Appendicitis is one of the most common surgical emergencies in children, and timely intervention is crucial to prevent complications. When the appendix ruptures, it leads to peritonitis, abscess formation, and systemic illness, which require urgent surgical and medical management. Traditionally, open appendectomy was the standard approach, but in recent years, laparoscopic surgery has gained prominence. Laparoscopic management of ruptured appendix in pediatric patients is now widely recognized for its safety, efficacy, and long-term benefits.

Understanding Ruptured Appendix in Children

In children, appendicitis often progresses more rapidly than in adults due to their thinner appendiceal wall and less developed omental barrier. Delayed diagnosis, nonspecific symptoms, and communication difficulties in younger children further increase the risk of rupture. Studies suggest that nearly 30–40% of pediatric appendicitis cases present with perforation or rupture at the time of surgery.

A ruptured appendix results in the spread of infectious material into the peritoneal cavity, leading to localized abscesses or generalized peritonitis. Clinical signs include high-grade fever, diffuse abdominal pain, guarding, vomiting, and, in severe cases, signs of sepsis.

Role of Laparoscopy in Pediatric Surgery

Minimally invasive surgery has transformed pediatric surgical practice. For ruptured appendicitis, laparoscopy offers both diagnostic and therapeutic benefits. It allows direct visualization of the entire peritoneal cavity, ensures complete removal of the inflamed appendix, and facilitates peritoneal lavage to clear pus and debris. The ability to examine all quadrants of the abdomen is particularly important in pediatric cases where infection may be widespread.

Indications for Laparoscopic Management

Laparoscopic surgery is indicated in most pediatric patients with ruptured appendicitis, provided the child is hemodynamically stable and the surgical expertise is available. Key indications include:

Perforated appendix with localized or generalized peritonitis.

Rupture with abscess formation that can be drained laparoscopically.

Need for diagnostic clarification in unclear cases.

Contraindications include severe hemodynamic instability, uncontrolled sepsis requiring immediate open exploration, or lack of laparoscopic facilities.

Laparoscopic Technique

The laparoscopic approach for ruptured appendix in pediatric patients involves several key steps:

Patient Preparation

Adequate resuscitation with intravenous fluids and correction of electrolyte imbalance.

Administration of broad-spectrum intravenous antibiotics.

General anesthesia with endotracheal intubation.

Port Placement

Typically, a three-port technique is used: a 5–10 mm umbilical port for the camera, and two 3–5 mm working ports in the lower abdomen.

Smaller ports are preferred to reduce trauma and scarring in children.

Exploration and Appendectomy

The peritoneal cavity is inspected to identify the ruptured appendix and extent of contamination.

The mesoappendix is divided using bipolar cautery, harmonic scalpel, or clips.

The base of the appendix is ligated with absorbable endoloops or sutures and divided.

Peritoneal Toilet

Thorough lavage of the peritoneal cavity with warm saline is performed to remove pus, fecal matter, and fibrinous debris.

Special attention is given to dependent areas such as the pelvis and paracolic gutters.

Suction is used to clear all irrigating fluid, minimizing the risk of postoperative abscess formation.

Drain Placement

Depending on the degree of contamination, a pelvic drain may be placed to prevent fluid collection and infection.

Specimen Retrieval

The appendix is placed in a retrieval bag and extracted through the umbilical port to prevent wound contamination.

Advantages of Laparoscopic Management

Laparoscopy offers multiple advantages over open surgery, particularly in pediatric patients:

Better Visualization: The magnified view enables precise dissection and assessment of the entire abdomen.

Comprehensive Peritoneal Cleaning: Improved ability to remove purulent fluid and debris reduces risk of residual abscess.

Reduced Postoperative Pain: Smaller incisions lead to less pain and quicker mobilization.

Shorter Hospital Stay: Children typically recover faster, leading to earlier discharge.

Cosmetic Superiority: Minimal scarring is especially beneficial in young patients.

Lower Risk of Adhesions: Reduced intra-abdominal adhesions lower the risk of bowel obstruction later in life.

Postoperative Care

Post-surgery, children are monitored closely for signs of infection, abscess formation, and bowel function recovery. Key aspects include:

Continuation of broad-spectrum intravenous antibiotics for 5–7 days, later tailored based on culture results.

Gradual reintroduction of oral fluids and diet once bowel sounds return.

Adequate pain management with acetaminophen or NSAIDs.

Early ambulation to promote recovery and prevent complications.

Monitoring of drains if placed, with removal once output decreases.

Outcomes and Prognosis

Several studies have shown that laparoscopic appendectomy for ruptured appendix in children is safe and effective, with outcomes comparable or superior to open surgery. The risk of postoperative intra-abdominal abscess remains a concern, but with meticulous lavage and proper antibiotic therapy, this risk can be minimized. Long-term prognosis is excellent, and most children regain full health with minimal complications.

Conclusion

Laparoscopic management of ruptured appendix in pediatric patients has become the preferred surgical approach in modern pediatric surgery. It provides excellent diagnostic accuracy, effective removal of infected tissue, and thorough peritoneal cleaning while minimizing surgical trauma. The benefits of less pain, faster recovery, reduced adhesion risk, and better cosmetic outcomes make laparoscopy highly suitable for children. With experienced surgical teams and proper postoperative care, laparoscopic management ensures safe outcomes and a smooth recovery for young patients suffering from this potentially life-threatening condition.