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Single incision pediatric endosurgery (SIPES) appendectomy—is obesity a contraindication?
Journal of Pediatric Surgery (2013) 48, 1399–1404
www.elsevier.com/locate/jpedsurg
Single incision pediatric endosurgery (SIPES) appendectomy—is obesity a contraindication?☆,☆☆ Govardhana R. Yannam a , Russell Griffin b , Scott A. Anderson a , Elizabeth A. Beierle a , Mike K. Chen a , Carroll M. Harmon a,⁎ a
Division of Pediatric Surgery, Department of Surgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA b Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA Received 17 February 2013; accepted 9 March 2013
Key words: Appendectomy; Single incision; Laparoscopy; Pediatrics; SIPES; Obesity
Abstract Introduction: Single-incision pediatric endosurgery (SIPES) is gaining popularity and has been reported to be safe in acute (non-perforated) and perforated appendicitis. The feasibility of SIPES appendectomy in obese children is uncertain. Materials and methods: After IRB approval, data were collected from a prospectively maintained SIPES appendectomy database for cases performed between April 2009 and March 2012. Patients were divided into obese and non-obese groups based on Center for Disease Control criteria. The surgical techniques, operative times, complications, conversion rates, and outcomes were recorded. Chi-square test and t-test were used for statistical analysis. Results: SIPES appendectomy was attempted in 500 children. There were 21% obese, and 37% were female with median age of 10.9 ± 3.8 years. Mean operative time, blood loss, requirement of additional trocars, and intraoperative complications in non-obese and obese children were not significantly different. Mean hospital stay (2.3 days in each group), post operative wound infections (3.3% vs. 4.8%, p = 0.55, non-obese vs. obese), and intraabdominal abscesses (4.3% vs. 2.9%, p = 0.77, non-obese vs. obese) were not significantly different. Conclusion: SIPES appendectomy may be accomplished successfully and safely in obese children. Obesity did not appear to be associated with increased risk of complications and was not a contraindication for SIPES appendectomy. © 2013 Elsevier Inc. All rights reserved.
☆
Funding source: None. Disclosure statement: No competing financial interests exist for any of the authors. ⁎ Corresponding author. Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA. Tel.: + 1 205 939 6368; fax: +1 205 975 4972. E-mail address: [email protected] (C.M. Harmon). ☆☆
0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.03.043
Single-incision pediatric endosurgery (SIPES) has gained considerable popularity and is being used for the management of several conditions such as appendectomy and cholecystectomy [1–3]. The theoretical advantages of SIPES over conventional laparoscopic surgery include reduced postoperative pain, faster return to activity and better
1400 cosmesis. Several series have reported the safety and feasibility of SIPES in the treatment of acute appendicitis [4,5]. However, concerns have been raised about SIPES applicability in patients with perforated appendicitis [4,6], patients undergoing interval appendectomy and in obese patients [4,6,7]. We have previously reported our positive experience with the safety and efficacy of SIPES appendectomy in children with perforated appendicitis and for interval appendectomy [5]. The prevalence of obesity in children with appendicitis varies from 17 to 20% [8,9], similar to the current prevalence of childhood obesity (16.9%) in US general population [10]. Obese children may pose technical difficulties during open surgical procedures and are known to be at risk for surgical site infections and intraabdominal abscess [11–14]. Literature on the applicability of SIPES appendectomy in obese children is sparse, limited to one retrospective study in a small series of patients [3]. Our current prospective study was designed to address the safety and feasibility of SIPES appendectomy in obese patients from a large cohort of 500 children. Subgroup analysis was performed to determine whether obesity affects outcome based on the indications of appendicitis and based on level of training of the operating surgeon.
1. Materials and methods 1.1. Data source and study population After obtaining institutional review board approval (#X100104007), a review of all patients less than 19 years of age who underwent SIPES appendectomy at our institution between April 2009 and March 2012 was performed. Data were prospectively collected on all SIPES appendectomy patients performed and the following data were extracted from our SIPES database: age, gender, indication, type of SIPES port used, usage of additional ports, intraoperative events including operative time and blood loss and duration of hospital stay and histopathology. Postoperative complications were assessed during hospital stay and upon follow-up in our outpatient clinic. Data on patients who were subsequently admitted/treated for complications owing to appendectomy were also analyzed. Subgroup analysis was performed according to the primary pathology of the appendix grouped into three categories: acute appendicitis, perforated appendicitis, and children undergoing interval appendectomy, and based on who performed the primary procedure (fellows vs. residents) under supervision of 7 attending pediatric surgeons. Patients were divided into obese and non-obese groups based on Center for Disease Control (CDC) criteria for obesity in children (BMI ≥ 95th percentile for children of the same age and sex). Body mass index (BMI) was calculated using the standard formula of kilograms per meter square and
