Acute appendicitis is a common surgical emergency encountered by paediatric surgeons, with an increase in incidence with age. The lifetime risk of developing acute appendicitis is around 7% . In the infantile group, it is 1 in 10 000 to approximately 20 per 10 000 in children under 14 years . Less than 5% of appendicitis cases get diagnosed before the age of 5 years . Our average age was lower at 9 years. There was a male (56%) predominance over females in our study group, which is in keeping with international data . There was no statistical significance in the gender and age distribution in the “D” and “ND” groups. Most of our patients were of African race, which is keeping with the race distribution of our hospital drainage area. There was no statistical difference in the race distribution between the “D” and “ND” groups. Even though acute appendicitis is one of the most encountered surgical pathologies, many of the management aspects remain controversial, from simple to complicated appendicitis.
Appendicitis has a diverse clinical presentation from simple to complicated appendicitis with septic shock. A delay in the correct diagnosis is the reason that pre-schooler with appendicitis present with more complicated appendicitis when compared to their older counter parts [9, 10]. Patient geography and socioeconomics also play an important role, especially in our setting, where availability of patient transport is limited and often far away from a centre that offers paediatric surgical services. All the above factors contribute to a delay in health-seeking, accurate diagnosis and appropriate treatment. As a result, over 80% of our patients present with complicated appendicitis, which is significantly higher than the international figure of 30% .
With the advancement of laparoscopy equipment and techniques over the years, LA has become the technique of choice, even in complicated appendicitis [3, 5, 12]. In simple appendicitis, the appendectomy can be done with ease and little controversy or debate surrounding the technique.
In complicated appendicitis, various controversies and debates surround the optimal operative technique. First is the definition of complicated appendicitis. Most surgeons agree that an appendicitis associated with a perforation, faecolith, gangrene or abscess is complicated .
Complicated appendicitis is associated with higher rates of post operative complications. The most common complications include IAC, wound sepsis and prolonged post-operative ileus. More than 80% of our patients present with complicated appendicitis, of which 91% are managed with LA. This is contrast with developed countries’ data where most patients present with simple appendicitis. In our practice, laparotomy is reserved for patients who are severely ill, hemodynamically unstable and often in septic shock. With post-operative IAC being one the most common complications, various controversial strategies exist to limiting this complication. The most common strategies include peritoneal irrigation and post-operative peritoneal drain.
The use of peritoneal irrigation stems from an old principle of “dilution is the solution to pollution”. This, however, has been challenged by St Peter et al. and a more recent meta-analysis, showing no benefit in preventing post-operative IAC in adults and children [13, 14]. In a randomised prospective study conducted at our institution on adults, potential harm was indicated with irrigation . Based on this evidence, “suction only” was performed in all the patients in the study group.
The use of surgical drains dates to Hippocrates (460–377BC) for the treatment of empyema . The rationale for draining residual fluid is that it decreases the volume of infected fluid, thereby decreasing the probability of a post-operative collection formation. Post-operative peritoneal drain placement is still frequently used for various surgical pathologies which are institution- and surgeon-dependent. Its role in complicated appendicitis is being challenged. There is limited international randomised prospective data supporting the use of drains, even more so in children. During the 19th century, it was highlighted that drains might have associated complications. There are no prospective studies supporting the use of post operative peritoneal drains. Multiple studies have since then highlighted these complications including wound sepsis, longer hospital stay, longer antibiotic and analgesia use [17–20]. Therefor the data suggest no difference in outcome, but a potential risk associated with the use of peritoneal drains.
From this study, it appears that the drain did not make a statistical difference in patient outcomes. The data show that we have a complication rate of 26% of patients undergoing LA for complicated appendicitis. Of our complications, 89% were intrabdominal collections, where 66% of them required reoperations. Four (4) relook laparoscopies as well as 1 relook laparotomy were done. One (1) intra-abdominal collection was treated conservatively with culture-directed antibiotics. Two-thirds of the complications arose from the “ND” group. The incidence of complications in the “ND” group was 35% compared to 18% in the “D” group. Theatre time was prolonged in the “D’’ group, which was most likely due to the additional procedural step of inserting a peritoneal drain.
It is evident that the amount of contamination plays a more important role in determining the probability of developing complications, as 38% of patients with generalised pus developed complications compared to 7% of patients with localised pus. It, however, did not reach statistical significance but could indicate a clinical significance.