See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/302918998

Operative management of appendicitis

Article in Seminars in Pediatric Surgery · May 2016

DOI: 10.1053/j.sempedsurg.2016.05.003

CITATIONS READS

0 59

2 authors, including:

Shawn D St. Peter

Children’s Mercy Kansas City
416 PUBLICATIONS 6,722 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

ATOMAC Solid Organ Injury View project

All content following this page was uploaded by Shawn D St. Peter on 20 June 2016.

The user has requested enhancement of the downloaded file.

Author's Accepted Manuscript

Operative management of appendicitis

Shawn D St. Peter MD, Charles L. Snyder MD

PII: S1055-8586(16)30016-6 www.elsevier.com/locate/semped-

DOI: http://dx.doi.org/10.1053/j.sempedsurg.2016.05.003 surg

Reference: YSPSU50628

To appear in: Seminars in Pediatric Surgery

Cite this article as: Shawn D St. Peter MD, Charles L. Snyder MD, Operative
management of appendicitis, Seminars in Pediatric Surgery, http://dx.doi.org/
10.1053/j.sempedsurg.2016.05.003

This is a PDF file of an unedited manuscript that has been accepted for
publication. As a service to our customers we are providing this early version of
the manuscript. The manuscript will undergo copyediting, typesetting, and
review of the resulting galley proof before it is published in its final citable form.
Please note that during the production process errors may be discovered which
could affect the content, and all legal disclaimers that apply to the journal
pertain.

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
 OPERATIVE MANAGEMENT OF APPENDICITIS

Shawn D. St. Peter, MD

Charles L. Snyder, MD

From the Center for Prospective Clinical Trials

Children’s Mercy Hospital
Kansas City, MO

Corresponding Author

Shawn D. St. Peter, MD

Director, Pediatric Surgical Fellowship and Scholars Programs
Director of Research, Department of Surgery
Professor of Surgery
Children's Mercy Hospital
2401 Gillham Road
Kansas City, MO 64108
Phone: 816 983 6479
Fax: 816 983 6885
Email: sspeter@cmh.edu

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
Abstract
Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains
one of the most common operations performed in children. The advent of data-driven medicine
has led to questions about every aspect of the operation: whether appendectomy is even
necessary, when it should be performed (timing), how the procedure is done (laparoscopic
variants versus open, irrigation versus no irrigation), length of hospital stay and antibiotic
duration. The goal of this analysis is to review the current status of, and available data
regarding, the surgical management of appendicitis in children.

Key words: Appendicitis, appendectomy, interval appendectomy, intra-abdominal abscess,

laparoscopy, children, pediatric

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
 The operative management of appendicitis varies with the extent of disease at

presentation. The three general categories of disease are those with appendicitis with no

evidence of perforation, those with perforated appendicitis, and those who present with a well-

defined abscess. This paper will review the definition and application of this classification

schema and the available data on the various operative approaches and technical factors

associated with the surgical procedures in use currently.

Acute Appendicitis

Acute nonperforated appendicitis is definitively cured with prompt appendectomy, this

is the rationale for early operation as the traditional standard of care. We now understand that

acute appendicitis can be treated effectively to the point of disease resolution and hospital

discharge with antibiotics alone.1-3 This concept is discussed at length in another section of this

edition. However, emerging data demonstrating the ability to treat appendicitis with antibiotics

lends insight to a long debated topic, the timing of appendectomy relative to presentation. If

antibiotics alone can treat the disease, it would be rational to assume that once antibiotics are

started, the operation is not emergent or perhaps even necessary, in the immediate setting. The

primary concern around which any argument regarding the timing of appendectomy is centered,

is the possibility that patients with non-perforated appendicitis will progress to perforation if

there is a delay in performing appendectomy. A retrospective study suggested that a longer in-

hospital wait for operation was associated with a higher perforation rate in children. However,

the patients appear to have been highly selected, since no one who underwent appendectomy

within nine hours had a perforation,4 implying that no one in the early operative group had a

perforation at admission. Given the known data regarding the percentage of children with

