This document discusses the use of laparoscopy to manage various acute abdominal conditions in children, including trauma, small bowel obstruction, intestinal perforation, ovarian torsion, volvulus, and intussusception. It also discusses the use of laparoscopy for acute appendicitis. Key points include that laparoscopy can successfully diagnose and treat many traumatic injuries and allow for directed open incisions if needed. It is also useful for small bowel obstructions, especially to identify the source, and for evaluating possible bowel injuries or free air. Laparoscopy may help conserve ovarian tissue in torsion cases. It can also be used for malrotation/volvulus cases if the patient is stable and reduce intussusceptions.

1. 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

2. Acute Abdominal Conditions
• Abdominal trauma
• Small bowel obstruction
• Intestinal perforation – free air
• Ovarian torsion
• Volvulus
• Intussusception
and . . . .

3. Acute Appendicitis

4. Laparoscopy -Trauma
Background
• 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

5. Laparoscopy - Trauma
Background
• FAST & DPL not as helpful in deciding
management in children
• Equivocal findings for an injury are
sometimes found on CT scan

6. 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?

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

8. Minimally Invasive Surgery for Pediatric
Trauma – A Multi-Center Review
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
1. The Children’s Mercy Hospital, Kansas City, MO
2. Emory University, Children’s Healthcare of Atlanta at Egleston, Atlanta, GA
3. Children’s Medical Center, Dallas, TX
4. Children’s National Medical Center, Washington, DC
5. Children’s Hospital of Wisconsin, Milwaukee, WI
6. Akron Children’s Hospital, Akron, OH
2014 IPEG/BAPS Meeting

9. Operative Interventions
• 205 total MIS procedures
 187 patients (94%) – laparoscopy
 8 patients (4%) – thoracoscopy
 5 patients (2%) – both
• 36% converted to open

10. Indications for Laparoscopy
Indication for Operation Number Completed
Laparoscopically
Number
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
8 3 11 27%
seatbelt sign
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
1 0 1 0%
requirement

11. 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

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

13. 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)

14. Laparoscopic Traumatic
Diaphragmatic Hernia Repair

15. Laparoscopic Traumatic
Diaphragmatic Hernia Repair

16. Laparoscopy for
Possible Traumatic Bowel Injury

17. Laparoscopy for Possible Traumatic
Bowel Injury

18. Laparoscopy for
Penetrating Traumatic Injury

19. 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

21. 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

22. Laparoscopy for Small Bowel
Obstruction

23. Intestinal Perforation – Free Air
• Patient hemodynamically stable
• Reason for perforation unclear
• Allows directed open incision (if necessary)

24. Laparoscopy for Ovarian Torsion

25. 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

26. 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

27. • 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

28. Laparoscopy for Intussusception
• Hemodynamically stable
infant
• Our usual initial approach
• Convert if unsuccessful
• 5 mm atraumatic clamps
position across width of
bowel

29. • 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

30. 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?

31. 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

32. 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.

33. 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

34. 2. How do we define
perforated appendicitis?
• 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

35. J Pediatr Surg 43:2242-2245, 2008

36. Definition of Perforation Used in
Prospective Randomized Trial
Hole in appendix Visible appendicolith

37. 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%

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

39. • Perforated appendicitis: hole in appendix or fecalith
in abdomen
• Minimum irrigation 500 cc saline

40. Results
Patient 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 2012
Ann Surg 256:581-585, 2012

41. Results
Outcomes
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 2012
Ann Surg 256:581-585, 2012

42. Conclusions
There is no advantage to irrigation of the
peritoneal cavity over suction alone during
laparoscopic appendectomy for perforated
appendicitis
ASA 2012
Ann Surg 256:581-585, 2012

43. 5. Is a single umbilical laparoscopic
approach advantageous?

44. Prospective Randomized Trial
Single Umbilical Incision vs 3-Port
Laparoscopic Appendectomy
• 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
ASA 2011
Ann Surg 254:586-590, 2012

45. 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 2011
Ann Surg 254:586-590, 2012

46. 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 2011
Ann Surg 254:586-590, 2012

47. Other Outcomes
Single Site
(N=180)
3-Port
(N=180) P-Value
Surgical Difficulty
(1 – Easy to 5 –
Difficult)
2.3 +/- 1.4 1.7 +/- 1.0 < 0.001
Abscess 0.0% 0.6% 0.99
Time to Liquid Diet
4.1 +/- 3.7 3.7 +/- 3.1 0.25
(Hours)
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 2011
Ann Surg 254:586-590, 2012

49. QUESTIONS
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