Transumbilical Laparoscopic-Assisted Appendectomy Without Pneumoperitoneum in Children: Feasibility and Outcomes From...

Transumbilical laparoscopic-assisted appendectomy (TULAA) is a minimally invasive technique for pediatric acute appendicitis. While most TULAA procedures utilize pneumoperitoneum, we adopted a modified technique involving mechanical elevation of the abdominal wall without insufflation. This study aimed to evaluate the safety and efficacy of TULAA without pneumoperitoneum by analyzing clinical outcomes in pediatric patients who underwent this procedure at our institution.

We retrospectively analyzed 252 pediatric patients who underwent TULAA without pneumoperitoneum between January 2014 and December 2023. We performed this procedure in patients with acute appendicitis, excluding those with perforated appendicitis accompanied by intra-abdominal abscess formation. A 2 cm umbilical incision was made, and the abdominal wall was elevated using a reusable ring retractor mounted on a mechanical holder. For cases in which completion of this procedure was difficult, the procedure was converted by adding pneumoperitoneum or additional trocars. Clinical outcomes were evaluated, and preoperative variables were compared between the completion and non-completion groups.

The procedure was completed without conversion in 92.5 % of cases, with no cases requiring open surgery. The median operative time was 90 min (range: 39-379 min). Early postoperative complications occurred in 5.1 % of patients, including intra-abdominal abscess formation and bowel obstruction. Dense adhesions between the appendix and surrounding tissues were the leading cause of conversion. Compared with the completion group, the non-completion group had a significantly longer duration from symptom onset to surgery and higher white blood cell counts and C-reactive protein levels (P < 0.05).

TULAA without pneumoperitoneum is a safe and effective alternative for managing pediatric acute appendicitis, avoiding gas-related complications. Although dense adhesions may necessitate conversion, elevated preoperative inflammatory markers may help predict procedural feasibility. We acknowledge that this technique was associated with prolonged operative times, and it was applied to patients, excluding those with perforated appendicitis accompanied by intra-abdominal abscess formation.