimally Invasive Surgery for Pediatric Trauma – A Multi-Center Review

1. The Children’s Mercy Hospital, Kansas City, MO2. Emory University, Children’s Healthcare of Atlanta at Egleston, Atlanta, GA

3. Children’s Medical Center, Dallas, TX4. Children’s National Medical Center, Washington, DC

5. Children’s Hospital of Wisconsin, Milwaukee, WI6. Akron Children’s Hospital, Akron, OH

2014 IPEG/BAPS Meeting

Hanna Alemayehu, MD1 Matthew Clifton, MD2; Matthew Santore, MD2; Diana Diesen, MD3; Timothy Kane, MD4; Mikael Petrosyan, MD4; Ashanti Franklin, MD4; Dave Lal, MD, MPH5; Todd Ponsky, MD6; Margaret Nalugo, MPH6; George W. Holcomb III, MD, MBA1; Shawn D. St. Peter, MD1

Operative Interventions

• 205 total MIS procedures 187 patients (94%) – laparoscopy 8 patients (4%) – thoracoscopy 5 patients (2%) – both

• 36% converted to open

Indications for LaparoscopyIndication for Operation Number Completed

LaparoscopicallyNumber

Converted to Laparotomy

Total Number

Conversion Rate

Penetrating Injury 45 17 62 27%

Peritonitis 7 24 31 77%

Free fluid with abdominal pain 17 10 27 37%

Pneumoperitoneum 9 9 18 50%

Other 15 3 18 16%

Worsening abdominal pain with seatbelt sign

8 3 11 27%

Imaging suspicious for hollow viscus injury

5 6 11 55%

Imaging suspicious for pancreatic duct injury

7 0 7 0%

Equivocal wound exploration 6 0 6 0%

Continued transfusion requirement

1 0 1 0%

Conclusion

• Overall MIS was successful in excluding or diagnosing injury, and completing therapeutic intervention in 65% of cases

• Laparoscopy and thoracoscopy can be performed safely and effectively for both diagnostic and therapeutic purposes in stable pediatric trauma patients

Pediatr Surg Int. 2014 Sep 21(epub ahead of print)

Laparoscopic Pancreatic Resection forTrauma

• 2000 – 2012• 13 US pediatric trauma centers• 167 patients

95 managed nonoperatively 57 underwent resection

80% laparoscopically since 2008

Pediatr Surg Int. 2014 Sep 21(epub ahead of print)

Laparoscopic TraumaticDiaphragmatic Hernia Repair

Laparoscopic TraumaticDiaphragmatic Hernia Repair

Laparoscopy forPossible Traumatic Bowel Injury

Laparoscopy for Possible Traumatic Bowel Injury

Laparoscopy forPenetrating Traumatic Injury

Conclusions

• Laparoscopy can be a useful tool for diagnosis of a traumatic injury when the diagnosis is not clear

• Some traumatic injuries can be managed entirely laparoscopically or with the use of a small umbilical incision

• Patient must be hemodynamically stable if the laparoscopic approach is utilized

Laparoscopy for Small Bowel Obstruction

• Jan 01 – Dec 08• 34 patients

Mean age 8.1 yrs ± 5.9 Adhesions – 74% Conversion – 11 pts

Inadeq working space Volvulus Could not identify source Enterotomy

Our protocol: Initial laparoscopic management unless contraindications present

Laparoscopy for Small Bowel Obstruction

Intestinal Perforation – Free Air

• Patient hemodynamically stable• Reason for perforation unclear• Allows directed open incision (if necessary)

Laparoscopy for Ovarian Torsion

Emphasis Now On Conservation Of Ovarian Tissue

• Long-term results of conservative management of adnexal torsion in children J. Pediatric Surgery (2005) 40: 704– 708

• Ovarian torsion in children: Management and outcomes J. Pediatric Surgery (2013) 48: 1946–1953

• Predominant etiology of adnexal torsion and ovarian outcome after detorsion in premenarchal girls Eur. J. Pediatric Surgery (2010) 20: 298 – 301

Laparoscopy for Malrotation - Volvulus

• Hemodynamically stable patient

• Difficult to reduce volvulus in an infant (not enough working space)

• Laparoscopy very good for pt with malrotation but no volvulus

• 1996 – 2009

• 284 Ladd procedures Open – 241 Laparoscopic - 43

• Laparoscopic – 33% conversion – almost all

due to volvulus

• Recurrent volvulus – 6 pts (2.4%) - all s/p open Ladd procedure

Laparoscopy for Intussusception

• Hemodynamically stable infant

• Our usual initial approach

• Convert if unsuccessful

• 5 mm atraumatic clamps position across width of bowel

• 1998 – 2008

• 22 pts (2.9 yrs, mean) 19 ileocolic 3 small bowel

• 20 pts successfully managed laparoscopically or via extending umbilical incision ( 9 pts 7 bowel resections)

• 2 required RLQ laparotomy

Acute Appendicitis

1. When do we operate?

2. How do we define perforation?

3. What is the incidence of a postoperative abscess?

4. Should we irrigate the abdomen?

5. Is there an advantage to a single umbilical laparoscopic approach?

1. When to operate?Current Practice at CMH

• Patients identified with appendicitis are booked for laparoscopic appendectomy• All receive a dose of rocephin (50mg/kg) and flagyl

(30mg/kg)

• This antibiotic regimen was shown to be most cost effective in PRT

• If patients present at night, the operations are scheduled for the ‘surgeon of the week’ the next day (8 am or 1 pm start)

• Appendectomies rarely occur after 10 PM at night

Non-Operative Mgmt• Non-operative management with antibiotics for

both acute and perforated appendicitis in adults is successful as primary, definitive therapy in up to 70% of patients.