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
perforation or complicated disease, this is quite atypical and suggests selection bias. This study

also focused only on time from presentation to operation. A more recent study investigating

time to appendectomy relative to onset of symptoms found no association between a longer

time to appendectomy and worse outcomes.5 Both of these studies involved relatively small

cohorts. A recent multicenter study including over 1,300 patients demonstrated that delay in

appendectomy did not impact the incidence of surgical site infections.6 The only variables

correlating with surgical site infections were the duration of symptoms, shock or sepsis at

presentation, and the presence of complicated appendicitis. Since the most robust data

available suggest timing of appendectomy does not impact adverse event rates, appendectomy

in the middle of the night is no longer justified. National health care trends towards maximizing

system efficiency and delivery of care, combined with data suggesting overnight appendectomy

places undue stress on the surgeon, surgical team, family, and hospital staff 7-9 argue for

approaching appendectomy as an elective procedure once antibiotic therapy has been initiated.

This information may be useful during the initial consultation, to ease patient and family

anxiety.

Perforated Appendicitis

The best management strategy for perforated appendicitis is still a topic of debate. The

three options consist of antibiotics only, antibiotics followed by interval appendectomy, and

appendectomy at presentation.

The rationale for treating initially with antibiotics is to avoid a difficult operation in the

setting of peritonitis. Once the infection is controlled with antibiotics and operative difficulty is

decreased, then the decision is whether to even perform the appendectomy or not. Foregoing

the appendectomy assumes a low risk of recurrent appendicitis; short-term data suggests the

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
risk is approximately 8-14%.10,11 It is currently impossible to estimate the lifetime risk of leaving

the offending organ in place. There are no longitudinal population-based studies of these

children as they mature through adulthood and old age; therefore, recurrence curves are

unknown quantity. However, assuming the current series are accurate in estimating the short-

term risk of recurrent appendicitis at 1-3% per year, and that the rate remains stable,

appendectomy may be indicated in a child with 60 to 80 years of life expectancy. We found only

16% of patients had luminal obliteration at the time of interval appendectomy, implying the

remaining appendices would remain at risk for recurrent appendicitis.

Additionally, some authors have noted a high rate of pathologic findings in interval

appendectomy specimens.12-14 Although rare in children, missed appendiceal neoplasms are a

potential undesirable side effect of the nonoperative approach. A survey of the American

Pediatric Surgical Association (APSA) in 2005 found that 86% of the responders perform interval

appendectomy routinely after nonoperative management of perforated appendicitis.15

Initial management with antibiotics followed by elective appendectomy depends on the

patient responding to medical management and becoming asymptomatic. Several groups have

attempted to evaluate which patients are more likely to fail and require an early appendectomy

prior to the scheduled interval operation. One study found a high failure rate in patients with

more than 15% band forms in the differential white cell count on presentation.16 The presence

of an appendicolith on imaging has also been associated with failure of medical management.17

Others have found that evidence of disease or contamination beyond the right lower quadrant

on imaging was a predictor of failure.18

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
 The management pathway of initial antibiotic therapy followed by interval

appendectomy includes a de facto assumption that the clinician can distinguish perforated from

non-perforated appendicitis based on the preoperative presentation (clinical, laboratory, and

radiographic studies). A blinded review of CT scans at our institution found that radiologists and

surgeons (of all levels of experience) were unable to diagnose perforation with greater than 80%

accuracy.19 Treating a child with non-perforated appendicitis with a protracted course of

antibiotics and interval appendectomy is gross overtreatment. These patients do not require

postoperative antibiotics after appendectomy and currently are usually discharged from the

hospital on the day of operation.20

While the goal of ‘antibiotic therapy first’ is to avoid a difficult and potentially

dangerous operation, this has been documented to be an operation that most experienced

surgeons can perform safely, and with a minimally invasive approach. Laparoscopic

appendectomy has been shown to be reliably feasible and safe in both children and adults who

present with a phlegmonous right lower quadrant mass.21,22

Several studies have compared early versus delayed appendectomy for perforated

appendicitis, culminating in a meta-analysis published in 2010. This report reviewed 17 studies,