G.R. Yannam et al. the BMI was plotted on the CDC growth chart to obtain BMI percentile according to age and gender. Our technique for SIPES appendectomy has been previously reported [2,5]. Briefly, all appendectomy operations were performed by an intracorporeal approach and we used the same technique irrespective of body habitus. A vertical skin incision of approximately 1.5–2.0 cm was made in the umbilicus and the underlying fascia opened over a length of 2–2.5 cm to enter the peritoneal cavity. After introducing the SIPES “trocar” (typically a Triport™, Olympus, PA, USA) and a 5 mm, 45°, 45 cm scope (Stryker Endoscopy, San Jose, CA, USA.), the patient was placed in moderate Trendelenburg position with left tilt for better exposure of the right lower quadrant. With reusable 5 mm standard straight laparoscopic instruments and a straight hook electrocautery the appendix was mobilized and the mesoappendix divided. A 12-mm endosurgical stapler (typically 2.5 mm staples) (Covidien, MA USA) was used to staple and divide the appendix at the base. The appendix was extracted through the plastic umbilical SIPES “trocar” thus protecting the wound from the inflamed appendix. After deflating capnoperitoneum, the fascial incision was approximated with a running 2–0 or 0 polyglactin suture. Finally, the skin incision was closed using interrupted subcuticular 4–0 polyglecaprone sutures, with the central stitches anchored to the fascia in order to invert the umbilicus. Additional trocars were added if the surgeon felt that this was necessary to perform a safe operation. If early ruptured appendicitis was suspected preoperatively, those children without an abscess or with the presence of an appendicolith were typically operated within 12 hours. If a clear abscess or mass/phlegmon owing to rupture was appreciated preoperatively, antibiotic treatment was initiated and an interval appendectomy was planned six to eight weeks later. All patients with acute appendicitis and patients with interval appendectomy received one dose of intravenous antibiotics preoperatively. Patients with perforated appendicitis meeting the above criteria for operation received intravenous antibiotics once the diagnosis was established and typically continued for a period of 7–10 days. Patients, who had a preoperative clinical diagnosis of acute appendicitis but were found to have perforation intraoperatively, were also typically treated with 7–10 days of antibiotics. It should be noted that this series includes patients analyzed in our recent report describing our overall experience with SIPES appendectomy for acute appendicitis, perforated appendicitis and interval appendectomy. Concerns of the suitability of SIPES appendectomy for obese patients among the pediatric surgical community encouraged this study.
1.2. Statistical analysis Obese and non-obese appendectomy patients were compared regarding demographic and intraoperative characteristics using Chi-square test and t-test for categorical and
SIPES appendectomy is obesity a contraindication? continuous variables, respectively. A Chi-square test was additionally used to determine whether the distribution of complications differed by obesity status. For all analyses, a p-value b 0.05 was considered statistically significant, and SAS version 9.2 (Cary, NC) was used.
2. Results
Table 2 Comparison of intraoperative characteristics between non-obese and obese appendectomy patients.
Mean Operative time (min) Fellows Residents
We attempted 500 SIPES appendectomies over a 3 year study period. There were 105 (21%) obese children. Comparison of preoperative variables between obese and non obese patients is listed in Table 1. Overall, mean age was 10.9 ± 3.8 years (range 1.4–18.9) and there were 185 females. There was no difference in mean age between obese and non-obese patients. Interestingly, those who were obese were more likely to be between the age of 7 to 10 years and less likely to be female (Table 1). In the overall group, 353 children (70.6%) had acute (non-perforated) appendicitis, 89 children (17.8%) had perforated appendicitis, and 58 children (11.6%) underwent interval appendectomy after previous antibiotic treatment for perforated appendicitis. Obese children compared to non-obese children were more likely to undergo SIPES appendectomy for acute appendicitis (76% vs 69%, p = 0.04). All SIPES appendectomies except one were performed using an intracorporeal approach. To assess the impact of body habitus on the technical difficulty of SIPES appendectomy, we compared intraoperative variables (mean operative time, blood loss, intraoperative complications, requirement of additional trocars to complete the procedure and conversion to open procedure) between obese and non-obese groups (Table 2). There were no differences in regards to operative time or blood loss between obese and non-obese patients. Though mean operative times are higher when residents rather than fellows performed the procedure (46.5 ± 15.4 vs 36.0 ± 15.8 min, p b 0.05), there was no difference in obese and non-obese groups based on level of training (Table 2). There was a clear Table 1 Comparison of preoperative characteristics between non-obese and obese appendectomy patients.
Age (Years) Mean 0–6 years (%) 7–10 years (%) N 11 years (%) Female (%) Mean weight (kg) Indications Acute Appendicitis Perforated Appendicitis Interval Appendectomy
1401
Non-obese (n = 395)
Obese (n = 105)
p-value
10.8 ± 4.0 82 (20.8) 107 (27.1) 206 (52.2) 158 (40.0) 40.0 ± 16.3
11.2 ± 3.3 0.2335 10 (9.5) 45 (42.9) 0.0016 50 (47.6) 27 (25.7) 0.0087 64.7 ± 25.0 b 0.0001
273 (69.1) 53 (13.4) 69 (17.5)
80 (76.2) 5 (4.8) 20 (19.0)
0.0400
Blood loss (ml) Conversion to lap (%) Additional trocars Intraoperative complications
Non-obese (n = 395)
Obese (n = 105)
p-value
38.9 ± 16.7
40.7 ± 14.9
0.3235
35.9 ± 16.1 (n = 276) 46.2 ± 16.0 (n = 116) 3.7 ± 7.4 16 (4.1)
36.9 ± 14.4 (n = 68) 47.7 ± 13.4 (n = 37) 4.8 ± 6.1 2 (1.9)
0.6389
(DILS 12, (DILS 1, TILS 3, open 1) TILS 1) 0 3#
0.5960 0.1303
0.3880 NA
DILS- 1 additional port, TILS- 2 additional ports. # 1 cecal thermal injury which was implicated via SIPES, 1 cecal serosal injury, which was sutured, 1 stapler malfunction required imbricating staple line.
