Acute appendicitis is the most common surgical emergency in children, with peak incidence between 10 and 19 years of age. Prompt diagnosis and surgical intervention are critical to prevent complications such as perforation, abscess formation, and peritonitis. Traditionally managed with open appendectomy, the management of pediatric appendicitis has evolved significantly with the advent of laparoscopic appendectomy (LA). Laparoscopic techniques provide superior visualization, reduce postoperative pain, allow faster recovery, and offer excellent cosmetic results. In addition, laparoscopy is especially valuable in pediatric patients where diagnosis can be challenging due to atypical presentations.

Indications

Laparoscopic appendectomy in children is indicated for:

Acute Uncomplicated Appendicitis: Classic cases with localized right lower quadrant inflammation.

Complicated Appendicitis: Cases with perforation, localized abscess, or early peritonitis amenable to minimally invasive management.

Diagnostic Laparoscopy: Children presenting with atypical abdominal pain or inconclusive imaging, where appendicitis is suspected.

Incidental Appendectomy: Occasionally performed during other laparoscopic procedures in children with risk factors or incidental findings.

Contraindications include hemodynamic instability, severe generalized peritonitis, uncorrectable coagulopathy, or contraindications to general anesthesia.

Preoperative Evaluation

Thorough preoperative assessment ensures patient safety and optimal surgical outcomes:

History and Physical Examination: Assessment of abdominal pain, tenderness in the right lower quadrant, fever, nausea, and vomiting.

Laboratory Investigations: Complete blood count for leukocytosis, C-reactive protein, and basic metabolic profile.

Imaging Studies:

Ultrasound: Preferred initial imaging modality due to its noninvasive nature and absence of radiation. Can show enlarged, non-compressible appendix and periappendiceal fluid.

CT Scan or MRI: Reserved for complicated or unclear cases to confirm diagnosis and assess for abscess or perforation.

Anesthesia Assessment: Comprehensive evaluation for safety under general anesthesia, including airway assessment and review of comorbidities.

Parents are counseled regarding the procedure, expected outcomes, potential complications, and recovery timeline. Prophylactic antibiotics are administered according to institutional protocols.

Surgical Technique

Laparoscopic appendectomy in pediatric patients is performed under general anesthesia using standard minimally invasive principles:

Patient Positioning and Port Placement:
The child is placed in the supine position with a slight Trendelenburg tilt and, if needed, left tilt to displace bowel loops. Pneumoperitoneum is established using CO₂ at lower pressures (8–12 mmHg) appropriate for pediatric patients. Standard port placement includes:

5–10 mm umbilical port for the laparoscope

Two additional 3–5 mm working ports in the left lower quadrant and suprapubic region

Exploration and Appendix Identification:

The abdominal cavity is inspected for abnormalities. Adhesions are carefully dissected, and the appendix is identified. Visualization of the cecum and terminal ileum ensures accurate diagnosis and rules out alternative pathologies.

Mesoappendix Division:

The mesoappendix, containing the appendicular artery, is carefully coagulated and divided using bipolar cautery or ultrasonic energy devices. Meticulous hemostasis is maintained to prevent intraoperative bleeding.

Appendix Ligation and Division:

The base of the appendix is ligated securely using absorbable sutures, endoloops, or extracorporeal techniques such as Mishra’s Knot. The appendix is divided distal to the ligature and placed in a retrieval bag to prevent spillage and contamination.

Peritoneal Irrigation:

In cases of perforated appendicitis or purulent collection, the abdominal cavity is irrigated to reduce bacterial contamination.

Port Closure:
The pneumoperitoneum is released, and ports are removed. Fascial closure is performed for larger ports, while skin is closed using absorbable sutures or subcuticular technique to optimize cosmetic results.

Postoperative Care

Postoperative management emphasizes early recovery and prevention of complications:

Pain Management: Multimodal analgesia using acetaminophen, NSAIDs, or opioids as required.

Early Oral Intake: Children are encouraged to start with liquids, progressing to regular diet as tolerated.

Monitoring: Observation for signs of infection, bleeding, bowel function, and urinary output.

Discharge and Follow-Up: Most children are discharged within 24–48 hours, with complete recovery expected in 5–7 days.

Outcomes and Advantages

Laparoscopic appendectomy in pediatric patients offers several advantages over open surgery:

Reduced Postoperative Pain: Smaller incisions minimize tissue trauma.

Faster Recovery: Children resume normal activities more quickly.

Superior Cosmetic Results: Minimal visible scarring is particularly important in pediatric populations.

Diagnostic Advantage: Allows visualization of the entire abdominal cavity for accurate diagnosis and management.

Lower Incidence of Wound Infection: Minimally invasive approach reduces the risk of postoperative infection.

Potential complications, though rare, include intra-abdominal abscess, bleeding, port-site infection, or injury to adjacent structures. These risks are minimized by meticulous surgical technique, careful patient selection, and adherence to laparoscopic principles.

Conclusion

Laparoscopic appendectomy for acute appendicitis in pediatric patients is a safe, effective, and minimally invasive approach. It provides rapid recovery, reduced postoperative pain, superior cosmetic outcomes, and excellent long-term results. By combining precise surgical technique with the advantages of laparoscopy, this approach has become the preferred standard of care for managing appendicitis in children, ensuring optimal outcomes and improved patient satisfaction.