Laparoscopic-Assisted Appendectomy in Children: The Two-Trocar Technique

Dear Sirs,

Dr. Valioulis et al presented an elegant two-trocar laparoscopic-assisted method to optimise appendectomy in children. Having first used a videoscope introduced through a 5-mm umbilical port to inspect the abdomen, they reinserted the scope through another 5-mm cannula in the suprapubic region to visualise the appendix while it was being seized by a 5-mm endograsper and exteriorised through the umbilical incision. A conventional appendectomy was accomplished.

Fig. [1] of the original article depicts the delivery of an appendix through an umbilical wound that has been stretched by two retractors to more than half of the size of the operator's thumbs (having allowed for oblique projection). Your readers might be quick to point out that a 7- or 10-mm operative telescope with an instrument channel could have been eased through this wound and could have effected exteriorisation of the appendix, thereby sparing the patient a suprapubic 5-mm wound. Besides, the contaminated organ could have been withdrawn through these larger cannulae. Indeed, both of the two contemporary series of umbilical one-trocar laparoscopic-assisted appendectomies reported lower wound infection rates compared to that of the authors (0 % and 0.5 % vs. 2.6 %) ([1], [2]).

Fig. 1 Schema of an optimal approach proposed for paediatric appendicitis (less suitable for small babies).

It is worth noting that the authors were just as quick to state from the outset that the videoscope placed in the suprapubic port was used primarily for improving visualisation of the appendix, especially when the latter was in the retrocaecal or pelvic position. Undeniably, a videoscope passed through a suprapubic port instead of an umbilical port does afford better visualisation of the appendix underneath the caecum, and the described technique could have facilitated and expedited their appendectomies. However, contrary to our expectations, their mean operative time was longer and their success rate (in terms of completion without added trocars) was lower than that reported in a large series of one-trocar laparoscopic-assisted appendectomies from their fellow countrymen (19 min vs. 15 min, and 76.3 % vs. 92 %, respectively) ([2]). The authors contended that the cited series enrolled more uncomplicated cases, whereas 23.6 % of their patients were peritonitis cases. One may argue then “why not use the more expeditious one-trocar technique for the uncomplicated cases and reserve the two-trocar technique for the more difficult ones requiring better visualisation?”

As a corollary, an optimal protocol for managing paediatric appendicitis emerges incorporating the brilliant work of all the aforementioned authors (Fig. [1]). Preliminary experience with this individualised approach has been very encouraging. Finally, it cannot be over-emphasised that conversion to more ports is not at variance with “success” but rather should be regarded as sound judgement in the best interests of the individual patient.

References

• 1 Esposito C. One-trocar appendectomy in pediatric surgery.  Surg Endosc. 1998;  12 177-178
• 2 Valla J S, Ordorica-Flores R M, Steyaert H, Merrot T, Bartels A M, Breaud J, Ginier C, Cheli M. Umbilical one-puncture laparoscopic assisted appendectomy in children.  Surg Endosc. 1999;  13 83-85