learning curve for SIPES appendectomy and noted across all groups. Mean operative times for all patients, obese and nonobese groups were significantly shorter with experience. We compared operative times between first 25 cases (44.3 ± 16.7 min) to last 25 cases (35.3 ± 13.5 min) in the obese group (p = 0.04), first 100 cases (38.9 ± 12.4 min) with last 100 cases (33.8 ± 13.2 min) in non-obese group (p = 0.005), and first 100 cases (41.0 ± 13.5 min) with last 100 cases (34.2 ± 13.5 min) in the entire group (p = 0.0005). One patient in the non-obese group required conversion to an open procedure owing to appendiceal phlegmon. Sixteen patients (4%) in the non-obese and 2 in obese (2%) group required additional trocar placement. There were 3 intraoperative complications, all of which occurred in the nonobese children: 1 coagulation injury to the cecum, which was stapled; 1 cecal serosal tear which was caused during trocar placement and sutured after conversion to conventional 3 trocar laparoscopy and one questionable defective staple line which was imbricated by a 3–0 vicryl suture using intracorporeal suturing (Table 2). Comparison of pathologic diagnoses between obese and non-obese patients is shown in Table 3. Obese patients were more likely than non-obese patients to have an either acute and/or perforated appendicitis. To assess the impact of body habitus on surgical stress and postoperative outcomes, we compared postoperative hospital stay and complication risks between obese and non-obese groups (Table 4). Mean hospital stay between groups was similar. Wound infection, intraabdominal abscess and other complications along with type of management required are listed in Table 4. Postoperative wound infection and intraabdominal abscess rates in the obese group were similar to the non-obese group. Other complications in obese patients included postoperative abdominal pain requiring hospital/ER admission
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G.R. Yannam et al.
Table 3 Comparison of histopathological types between nonobese and obese group. Non-obese Obese p-value (n = 395) (n = 105) Pathology (%) Acute/perforated appendicitis 315 (79.6) 94 (89.7) 0.0464 Post inflammatory changes 54 (13.7) 5 (4.7) after interval appendectomy No pathological change 16 (4.1) 4 (3.7) Other pathology 10 (2.5) 2 (1.9) Fecolith (%) Yes 96 (24.4) 17 (15.9) 0.0681 No 299 (75.6) 88 (84.1)
in 2 patients. One of them underwent diagnostic laparoscopy for suspected incisional hernia which was not found. Two patients were admitted for fever of undetermined etiology and one patient with ruptured appendicitis and fulminate sepsis required a chest tube for pleural effusion. Other complications in the non-obese group included 4 patients admitted for fever of undetermined etiology, 3 patients admitted/ER visits with non-specific abdominal pain, Clostridium difficile colitis in 3, prolonged ileus in 2, bleeding from the umbilical wound in 1, and 1 small bowel obstruction which was successfully managed non-operatively. There was no association between obese and non-obese patients regarding the risk of wound infection, intraabdominal abscess, or other miscellaneous complications following SIPES appendectomy (Table 4).
3. Discussion Childhood obesity is a major health problem in the United States. The prevalence of obesity among children and adolescents has more than tripled in the last 3 decades, and the latest CDC estimate on the prevalence of obesity in children and adolescents for year 2009–2010 was 16.9% Table 4 Comparison of postoperative variables between nonobese and obese appendectomy patients.
Mean Hospital Stay (days) Wound infection (%) Treated Medically (%) Treated Surgically (%) Intra-abdominal abscess (%) Antibiotics only (%) Interventional Radiology drainage (%) Surgical Drainage (%) Other complications (%)
Non-obese (n = 395)
Obese p-value (n = 105)
2.3 ± 3.0 13 (3.3%) 11 (84.6%) 2 (15.4%) 17 (4.3) 10 (58.8%) 4 (23.5%)
2.3 ± 4.1 5 (4.8%) 4 (80%) 1 (20%) 3 (2.9) 1 (33.3%) 2 (66.7%)
3 (17.6%) 14 (3.5)
0 (0.0) 5 (4.8)
0.9882 0.5536 0.8139 0.7789 0.5368
0.5675
[10]. Obese children may be at risk for both short and longterm health consequences and it is important for the pediatric surgical community to understand the effects of obesity on specific surgical diseases. The prevalence of obesity reportedly varies from 17–20% of children presenting with appendicitis [8,9], comparable to our series and corresponding to the prevalence of obesity in general population [10]. Obesity in adults is associated with delays in diagnosis, challenging operative exposure and technique, complicated postoperative recovery such as prolonged hospital stays, increased surgical site infections and intraabdominal abscesses [11–14]. Studies in adults have shown that laparoscopic operations were especially advantageous for obese patients and shown to be associated with fewer infections and improved surgical outcomes compared to open operations [15,16]. In a recent Cochrane review, the overall benefit of adult laparoscopic appendectomy over open was small, but significantly better outcomes (lower wound infection and shorter hospital stay) were observed in obese vs. non-obese patients [17]. Other studies also confirmed that obese patients specifically benefited from laparoscopic appendectomy compared to open procedure (lower morbidity and shorter hospital stay) and authors concluded that laparoscopy should be preferred technique for obese patients [18,19]. Single port access laparoscopic procedures are gaining rapid acceptance in obese adults. Several studies reported its safety and feasibility in bariatric surgery [20], donor nephrectomy [21] and for various gynecological procedures [22]. Information on SIPES procedures in obese children is very limited with only a single report of SIPES appendectomy in obese children [3]. In children several studies [23,24], similar to our previous study [25], have concluded that laparoscopic appendectomy provides considerable benefit over open procedure in terms of shorter hospital stay, less postoperative pain and faster convalescence, and a lower complication rates. We and others [26] have recently reported that operative times were less with SIPES appendectomy compared to standard 3-port appendectomy in children [4,5,27]. Data on outcomes of traditional 3 port laparoscopic appendectomy in obese children are sparse with a few studies reporting a trend toward longer operative times, hospital stay, and increased postoperative complication rates in obese patients [8,28]. Others have reported shorter operating times and hospital stays with lower complication rates [9]. To date there has been only one published report of SIPES appendectomy in obese children (n = 29) compared with non-obese children (n = 65). Our report concurs with this report, noting comparable operating times [3]. SSI and intra-abdominal abscess rates were comparable in obese and nonobese patients in our study. There have been reports showing that wound infections and intraabdominal abscess rates are higher in obese patients after open surgery [11–14] but wound infection and intraabdominal abscess rates were lower with laparoscopic surgery in adults [15–17]. Reports in the pediatric literature echo those in adults with