16 of which were retrospective and non-randomized; the other was prospective but non-

randomized.23 This review compared 847 patients who underwent delayed appendectomy and

725 who underwent early appendectomy. The delayed operation was associated with

significantly less overall complications, wound infections, abdominal/pelvic abscesses,

ileus/bowel obstructions, and reoperations. No significant difference was found in the duration

of first hospitalization, the overall duration of hospital stay, and the duration of intravenous

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
antibiotics. Overall complications remained significantly less in the conservative treatment

group during sensitivity analysis of studies including only pediatric patients. Due to the poor

quality data, the authors suggested that high quality studies were necessary for a definitive

conclusion.

Higher quality data now exists with the completion of a prospective, randomized trial

comparing appendectomy on presentation to initial antibiotic therapy and appendectomy 6-8

weeks later.24 Children with a presumed preoperative diagnosis of perforated appendicitis were

included. They randomized 131 children with or without abscess; 64 in the initial appendectomy

group, and 67 in the initial antibiotic followed by interval appendectomy group. The length of

hospitalization was two days longer with initial antibiotics followed by interval appendectomy (P

= 0.03). The overall adverse event rate substantially favored early appendectomy with a relative

risk of 1.86 associated with initial antibiotic therapy and delayed appendectomy (95% CI, 1.21 to

2.87, P = 0.003). Importantly, children who had delayed appendectomy had higher costs and

were more likely to receive a central line. The results of this trial firmly demonstrate patient

benefits from early laparoscopic appendectomy in children with a preoperative diagnosis of

perforated appendicitis.

Role of Irrigation

An abundance of data from several decades failed to demonstrate a clinical role for

irrigation in the face of peritoneal contamination.25 Despite this lack of compelling data in all the

previous studies investigating the role of irrigation, in a survey of North American pediatric

surgeons published in 2004 only 7% of the respondents reported using no irrigation.26 Two

retrospective studies comparing irrigation to no irrigation during appendectomy (mostly

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
laparoscopic) both demonstrated an increase in abscesses resulting from the use of irrigation,

leading both to recommend no irrigation.27,28

We completed a prospective, randomized trial comparing normal saline irrigation to

suction alone during laparoscopic appendectomy for perforated appendicitis in children.29

Perforation was defined as a hole in the appendix or a fecalith in the abdomen. We had

previously shown that using these criteria as the definition of perforation separated those with

post-operative risk of abscess of approximately 20% (perforated) to children with an abscess risk

under 1% (non-perforated).30

In the irrigation arm, a 1L bag of sterile normal saline was attached to the irrigation

device. A minimum of 500mL of saline was required, with no maximum volume limit. There

were 220 patients randomized. At presentation, there were no differences between the two

groups in age, weight, body mass index percentile, gender distribution, duration of symptoms,

presenting leukocyte count, or temperature.

The primary outcome variable was the development of an abdominal abscess, and there

was no difference between groups: 19.1% with suction only and 18.3% with irrigation (P=1.0)

developed an abscess. There was no difference in time to starting clear liquids, advancement to

a regular diet, or discharge. Hospital charges were the same. There was also no difference in

mean maximum daily temperatures. Additionally, there was no difference in any aspect of their

management, hospital course or outcomes. The study demonstrated miniscule effect sizes in

either direction, suggesting that irrigation is unlikely to have an impact on clinical course during

laparoscopic appendectomy.

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
Abscess on Presentation

Patients presenting with a well-defined abscess on imaging studies are another focus of

controversy. One option is initial treatment of the abscess with percutaneous drainage with or

without drain placement, followed by interval appendectomy when the inflammation has

resolved. This algorithm was initially described over 25 years ago,20 and became an important

part of contemporary practice.31-33 However, as previously mentioned, improvement in

laparoscopic skills and instruments allow the operation to be done with minimal morbidity.

