World Journal of Surgery and Surgical Research Research Article

Published: 02 Apr, 2018

Small Bowel Obstruction after Laparoscopic

Appendectomy in Children
Belén Aneiros Castro1*, Indalecio Cano Novillo1, Araceli García Vázquez1, Pedro Yuste
García2, Eduardo Ferrero Herrero2 and Andrés Gómez Fraile1
1
Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
2
Department of General Surgery, Hospital 12 de Octubre, Madrid, Spain

Abstract
Introduction: The aim of this study is to determine the characteristics and the treatments of the
patients with bowel obstruction after laparoscopic appendectomy.
Material and Methods: A retrospective study was conducted to analyze laparoscopic appendectomy
performed in our center between 2000 and 2013. Bowel obstruction was diagnosed by physical
examination and radiographic. Stata software was used to analyze all the statistical data.
Results: There were 1,734 patients, of which 17 patients developed bowel obstruction (1%). The
mean age of the patients was 8.0 years. Overall, 70.6% were male and 29.4% were female. Bowel
obstruction occurred in 12 patients in the immediate post-operative period, in 8 patients in
the delayed post-operative period and in 3 patients in both periods. All the patients with bowel
obstruction in the immediate post-operative period underwent operative intervention; 50% were
completed by the laparoscopic approach and 50% by open approach. Intra-abdominal abscess
occurred in 66.6% of the patients. In the delayed post-operative period, 7 patients were managed
conservatively and 1 patient was managed by open surgical approach. The patients that developed
bowel obstruction in both periods were managed by open surgical approach in the immediate post-
operative period.
Conclusion: Bowel obstruction after laparoscopic appendectomy is an uncommon complication.
Like the most recent studies, our results support that laparoscopic appendectomy reduces the
OPEN ACCESS incidence of bowel obstruction. In addition, this approach can be used to treat this complication in
determinate cases.
*Correspondence:
Belén Aneiros Castro, Department Keywords: Bowel obstruction; Appendectomy; Laparoscopy
of Pediatric Surgery, Hospital 12
de Octubre, Madrid, Spain, Tel:
Introduction
+34630668108; In the last decades, minimally invasive surgery has increasingly been acknowledged in different
E-mail: belenaneiroscastro@gmail.com surgical specialties. At present, it is the gold standard approach for the management of several
Received Date: 03 Mar 2018 pathologies. The adaptation of laparoscopic instruments for pediatric patients has allowed us to
Accepted Date: 28 Mar 2018 perform minimally invasive techniques in children [1]. Several studies have demonstrated that
Published Date: 02 Apr 2018 laparoscopic approach for appendectomies has advantages over open technique such as decreased
rate of wound infection and small bowel obstruction, shorter hospital stay, better cosmesis and less
Citation:
postoperative pain. Furthermore, it has also been observed diagnostic and therapeutic advantages
Castro BA, Novillo IC, Vázquez AG,
with regard to the open technique, especially in fertile women [2].
García PY, Herrero EF, Fraile AG. Small
Bowel Obstruction after Laparoscopic The development of intestinal adhesions after an Intra-abdominal surgery is generally inevitable.
Appendectomy in Children. World J They can have serious consequences for patients such as infertility, chronic abdominal pain or bowel
Surg Surgical Res. 2018; 1(1): 1001.
obstruction. The management of intestinal adhesions depends on the symptoms and physical signs
of the patients. Laparoscopic approach allows an effective treatment in selected patients, which
Copyright © 2018 Belén Aneiros reduces the morbidity associated with open procedures [3]. The aim of this study is analyze the
Castro. This is an open access characteristics of the patients with small bowel obstruction after laparoscopic appendectomy.
article distributed under the Creative Furthermore, we want to investigate which is the best therapeutic management for these patients.
Commons Attribution License, which
permits unrestricted use, distribution,
Material and Methods
and reproduction in any medium, The data of the patients who underwent laparoscopic appendectomy in our department between
provided the original work is properly January 2000 and December 2013 were retrospectively analyzed. A total of 1,734 pediatric patients
cited. were included in this study. Demographic parameters, clinical records, surgical interventions

Remedy Publications LLC., | http://surgeryresearchjournal.com 1 2018 | Volume 1 | Issue 1 | Article 1001