SIPES appendectomy is obesity a contraindication? decreased infections with the use of laparoscopy [3,8,9]. Similar infection rates to ours were noted in another SIPES appendectomy study comparing obese vs. non-obese patients [3]. Higher rates of intraabdominal abscess reported in some studies [8,28] after laparoscopic appendectomy may be related to technical difficulty in exteriorizing the appendix in obese patients [8]. We believe that our low SSI rate in non-obese and especially in obese patients may have been owing to these factors: a) completion of the entire procedure intracorporeally to reduce the risk of rupturing the inflamed appendix, more so in cases with extensive inflammation/gangrenous appendix; b) use of a trocar that protects the wound as the appendix is extracted that allows for specimen removal without the need for an endoscopic retrieval bag. Endoscopic retrieval bag was early in our experience when the SILSTM (Covidien, Mansfield, MA, USA) port or staggered conventional trocars used for SIPES procedures for wound protection and low cost vacuum dressing to cover the umbilical incision may contribute to a certain extent as well [29]. Although the actual benefits of single-incision surgery have yet to be determined, the potential benefits include less postoperative pain, improved cosmesis, and increased patient satisfaction. It had been debated whether SIPES causes more postoperative pain than conventional 3 port laparoscopic appendectomy. Although not systematically assessed in this study, our overall impression has been that the post operative analgesics requirement is similar between conventional 3 port laparoscopic appendectomy and SIPES appendectomy in general. In addition, there has not been a clear difference between post SIPES appendectomy analgesia between obese and non obese children. Other studies have reported that analgesic requirements are not different [4,27] or lower [30] comparing SIPES appendectomy with 3-port appendectomy in children. Another fundamental point of controversy regarding single site laparoscopic surgery is the question as to whether there is a cosmetic benefit and patient satisfaction. SIPES procedures are regarded to provide excellent results in cosmesis with almost no visible scar. Yet, the importance of the cosmesis has been challenged as patients also seem to be quite satisfied after conventional laparoscopic surgery [14]. In a small retrospective study in adults after cholecystectomy, SIPES did not offer any cosmetic advantage over conventional laparoscopic cholecystectomy [31] and a large multicenter, double blinded randomized controlled trial is underway [32]. Though having only one incision hidden in the base of the umbilicus instead of 3 incisions with 2 being outside of the umbilicus might logically be considered to be more cosmetic, there is an ongoing debate about this among surgeons [33–37]. We believe that there is a learning curve to being able to make a SIPES incision hidden in the umbilical base and in closing the wound in a way that minimizes post operative umbilical deformity. Early in our SIPES experience we had several patients or parents who were concerned about the post operative umbilical appear-
1403 ance; however, with experience we have rarely had concerns expressed in our last 600 cases. In fact, a fairly common experience is for the parent of one of our SIPES children who has had a traditional 3 port appendectomy (or 4 port cholecystectomy) to praise their child's hidden incision; often times demonstrating their own extra trocar scars in the clinic. Regarding obesity, making an incision and entering the peritoneal cavity in the deep umbilicus of an obese patient may present a technical challenge; however the post operative cosmetic appearance is even more dramatic than perhaps in a thin patient. Certainly, a systematic evaluation of the patient and/or parents view of the potential benefit of SIPES procedures is needed in the future. Concerns have been raised of increased risk of ventral hernia in patients, especially obese patients, undergoing single site laparoscopic surgery (adults or children) because of the single larger incision compared to multiple smaller trocar incisions. There was one study, comparing rate of incisional hernia after SIPES procedures with conventional laparoscopy in adults. After a median postoperative follow-up time of 16 months, the incidence of incisional hernia was 2.4% after 211 SIPES procedures for gynecological indication and obesity was the only factor associated with this complication [22]. To date, there have been no reports of this complication after SIPES procedures in children, and we did not encounter this complication in our appendectomy study population. The risk for a ventral hernia appears negligible as we have encountered only a single case of incisional hernia (after a fundoplication in a malnourished child) in over 800 SIPES procedures (unpublished data). As with any retrospective clinical trial, there were some limitations with this study. A significant percent of children have follow-up limited to one postoperative visit, prohibiting the ability to assess long-term complications such as incisional hernia and cosmetic benefit in a definitive way. In addition, there is the possibility that the outcomes were affected by either different types of trocars used or the fact that 7 different surgeons performed the procedures. However, we expect any bias resulting from trocar type or surgeon performance to be no differential between obese and nonobese children. We did not assess postoperative pain and cosmesis using standard instruments. Based on our large experience, SIPES appendectomy has become the procedure of choice for any appendiceal pathology at our institution. Our study suggests that obesity was not a contraindication for SIPES appendectomy and body habitus does not adversely affect the intraoperative or short-term postoperative outcomes.