• About 20-30% will fail antibiotic management and will need an operation

• Appendectomy is now probably considered the gold standard of treatment options, but unclear if this will change in the next 10 years.

Operation At Presentation Versus The Following Day

Yardeni D, Hirschl RB, Drongowski RA, et al: Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J Pediatr Surg 39:464–469, 2004.

• Retrospective comparison in children (Level 3 study) between operation < 6 hrs after presentation or the following day

• 126 patients (38 early vs 88 late)

• No differences in operating time, perforation rate, or complications

• The literature is replete with retrospective studies regarding perforated appendicitis

• All of these studies fail to strictly define perforation

Dependent on surgeon’s definition

“Gangrenous”, “suppurative”, “perforated”

• Therefore, the conclusions from these retrospective reports must be approached cautiously

2. How do we define perforated appendicitis?

J Pediatr Surg 43:2242-2245, 2008

Visible appendicolithHole in appendix

Definition of Perforation Used in Prospective Randomized Trial

3. What is the incidence of postoperative abscess?

• Acute, non-perforated appendicitis 609 pts (Apr 03 – Nov 06) 3 postop abscesses (0.49%)

• Perforated appendictis 20%

4. Should we irrigate and suction the abdominal cavity for perforated appendicitis?

• Perforated appendicitis: hole in appendix or fecalith in abdomen

• Minimum irrigation 500 cc saline

ResultsPatient Demographics

No Irrigation (n = 110) P Value

Age (years)

Weight (kg)

BMI (%tile)

Gender (% male)

9.7 +/- 3.6

41.2 +/- 19.8

65.0 +/- 32.3

59.1%

10.4 +/- 3.8

41.5 +/- 18.8

60.7 +/- 31.9

52.7%

0.17

0.92

0.36

0.89

Irrigation (n = 110)

ASA 2012Ann Surg 256:581-585, 2012

ResultsOutcomes

No Irrigation (n = 110)

Abscess (%)

Op Time (mins)

Initial PO’s (days)

Reg Diet (hrs)

Narcotic Doses

Days of Stay

Charges ($K)

P Value

19.1%

38.7 +/- 14.9

2.6 +/- 1.5

3.4 +/- 1.7

11.4 +/- 5.4

5.5 +/- 3.0

48.1 +/- 20.1

18.3%

42.8 +/- 16.7

2.5 +/- 1.3

3.5 +/- 1.5

11.6 +/- 6.3

5.4 +/- 2.7

48.1 +/- 18.2

1.0

0.06

0.70

0.63

0.76

0.93

0.97

Irrigation (n = 110)

ASA 2012Ann Surg 256:581-585, 2012

Conclusions

There is no advantage to irrigation of the

peritoneal cavity over suction alone during

laparoscopic appendectomy for perforated

appendicitis

ASA 2012Ann Surg 256:581-585, 2012

5. Is a single umbilical laparoscopic approach advantageous?

Prospective Randomized Trial

• 360 total patients• Acute non-perforated appendicitis• August 09 – November 10• Primary outcome variable – postoperative wound

infection• Standardized pre and postoperative management• Quality of life surveys at 6 weeks and 6 months

Single Umbilical Incision vs 3-PortLaparoscopic Appendectomy

ASA 2011Ann Surg 254:586-590, 2012

Patient Characteristics at Operation

Single Incision (N=180)

3-Port (N=180)

P-value

Age (yrs) 11.05 ± 3.47 11.04 ± 3.41 0.98

Weight (kg) 42.7 ± 18.5 42.5 ± 17.4 0.90

Gender (% male) 54.4% 51.1% 0.53

Leukocyte count 14.7 ± 5.2 14.6 ± 5.4 0.89

ASA 2011Ann Surg 254:586-590, 2012

Outcome Data

Single Incision (N=180)

3-Port (N=180)

P-value

Wound Infection 3.3% 1.7% 0.50

Operative Time (mins) 35.2 ± 14.5 29.8 ± 11.6 <0.001

Postoperative Length of Stay (hours) 22.7 ± 6.2 22.2 ± 6.8 0.44

Hospital Charges ($) 17.6K ± 4.0K 16.5 ± 3.8K 0.005

ASA 2011Ann Surg 254:586-590, 2012

Other OutcomesSingle Site (N=180)

3-Port (N=180) P-

ValueSurgical Difficulty (1 – Easy to 5 – Difficult)

2.3 +/- 1.4 1.7 +/- 1.0 < 0.001

Abscess 0.0% 0.6% 0.99Time to Liquid Diet (Hours)

4.1 +/- 3.7 3.7 +/- 3.1 0.25

Time to Regular Diet (Hours)

7.2 +/- 5.1 6.9 +/- 5.2 0.48

Total Doses of Analgesics

9.6 +/- 4.9 8.5 +/- 4.3 0.04

ASA 2011Ann Surg 254:586-590, 2012

QUESTIONS

www.cmhclinicaltrials.com

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