Acute appendicitis is the most common surgical emergency in children, with peak incidence between the ages of 10 and 19 years. Traditionally, appendicitis in pediatric patients was managed with an open appendectomy; however, laparoscopic appendectomy (LA) has emerged as the preferred approach due to its minimally invasive nature, reduced postoperative pain, faster recovery, and improved cosmetic outcomes. Laparoscopy in children offers additional benefits, such as better visualization of the abdominal cavity, which is especially important in cases with atypical presentations or diagnostic uncertainty.

Indications

Laparoscopic appendectomy in pediatric patients is indicated for:

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

Complicated Appendicitis: Cases with perforation, abscess, or localized peritonitis that are suitable for minimally invasive management.

Diagnostic Uncertainty: Children presenting with nonspecific abdominal pain where appendicitis is suspected but not confirmed.

Incidental Appendectomy: Sometimes performed during other laparoscopic abdominal procedures in children with predisposing conditions.

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

Preoperative Evaluation

A careful preoperative assessment is essential in pediatric patients to ensure safety and optimize outcomes:

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

Laboratory Tests: Complete blood count to evaluate leukocytosis, C-reactive protein, and other relevant investigations.

Imaging Studies: Abdominal ultrasound is the preferred first-line investigation in children due to its noninvasive nature and lack of radiation. CT scan or MRI may be used in complicated or unclear cases.

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

Parents are counseled regarding the procedure, benefits, potential complications, and expected recovery.

Surgical Technique

Laparoscopic appendectomy in pediatric patients is performed under general anesthesia with the following key steps:

Patient Positioning and Port Placement:
The child is placed supine, sometimes with a slight Trendelenburg tilt to move bowel loops away from the surgical site. Pneumoperitoneum is established using CO₂ insufflation, typically at lower pressures (8–12 mmHg) appropriate for pediatric patients. Standard port placement includes:

A 5–10 mm umbilical port for the laparoscope

Two additional 3–5 mm ports in the lower abdomen for working instruments

Exploration and Appendix Identification:

The abdominal cavity is inspected for any other pathology. The appendix is identified, and adhesions, if present, are gently released. The cecum and terminal ileum are examined to confirm the diagnosis and rule out alternative causes of abdominal pain.

Mesoappendix Management:

The mesoappendix, containing the appendicular artery, is divided using bipolar cautery or ultrasonic energy devices. Care is taken to achieve hemostasis while avoiding injury to adjacent bowel or vessels.

Appendix Ligation and Division:

The base of the appendix is ligated securely, either intracorporeally or extracorporeally using absorbable sutures, or with endoloops. The appendix is divided distal to the ligature and placed in a retrieval bag to prevent spillage and contamination.

Abdominal Irrigation and Inspection:

In cases of perforated or gangrenous appendicitis, the abdominal cavity is irrigated to reduce bacterial load. Hemostasis is confirmed, and the cavity is inspected for other pathology.

Port Closure:

The ports are removed, pneumoperitoneum is released, and fascial and skin closure is performed using absorbable sutures or subcuticular technique to minimize scarring.

Postoperative Care

Children generally recover quickly following laparoscopic appendectomy. Postoperative care includes:

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

Early Ambulation and Diet: Oral intake is usually resumed within a few hours, starting with liquids and progressing to solid foods.

Monitoring for Complications: Observation for bleeding, infection, or signs of intra-abdominal abscess.

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

Outcomes and Advantages

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

Reduced Postoperative Pain: Smaller incisions minimize tissue trauma.

Faster Recovery and Shorter Hospital Stay: Early ambulation and feeding allow quicker return to normal activities.

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

Better Diagnostic Accuracy: Visualization of the entire abdominal cavity helps identify alternative or concurrent pathologies.

Lower Incidence of Wound Infections: Reduced incision size decreases infection risk.

Complications are rare but may include intra-abdominal abscess, port-site infection, bleeding, or injury to adjacent structures. These risks are minimized with meticulous surgical technique and appropriate patient selection.

Conclusion

Laparoscopic appendectomy in pediatric patients is a safe, effective, and minimally invasive approach for managing both uncomplicated and complicated appendicitis. By combining precise surgical technique with the advantages of laparoscopy, this procedure ensures reduced postoperative pain, faster recovery, superior cosmetic results, and excellent long-term outcomes. It has become the preferred surgical approach for pediatric appendicitis, providing children and their families with a safe and efficient treatment option.