Acknowledgments Authors acknowledge the help of Ms. Kristi Parker, Ms. Donna Bartle and Dr Benjamin Tuanama, MD in the preparation of manuscript.
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Single incision pediatric endosurgery (SIPES) appendectomy—is obesity a contraindication?☆,☆☆ Govardhana R. Yannam a , Russell Griffin b , Scott A. Anderson a , Elizabeth A. Beierle a , Mike K. Chen a , Carroll M. Harmon a,⁎ a
Division of Pediatric Surgery, Department of Surgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA b Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA Received 17 February 2013; accepted 9 March 2013
Key words: Appendectomy; Single incision; Laparoscopy; Pediatrics; SIPES; Obesity
Abstract Introduction: Single-incision pediatric endosurgery (SIPES) is gaining popularity and has been reported to be safe in acute (non-perforated) and perforated appendicitis. The feasibility of SIPES appendectomy in obese children is uncertain. Materials and methods: After IRB approval, data were collected from a prospectively maintained SIPES appendectomy database for cases performed between April 2009 and March 2012. Patients were divided into obese and non-obese groups based on Center for Disease Control criteria. The surgical techniques, operative times, complications, conversion rates, and outcomes were recorded. Chi-square test and t-test were used for statistical analysis. Results: SIPES appendectomy was attempted in 500 children. There were 21% obese, and 37% were female with median age of 10.9 ± 3.8 years. Mean operative time, blood loss, requirement of additional trocars, and intraoperative complications in non-obese and obese children were not significantly different. Mean hospital stay (2.3 days in each group), post operative wound infections (3.3% vs. 4.8%, p = 0.55, non-obese vs. obese), and intraabdominal abscesses (4.3% vs. 2.9%, p = 0.77, non-obese vs. obese) were not significantly different. Conclusion: SIPES appendectomy may be accomplished successfully and safely in obese children. Obesity did not appear to be associated with increased risk of complications and was not a contraindication for SIPES appendectomy. © 2013 Elsevier Inc. All rights reserved.
☆
Funding source: None. Disclosure statement: No competing financial interests exist for any of the authors. ⁎ Corresponding author. Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA. Tel.: + 1 205 939 6368; fax: +1 205 975 4972. E-mail address: [email protected] (C.M. Harmon). ☆☆
0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.03.043
Single-incision pediatric endosurgery (SIPES) has gained considerable popularity and is being used for the management of several conditions such as appendectomy and cholecystectomy [1–3]. The theoretical advantages of SIPES over conventional laparoscopic surgery include reduced postoperative pain, faster return to activity and better
1400 cosmesis. Several series have reported the safety and feasibility of SIPES in the treatment of acute appendicitis [4,5]. However, concerns have been raised about SIPES applicability in patients with perforated appendicitis [4,6], patients undergoing interval appendectomy and in obese patients [4,6,7]. We have previously reported our positive experience with the safety and efficacy of SIPES appendectomy in children with perforated appendicitis and for interval appendectomy [5]. The prevalence of obesity in children with appendicitis varies from 17 to 20% [8,9], similar to the current prevalence of childhood obesity (16.9%) in US general population [10]. Obese children may pose technical difficulties during open surgical procedures and are known to be at risk for surgical site infections and intraabdominal abscess [11–14]. Literature on the applicability of SIPES appendectomy in obese children is sparse, limited to one retrospective study in a small series of patients [3]. Our current prospective study was designed to address the safety and feasibility of SIPES appendectomy in obese patients from a large cohort of 500 children. Subgroup analysis was performed to determine whether obesity affects outcome based on the indications of appendicitis and based on level of training of the operating surgeon.