Percutaneous drainage with interval appendectomy also carries the risk of complications and

employs considerable medical resources.34 We randomized 40 patients who presented with a

well-formed abscess to drainage and interval appendectomy versus early laparoscopic

appendectomy at presentation.35 Hospital charges and overall outcomes were similar in our

patients, but we did not capture outpatient charges. These would of course be higher for those

in the interval appendectomy group receiving home health care. Quality of life assessment

favored early operation, since patients and families report ongoing stress due to continued

health care needs until the appendix is finally removed.36 Currently, we approach most

abscesses with early primary laparoscopic appendectomy, with the possible exception of the

patient who is clinically doing well (e.g., capable of eating and with minimal discomfort) at

presentation. These children are perhaps more likely to become ill from the operation (‘poking

the skunk’) than from drainage.

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
OPERATIVE APPROACH

Traditional open appendectomy is done through a muscle-splitting right lower quadrant

incision. Standard laparoscopic appendectomy typically involves a camera site at the umbilicus

with two additional working ports in the lower abdomen. The primary change in the operative

approach to appendicitis has been away from open operation and towards a minimally invasive

approach. Recent changes involve permutations of the minimally invasive approach, particularly

regarding the number of access sites.

A statewide analysis in California demonstrated a 33% increase in laparoscopic

appendectomies over three years prior to 2010.37 We examined the PHIS® database over a 12-

year period, from 1999 to 2010, and found an increase in laparoscopic appendectomy from 22%

to 91% (P < 0.0001).38 This change in approach was associated with decrease in complications

during this time. The rapidly changing utility of laparoscopy implies that the traditional open

approach will become a largely historical operation within the not too distant future.

During the initial experience with laparoscopy for perforated appendicitis, some authors

found a higher post-operative abscess rate than was reported for open appendectomy.39,40

However, the more recent experience, including multiple prospective trials, meta-analyses and

large multi-institutional comparative series clearly documents no difference in abscess risk

between the open and laparoscopic approach.41-47 Laparoscopy has been repeatedly shown to

decrease wound infections. 45,46,48-52 Further, the clinical importance of port site infections is

relatively small. Also, the laparoscopic operation has been found to reduce the risk of

postoperative adhesive small bowel obstruction.38,53

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
 The most recent debate about the operative approach to appendicitis involves the use

of single incision laparoscopy, where instruments are placed through the same incision used for

the camera port. There are many variations of the technique including using stab incisions for

instrument placement, using multilumen ports, and dividing the appendix intracorporeally or

extracorporeally.

We randomized 360 patients to either single site or standard 3 port laparoscopic

appendectomy for non-perforated appendicitis.54 Our approach for single site generally involved

1 or 2 stab incisions along the side of a 5mm transumbilical port. Once the appendix is mobilized

it was exteriorized through the umbilicus for resection. The primary outcome variable was

surgical site infection, and no difference was found between groups. The single site approach

took longer on average. Although the difference was highly significant, the effect size was only 5

minutes. There was no difference in length of stay and both groups were discharged within 24

hours. There was no difference in convalesce either. There have subsequently been many other

randomized trials involving all the described versions of the single site technique. The most

recent meta analysis confirms our findings with no major differences in outcomes, and across

the board the effect sizes are very small.55 The authors concluded that single incision

laparoscopic appendectomy may not be a better approach for pediatric patients.

While it seems intuitive that removing the appendix utilizing three separate small sites

or one slightly larger, central site would not result in major outcome differences, the major

purported advantage to single site laparoscopic surgery driving its use is cosmesis. Although

almost every report on single site approaches document outstanding subjective cosmesis, this is

rarely supported by objective data. After our randomized trial, we recorded the cosmetic

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
outcomes at a short term and long term follow up using the Patient Scar Assessment

Questionnaire (PSAQ), which has been validated in adults.56,57 The PSAQ has five sub-scales, four

of which are validated and used in the scoring. The validated subscales include: Appearance,

Consciousness, Satisfaction with Appearance, and Satisfaction with Symptoms. The single site

approach produced superior scores at early follow-up (about 6 weeks after the operation).