Belén Aneiros Castro, et al., World Journal of Surgery and Surgical Research

Table 1: Macroscopic characteristics of the appendix during the surgical Small bowel obstruction in both periods was found in three patients
intervention.
(17.6%). All of them were treated by open surgery in the immediate
  Cases Percentage
period. In the delayed period, one of them underwent open surgical
Phlegmonous 1 5,8% intervention and the other two patients underwent laparoscopic
Gangrenous 5 29,5% intervention.
Perforated 11 64,7% Small bowel obstruction is a relevant clinical condition that can
happen after an Intra-abdominal surgical intervention due to the
Table 2: Treatment of postoperative small bowel obstruction.
development of peritoneal adhesions between abdominal tissues
  Conservative treatment Laparoscopic surgery Open surgery and organs. These adhesions are also called “flanges” by surgeons.
Immediate 0 6 (50%) 6 (50%) Although studies are limited in pediatric patients, it has been
Delayed 7 (87,5%) 0 1 (12,5%) estimated that small bowel obstruction after an Intra-abdominal
surgery can occur in 1% to 6% of patients [3,4]. The incidence of
and postoperative results were evaluated. Diagnosis of small bowel postoperative adhesions varies according to the type of surgery and
obstruction was made according to the physical examination and the age of the patient. The formation and the closure of ileostomy
symptoms (abdominal pain, vomiting or lack of abdominal sounds) have the highest rate of postoperative bowel obstruction in pediatric
and radiological findings (dilated intestinal loops, lack of distal gas or patients (up to 25%); while appendectomy has the lowest rate (up to
hydro-aerial levels). 0.3%) [5].

Immediate bowel obstruction was established when this There are several studies comparing the outcomes of open or
complication appears during the length of stay while delayed bowel laparoscopic appendectomy in the literature. The rate of bowel
obstruction was determined when the patient was discharged from obstruction after laparoscopic appendectomy is statistically lower
the hospital. The minimum follow-up was at least 4 years. Statistical than after open surgery. It occurs in approximately 0.89% of patients
analyses were checked by STATA software. Continuous variables who underwent laparoscopic appendectomy and in 3.21% after open
were analyzed with the Wilcoxon test. Discrete variables were appendectomy. These percentages vary according to the type of
compared using the chi-square test. A p value of less than 0.05 was appendicitis (phlegmonous, gangrenous or perforated). Perforated
considered statistically significant. appendicitis has the highest rate of postoperative bowel obstruction
[6-8].
Results and Discussion
Initial therapeutic management of postoperative small bowel
Small bowel obstruction was observed in 17 of the 1,734 patients obstructions in adults is conservative when there are not clinical
(1%) included in this study. There were 12 boys and 5 girls. The mean signs of ischemia. However, it has been not demonstrated that this
of age was 8.0 years and the mean weight was 33.9 kg. Vomiting was management is safe for children. The rate of patients with postoperative
present in 14 patients (82.4%) and fever in 15 (88.2%). The mean time obstruction who respond to conservative treatment varies from 16%
from the onset of symptoms to the diagnosis of appendicitis was 2.62 to 63%. Therefore, many pediatric patients are treated by surgical
days. intervention [9]. Some authors have defended initial conservative
The macroscopic aspect of the appendix (Table 1) during the management during the first 48 hrs due to the majority of responder
surgical intervention was phlegmonous in 1 case (5.9%), gangrenous patients tend to improve at this time. In addition, the risk of intestinal
in 5 cases (29.4%) and perforated in 11 cases (64.7%). There was ischemia is lower during this period [10].
an inflammatory phlegmon in 9 patients (52.9%) and generalized Minimally invasive surgery also plays an important role in
peritonitis in 14 patients (82.4%). One patient (5.9%) required the treatment of postoperative bowel obstruction. It has been
conversion to open appendectomy. Abdominal drainage was placed demonstrated that laparoscopic adhesion removal has a lower rate
in 11 cases (64.7%). There were 3 intraoperative complications: 2 of complications, shorter length of stay and less risk of recurrence.
rupture of the appendix and 1 bleeding. The mean surgical time was However, this technique has high rate of conversion and requires
74.4 min. advanced laparoscopic skills [11].
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