1. Materials and methods 1.1. Data source and study population After obtaining institutional review board approval (#X100104007), a review of all patients less than 19 years of age who underwent SIPES appendectomy at our institution between April 2009 and March 2012 was performed. Data were prospectively collected on all SIPES appendectomy patients performed and the following data were extracted from our SIPES database: age, gender, indication, type of SIPES port used, usage of additional ports, intraoperative events including operative time and blood loss and duration of hospital stay and histopathology. Postoperative complications were assessed during hospital stay and upon follow-up in our outpatient clinic. Data on patients who were subsequently admitted/treated for complications owing to appendectomy were also analyzed. Subgroup analysis was performed according to the primary pathology of the appendix grouped into three categories: acute appendicitis, perforated appendicitis, and children undergoing interval appendectomy, and based on who performed the primary procedure (fellows vs. residents) under supervision of 7 attending pediatric surgeons. Patients were divided into obese and non-obese groups based on Center for Disease Control (CDC) criteria for obesity in children (BMI ≥ 95th percentile for children of the same age and sex). Body mass index (BMI) was calculated using the standard formula of kilograms per meter square and
G.R. Yannam et al. the BMI was plotted on the CDC growth chart to obtain BMI percentile according to age and gender. Our technique for SIPES appendectomy has been previously reported [2,5]. Briefly, all appendectomy operations were performed by an intracorporeal approach and we used the same technique irrespective of body habitus. A vertical skin incision of approximately 1.5–2.0 cm was made in the umbilicus and the underlying fascia opened over a length of 2–2.5 cm to enter the peritoneal cavity. After introducing the SIPES “trocar” (typically a Triport™, Olympus, PA, USA) and a 5 mm, 45°, 45 cm scope (Stryker Endoscopy, San Jose, CA, USA.), the patient was placed in moderate Trendelenburg position with left tilt for better exposure of the right lower quadrant. With reusable 5 mm standard straight laparoscopic instruments and a straight hook electrocautery the appendix was mobilized and the mesoappendix divided. A 12-mm endosurgical stapler (typically 2.5 mm staples) (Covidien, MA USA) was used to staple and divide the appendix at the base. The appendix was extracted through the plastic umbilical SIPES “trocar” thus protecting the wound from the inflamed appendix. After deflating capnoperitoneum, the fascial incision was approximated with a running 2–0 or 0 polyglactin suture. Finally, the skin incision was closed using interrupted subcuticular 4–0 polyglecaprone sutures, with the central stitches anchored to the fascia in order to invert the umbilicus. Additional trocars were added if the surgeon felt that this was necessary to perform a safe operation. If early ruptured appendicitis was suspected preoperatively, those children without an abscess or with the presence of an appendicolith were typically operated within 12 hours. If a clear abscess or mass/phlegmon owing to rupture was appreciated preoperatively, antibiotic treatment was initiated and an interval appendectomy was planned six to eight weeks later. All patients with acute appendicitis and patients with interval appendectomy received one dose of intravenous antibiotics preoperatively. Patients with perforated appendicitis meeting the above criteria for operation received intravenous antibiotics once the diagnosis was established and typically continued for a period of 7–10 days. Patients, who had a preoperative clinical diagnosis of acute appendicitis but were found to have perforation intraoperatively, were also typically treated with 7–10 days of antibiotics. It should be noted that this series includes patients analyzed in our recent report describing our overall experience with SIPES appendectomy for acute appendicitis, perforated appendicitis and interval appendectomy. Concerns of the suitability of SIPES appendectomy for obese patients among the pediatric surgical community encouraged this study.
1.2. Statistical analysis Obese and non-obese appendectomy patients were compared regarding demographic and intraoperative characteristics using Chi-square test and t-test for categorical and
SIPES appendectomy is obesity a contraindication? continuous variables, respectively. A Chi-square test was additionally used to determine whether the distribution of complications differed by obesity status. For all analyses, a p-value b 0.05 was considered statistically significant, and SAS version 9.2 (Cary, NC) was used.
2. Results
Table 2 Comparison of intraoperative characteristics between non-obese and obese appendectomy patients.
Mean Operative time (min) Fellows Residents
We attempted 500 SIPES appendectomies over a 3 year study period. There were 105 (21%) obese children. Comparison of preoperative variables between obese and non obese patients is listed in Table 1. Overall, mean age was 10.9 ± 3.8 years (range 1.4–18.9) and there were 185 females. There was no difference in mean age between obese and non-obese patients. Interestingly, those who were obese were more likely to be between the age of 7 to 10 years and less likely to be female (Table 1). In the overall group, 353 children (70.6%) had acute (non-perforated) appendicitis, 89 children (17.8%) had perforated appendicitis, and 58 children (11.6%) underwent interval appendectomy after previous antibiotic treatment for perforated appendicitis. Obese children compared to non-obese children were more likely to undergo SIPES appendectomy for acute appendicitis (76% vs 69%, p = 0.04). All SIPES appendectomies except one were performed using an intracorporeal approach. To assess the impact of body habitus on the technical difficulty of SIPES appendectomy, we compared intraoperative variables (mean operative time, blood loss, intraoperative complications, requirement of additional trocars to complete the procedure and conversion to open procedure) between obese and non-obese groups (Table 2). There were no differences in regards to operative time or blood loss between obese and non-obese patients. Though mean operative times are higher when residents rather than fellows performed the procedure (46.5 ± 15.4 vs 36.0 ± 15.8 min, p b 0.05), there was no difference in obese and non-obese groups based on level of training (Table 2). There was a clear Table 1 Comparison of preoperative characteristics between non-obese and obese appendectomy patients.