However, at 18 months this difference largely disappeared and the cosmetic scores approached

the best possible score in both groups. Since the only potential advantage for the single site

approach is cosmetic, and the long term cosmetic outcome is very similar to the three port

approach, it appears there is little to no objective advantage to single incision appendectomy.

This is not to say the single site approach is inferior, but no meaningful comparative data

suggest that it should be offered over three port appendectomy. Our group now utilizes the

single site approach selectively in non-obese patients with non-perforated appendicitis, with a

low threshold for additional port sites.

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
REFERENCES

1. Minneci PC, Sulkowski JP, Macion KM, et al. Feasibility of a nonoperative management
strategy for uncomplicated acute appendicitis in children. J Am Coll Surg 2014;219:272-
279.
2. Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendectomy for
treatment of acute uncomplicated appendicitis: an open label, non-inferiority,
randomized controlled trial. Lancet 2011;277:1573-1579.
3. Armstrong J, Merritt N, Jones S, et al. Non-operative management of early acute
appendicitis in children: Is it safe and effective? J Pediatr Surg 2014;49:782-785.
4. Bonadio W, Brazg J, Telt N, Pe M, Doss F, Dancy L, Alvarado M. Impact of in-hospital
timing to appendectomy on perforation rates in children with appendicitis. J Emerg
Med. 2015;49(5):597-604. doi: 10.1016/j.jemermed.2015.04.009. Epub 2015 Jul 10.
5. Mandeville K, Monuteaux M, Pottker T, Bulloch B. Effects of timing to diagnosis and
appendectomy in pediatric appendicitis. Pediatr Emerg Care. 2015;31(11):753-8. doi:
10.1097/PEC.0000000000000596.
6. Boomer LA, Cooper JN, Anandalwar S, et al. Delaying appendectomy does not lead to
higher rates of surgical site infections: a multi-institutional analysis of children with
appendicitis. Ann Surg 2015 Dec 16. [Epub ahead of print] PMID: 26692077
7. Surana R, Quinn F, Puri P. Is it necessary to perform appendectomy in the middle of the
night in children? Br Med J 1993;306:1168.
8. Yardeni D, Hirschl RB, Drongowski RA, et al. Delayed versus immediate surgery in acute
appendicitis: Do we need to operate during the night? J Pediatr Surg 2004;39:464–469
9. Stahlfeld K, Hower J, Homitsky S, et al. Is acute appendicitis a surgical emergency? Am
Surg. 2007;73(6):626-9; discussion 629-30.
10. Ein SH, Shandling B. Is interval appendectomy necessary after rupture of an appendiceal
mass? J Pediatr Surg 1996;31:849–850
11. Puapong D, Lee SL, Haigh PI, et al. Routine interval appendectomy in children is not
indicated. J Pediatr Surg. 2007;42(9):1500-3.
12. Gahukamble DB, Gahukamble LD. Surgical and pathological basis for interval
appendectomy after resolution of appendicular mass in children. J Pediatr Surg
2000;35:424–427.
13. Mazziotti MV, Marley EF, Winthrop AL, et al. Histopathologic analysis of interval
appendectomy specimens: Support for the role of interval appendectomy. J Pediatr Surg
1997;32:806–809
14. Knott EM, Iqbal CW, Mortellaro VE, Fitzgerlad KM, Sharp SW, St. Peter SD. Interval
appendectomy after non-operative management of perforated appendicitis: what are
the operative risks and luminal patency rates? J Surg Res 2012;177(1):127-30.
15. Chen C, Botelho C, Cooper A, et al. Current practice patterns in the treatment of
perforated appendicitis in children. J Am Coll Surg 2003;196:212–221

