Transumbilical laparoscopically assisted appendectomy in children: high-tech low-budget surgery

Two different laparoscopic appendectomy (LA) techniques, one performed with staplers (LAS) and the other using loops (LAL), were compared with transumbilical laparoscopically assisted appendectomy (TULAA).

A total of 72 children, 55 with a diagnosis of uncomplicated acute appendicitis and 17 with recurrent right lower abdominal pain, underwent operation during the period 2003-2006. The procedures used were: 34 LAS, 9 LAL, and 29 TULAA. Measured outcomes were operative time, postoperative complications, need for rescue analgesics, length of hospital stay, and procedure cost reflected by supplies used. The staplers, endoloops, clips, and sutures used to manage appendectomy were listed at current prices, summarized as number consumed per case, and compared. Data were analyzed by Fisher's exact test and the Mann-Whitney U-test where appropriate. Statistical significance was determined as p < 0.05.

Average price of materials used was 113.5 USD for LAS, 91 USD for LAL, and 14 USD for TULAA. Wound infections were recorded in two patients (4.6%) in the LA group and in four patients (13.7%) in the TULAA group (p = 0.17). One patient in the LAL group developed an abdominal abscess that was managed conservatively. Median operating time was 39 (24-66) min in the LA group versus 33 (25-55) min in the TULAA group (p < 0.05). Rescue analgesia was administered in 19/43 (44%) of LA patients and 9/29 (31%) of TULAA patients (p = 0.19). The length of hospital stay was 3.1 days for LA patients and 3.0 days for TULAA patients (p = 0.43). Two TULAA procedures (6.4%) were finished with additional port/s.

In this study, the cost of TULAA is 7.8 times lower than the cost of LA, 8.1 times lower than LAS, and 6.5 times lower than LAL. Higher cost of laparoscopy is solely attributable to the purchase price of the supplies used. Overall postoperative morbidity, the incidence of wound infection, the length of hospitalization, and the need for rescue analgesia did not show a statistical difference in comparing LA/TULAA. Operative time was shorter in the TULAA group. In terms of limited resources, TULAA could be the most appropriate minimally invasive technique for appendectomy in children.