Age (Years) Mean 0–6 years (%) 7–10 years (%) N 11 years (%) Female (%) Mean weight (kg) Indications Acute Appendicitis Perforated Appendicitis Interval Appendectomy
1401
Non-obese (n = 395)
Obese (n = 105)
p-value
10.8 ± 4.0 82 (20.8) 107 (27.1) 206 (52.2) 158 (40.0) 40.0 ± 16.3
11.2 ± 3.3 0.2335 10 (9.5) 45 (42.9) 0.0016 50 (47.6) 27 (25.7) 0.0087 64.7 ± 25.0 b 0.0001
273 (69.1) 53 (13.4) 69 (17.5)
80 (76.2) 5 (4.8) 20 (19.0)
0.0400
Blood loss (ml) Conversion to lap (%) Additional trocars Intraoperative complications
Non-obese (n = 395)
Obese (n = 105)
p-value
38.9 ± 16.7
40.7 ± 14.9
0.3235
35.9 ± 16.1 (n = 276) 46.2 ± 16.0 (n = 116) 3.7 ± 7.4 16 (4.1)
36.9 ± 14.4 (n = 68) 47.7 ± 13.4 (n = 37) 4.8 ± 6.1 2 (1.9)
0.6389
(DILS 12, (DILS 1, TILS 3, open 1) TILS 1) 0 3#
0.5960 0.1303
0.3880 NA
DILS- 1 additional port, TILS- 2 additional ports. # 1 cecal thermal injury which was implicated via SIPES, 1 cecal serosal injury, which was sutured, 1 stapler malfunction required imbricating staple line.
learning curve for SIPES appendectomy and noted across all groups. Mean operative times for all patients, obese and nonobese groups were significantly shorter with experience. We compared operative times between first 25 cases (44.3 ± 16.7 min) to last 25 cases (35.3 ± 13.5 min) in the obese group (p = 0.04), first 100 cases (38.9 ± 12.4 min) with last 100 cases (33.8 ± 13.2 min) in non-obese group (p = 0.005), and first 100 cases (41.0 ± 13.5 min) with last 100 cases (34.2 ± 13.5 min) in the entire group (p = 0.0005). One patient in the non-obese group required conversion to an open procedure owing to appendiceal phlegmon. Sixteen patients (4%) in the non-obese and 2 in obese (2%) group required additional trocar placement. There were 3 intraoperative complications, all of which occurred in the nonobese children: 1 coagulation injury to the cecum, which was stapled; 1 cecal serosal tear which was caused during trocar placement and sutured after conversion to conventional 3 trocar laparoscopy and one questionable defective staple line which was imbricated by a 3–0 vicryl suture using intracorporeal suturing (Table 2). Comparison of pathologic diagnoses between obese and non-obese patients is shown in Table 3. Obese patients were more likely than non-obese patients to have an either acute and/or perforated appendicitis. To assess the impact of body habitus on surgical stress and postoperative outcomes, we compared postoperative hospital stay and complication risks between obese and non-obese groups (Table 4). Mean hospital stay between groups was similar. Wound infection, intraabdominal abscess and other complications along with type of management required are listed in Table 4. Postoperative wound infection and intraabdominal abscess rates in the obese group were similar to the non-obese group. Other complications in obese patients included postoperative abdominal pain requiring hospital/ER admission
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G.R. Yannam et al.
Table 3 Comparison of histopathological types between nonobese and obese group. Non-obese Obese p-value (n = 395) (n = 105) Pathology (%) Acute/perforated appendicitis 315 (79.6) 94 (89.7) 0.0464 Post inflammatory changes 54 (13.7) 5 (4.7) after interval appendectomy No pathological change 16 (4.1) 4 (3.7) Other pathology 10 (2.5) 2 (1.9) Fecolith (%) Yes 96 (24.4) 17 (15.9) 0.0681 No 299 (75.6) 88 (84.1)
in 2 patients. One of them underwent diagnostic laparoscopy for suspected incisional hernia which was not found. Two patients were admitted for fever of undetermined etiology and one patient with ruptured appendicitis and fulminate sepsis required a chest tube for pleural effusion. Other complications in the non-obese group included 4 patients admitted for fever of undetermined etiology, 3 patients admitted/ER visits with non-specific abdominal pain, Clostridium difficile colitis in 3, prolonged ileus in 2, bleeding from the umbilical wound in 1, and 1 small bowel obstruction which was successfully managed non-operatively. There was no association between obese and non-obese patients regarding the risk of wound infection, intraabdominal abscess, or other miscellaneous complications following SIPES appendectomy (Table 4).
3. Discussion Childhood obesity is a major health problem in the United States. The prevalence of obesity among children and adolescents has more than tripled in the last 3 decades, and the latest CDC estimate on the prevalence of obesity in children and adolescents for year 2009–2010 was 16.9% Table 4 Comparison of postoperative variables between nonobese and obese appendectomy patients.