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
16. Kogut KA, Blakely ML, Schropp KP, et al. The association of elevated percent bands on
admission with failure and complications of interval appendectomy. J Pediatr Surg
2001;36:165–168
17. Aprahamian CJ, Barnhart DC, Bledsoe SE, et al. Failure in the nonoperative management
of pediatric ruptured appendicitis: predictors and consequences. J Pediatr Surg.
2007;42(6):934-8.
18. Levin T, Whyte C, Borzykowski R, et al. Nonoperative management of perforated
appendicitis in children: can CT predict outcome? Pediatr Radiol. 2007;37(3):251-5.
19. Fraser, JD, Aguayo, P, Sharp SW, et al. Accuracy of computed tomography in predicting
appendiceal perforation. J Pediatr Surg. 2014;49(6):1016-9; discussion 1019. doi:
10.1016/j.jpedsurg.2014.01.042. Epub 2014 Feb 13.
20. Aguayo P, Alemayehu H, Desai AA, Fraser JD, St Peter SD. Same day discharge after
laparoscopic appendectomy for perforated appendicitis. J Surg Res. 2014;190(1):93-7.
doi: 10.1016/j.jss.2014.03.012. Epub 2014 Mar 12.
21. Goh BK, Chui CH, Yap TL, et al. Is early laparoscopic appendectomy feasible in children
with acute appendicitis presenting with an appendiceal mass? A prospective study. J
Pediatr Surg. 2005;40(7):1134-7.
22. Senapathi PS, Bhattacharya D, Ammori BJ. Early laparoscopic appendectomy for
appendicular mass. Surg Endosc. 2002;16(12):1783-5.
23. Simillis C, Symeonides P, Shorthouse AJ, et al. A meta-analysis comparing conservative
treatment versus acute appendectomy for complicated appendicitis (abscess or
phlegmon). Surgery. 2010;147:818-829.
24. Blakely ML, Williams R, Dassinger MS, et al. Early versus interval appendectomy for
children with perforated appendicitis. Arch Surg 2011;146:660-665.
25. St Peter SD, Holcomb GW 3rd. Should peritoneal lavage be used with suction during
laparoscopic appendectomy for perforated appendicitis? Adv Surg. 2013;47:111-8.
26. Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: A
survey of North American Pediatric Surgeons. J Pediatr Surg 2004;39:875-879.
27. Hartwich JE, Carter RF, Wolfe L, et al. The effects of irrigation on outcomes in cases of
perforated appendicitis in children. J Surg Res. 2013;180(2):222-5. doi:
10.1016/j.jss.2012.04.043. Epub 2012 May 11.
28. Moore CB, Smith RS, Herbertson R, et al. Does use of intraoperative irrigation with open
or laparoscopic appendectomy reduce post-operative intra-abdominal abscess? Am
Surg. 2011;77:78-80.
29. St. Peter SD, Adibe OO, Iqbal CW, et al. Irrigation versus suction alone during
laparoscopic appendectomy for perforated appendicitis: A prospective randomized trial.
Ann Surg 2012;256:581-585.
30. St. Peter SD, Sharp SW, Holcomb III GW, et al. An evidence based definition for
perforated appendicitis derived from a prospective, randomized trial. J Pediatr Surg
2008;43:2242-2245.

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
31. Janik JS, Ein SH, Shandling B, et al. Nonsurgical management of appendiceal mass in late
presenting children. J Pediatr Surg 1980;15:574-576.
32. Morrow SE, Newman KD. Current management of appendicitis. Semin Pediatr Surg
2007;16:34-40.
33. Owen A, Moore O, Marven S, et al. Interval laparoscopic appendectomy in children. J
Laparoendosc Adv Surg Tech 2006;16:308-311.
34. Weiner DZ, Katz A, Hirschl RB, et al. Interval appendectomy in perforated appendicitis.
Pediatr Surg Int 1995;10:82-85.
35. Keckler SJ, St. Peter SD, Tsao K, et al. Resource utilization and outcomes from
percutaneous drainage and interval appendectomy for perforated appendicitis. J Pediatr
Surg 2008;43(6):977-80.
36. St. Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendectomy upon
presentation versus initial non-operative management and interval appendectomy for
perforated appendicitis with abscess: A prospective, randomized trial. J Pediatr Surg
2010;45:236-240.
37. Schurman JV, Cushing CC, Garey CL, et al. Quality of life assessment between
laparoscopic appendectomy at presentation and interval appendectomy for perforated
appendicitis with abscess: Analysis of a prospective, randomized trial. J Pediatr Surg
2011;46:1121-1125.
38. Jen HC, Shew SB. Laparoscopic versus open appendectomy in children: outcomes
comparison based on a statewide analysis. J Surg Res 2010;161:13-17.
39. Gasior AC, St. Peter SD, Knott EM, et al. National trends in approach and outcomes with
appendicitis in children. J Pediatr Surg. 2012;47(12):2264-7. doi:
10.1016/j.jpedsurg.2012.09.019.
40. Lintula H, Kokki H, Vanamo K, et al: Laparoscopy in children with complicated
appendicitis. J Pediatr Surg 2002;37:1317–1320.
41. Horwitz JR, Custer MD, May BH, et al: Should laparoscopic appendectomy be avoided
for complicated appendicitis in children? J Pediatr Surg 1997;32:1601–1603.
42. Esposito C, Borzi P, Valla JS, et al. Laparoscopic versus open appendectomy in children: a
retrospective comparative study of 2,332 cases. World J Surg 2007;31:750-755.
43. Aziz O, Athanasiou T, Tekkis PP, et al. Laparoscopic versus open appendectomy in
children: a meta-analysis. Ann Surg 2006;243:17-27.
44. Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a
prospective randomized double-blind study. Ann Surg 2005;242:439-48.
45. Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes
comparison based on a large administrative database. Ann Surg 2004;239:43-52.
46. Herman J, Duda M, Lovecek M, et al. Open versus laparoscopic appendectomy.
Hepatogastroenterology 2003;50:1419-1421.
47. Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected
appendicitis. Cochrane Database Syst Rev 2004;4:CD001546.

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
 48. Jaschinski T, Mosch C, Eikermann M, Neugebauer EA. Laparoscopic versus open
appendectomy in patients with suspected appendicitis: a systematic review of meta-
analyses of randomised controlled trials. BMC Gastroenterol. 2015 Apr 15;15:48.
49. Menezes M, Das L, Alagtal M, et al. Laparoscopic appendectomy is recommended for
the treatment of complicated appendicitis in children. Pediatr Surg Int. 2008;24:303-
305.
50. Paterson HM, Qadan M, de Luca SM, et al. Changing trends in surgery for acute
appendicitis. Br J Surg 2008;95:363-368.
51. Yau KK, Siu WT, Tang CN, et al. Laparoscopic versus open appendectomy for
complicated appendicitis. J Am Coll Surg 2007;205:60-65.
52. Khan MN, Fayyad T, Cecil TD, et al. Laparoscopic versus open appendectomy: the risk of
postoperative infectious complications. JSLS 2007;11:363-367.
53. Marzouk M, Khater M, Elsadek M, et al. Laparoscopic versus open appendectomy: a
prospective comparative study of 227 patients. Surg Endosc 2003;17:721-724.
54. Tsao KJ, St Peter SD, Valusek PA, et al. Adhesive small bowel obstruction after
appendectomy in children: comparison between the laparoscopic and open approach. J
Pediatr Surg 2007;42:939-942.
55. St. Peter SD, Adibe OO, Juang D, et al. Single incision versus standard 3-port
laparoscopic appendectomy: a prospective randomized trial. Ann Surg. 2011
Oct;254(4):586-90.
56. Zhang Z, Wang Y, Liu R. Systematic review and meta-analysis of single-incision versus
conventional laparoscopic appendectomy in children. J Pediatr Surg. 2015
Sep;50(9):1600-9. doi: 10.1016/j.jpedsurg.2015.05.018.
57. Durani P, McGrouther DA, Ferguson MW. The patient scar assessment questionnaire: a
reliable and valid patient-reported outcomes measure for linear scars. Plast Reconstr
Surg. 2009 123:1481-1489.
58. Draaijers LJ, Tempelman FR, Botman YA, et al. The patient and observer scar assessment
scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg.
2004;113:1960-1965.

Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City May 31, 2016.
View publication stats For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.