Mean Hospital Stay (days) Wound infection (%) Treated Medically (%) Treated Surgically (%) Intra-abdominal abscess (%) Antibiotics only (%) Interventional Radiology drainage (%) Surgical Drainage (%) Other complications (%)
Non-obese (n = 395)
Obese p-value (n = 105)
2.3 ± 3.0 13 (3.3%) 11 (84.6%) 2 (15.4%) 17 (4.3) 10 (58.8%) 4 (23.5%)
2.3 ± 4.1 5 (4.8%) 4 (80%) 1 (20%) 3 (2.9) 1 (33.3%) 2 (66.7%)
3 (17.6%) 14 (3.5)
0 (0.0) 5 (4.8)
0.9882 0.5536 0.8139 0.7789 0.5368
0.5675
[10]. Obese children may be at risk for both short and longterm health consequences and it is important for the pediatric surgical community to understand the effects of obesity on specific surgical diseases. The prevalence of obesity reportedly varies from 17–20% of children presenting with appendicitis [8,9], comparable to our series and corresponding to the prevalence of obesity in general population [10]. Obesity in adults is associated with delays in diagnosis, challenging operative exposure and technique, complicated postoperative recovery such as prolonged hospital stays, increased surgical site infections and intraabdominal abscesses [11–14]. Studies in adults have shown that laparoscopic operations were especially advantageous for obese patients and shown to be associated with fewer infections and improved surgical outcomes compared to open operations [15,16]. In a recent Cochrane review, the overall benefit of adult laparoscopic appendectomy over open was small, but significantly better outcomes (lower wound infection and shorter hospital stay) were observed in obese vs. non-obese patients [17]. Other studies also confirmed that obese patients specifically benefited from laparoscopic appendectomy compared to open procedure (lower morbidity and shorter hospital stay) and authors concluded that laparoscopy should be preferred technique for obese patients [18,19]. Single port access laparoscopic procedures are gaining rapid acceptance in obese adults. Several studies reported its safety and feasibility in bariatric surgery [20], donor nephrectomy [21] and for various gynecological procedures [22]. Information on SIPES procedures in obese children is very limited with only a single report of SIPES appendectomy in obese children [3]. In children several studies [23,24], similar to our previous study [25], have concluded that laparoscopic appendectomy provides considerable benefit over open procedure in terms of shorter hospital stay, less postoperative pain and faster convalescence, and a lower complication rates. We and others [26] have recently reported that operative times were less with SIPES appendectomy compared to standard 3-port appendectomy in children [4,5,27]. Data on outcomes of traditional 3 port laparoscopic appendectomy in obese children are sparse with a few studies reporting a trend toward longer operative times, hospital stay, and increased postoperative complication rates in obese patients [8,28]. Others have reported shorter operating times and hospital stays with lower complication rates [9]. To date there has been only one published report of SIPES appendectomy in obese children (n = 29) compared with non-obese children (n = 65). Our report concurs with this report, noting comparable operating times [3]. SSI and intra-abdominal abscess rates were comparable in obese and nonobese patients in our study. There have been reports showing that wound infections and intraabdominal abscess rates are higher in obese patients after open surgery [11–14] but wound infection and intraabdominal abscess rates were lower with laparoscopic surgery in adults [15–17]. Reports in the pediatric literature echo those in adults with
SIPES appendectomy is obesity a contraindication? decreased infections with the use of laparoscopy [3,8,9]. Similar infection rates to ours were noted in another SIPES appendectomy study comparing obese vs. non-obese patients [3]. Higher rates of intraabdominal abscess reported in some studies [8,28] after laparoscopic appendectomy may be related to technical difficulty in exteriorizing the appendix in obese patients [8]. We believe that our low SSI rate in non-obese and especially in obese patients may have been owing to these factors: a) completion of the entire procedure intracorporeally to reduce the risk of rupturing the inflamed appendix, more so in cases with extensive inflammation/gangrenous appendix; b) use of a trocar that protects the wound as the appendix is extracted that allows for specimen removal without the need for an endoscopic retrieval bag. Endoscopic retrieval bag was early in our experience when the SILSTM (Covidien, Mansfield, MA, USA) port or staggered conventional trocars used for SIPES procedures for wound protection and low cost vacuum dressing to cover the umbilical incision may contribute to a certain extent as well [29]. Although the actual benefits of single-incision surgery have yet to be determined, the potential benefits include less postoperative pain, improved cosmesis, and increased patient satisfaction. It had been debated whether SIPES causes more postoperative pain than conventional 3 port laparoscopic appendectomy. Although not systematically assessed in this study, our overall impression has been that the post operative analgesics requirement is similar between conventional 3 port laparoscopic appendectomy and SIPES appendectomy in general. In addition, there has not been a clear difference between post SIPES appendectomy analgesia between obese and non obese children. Other studies have reported that analgesic requirements are not different [4,27] or lower [30] comparing SIPES appendectomy with 3-port appendectomy in children. Another fundamental point of controversy regarding single site laparoscopic surgery is the question as to whether there is a cosmetic benefit and patient satisfaction. SIPES procedures are regarded to provide excellent results in cosmesis with almost no visible scar. Yet, the importance of the cosmesis has been challenged as patients also seem to be quite satisfied after conventional laparoscopic surgery [14]. In a small retrospective study in adults after cholecystectomy, SIPES did not offer any cosmetic advantage over conventional laparoscopic cholecystectomy [31] and a large multicenter, double blinded randomized controlled trial is underway [32]. Though having only one incision hidden in the base of the umbilicus instead of 3 incisions with 2 being outside of the umbilicus might logically be considered to be more cosmetic, there is an ongoing debate about this among surgeons [33–37]. We believe that there is a learning curve to being able to make a SIPES incision hidden in the umbilical base and in closing the wound in a way that minimizes post operative umbilical deformity. Early in our SIPES experience we had several patients or parents who were concerned about the post operative umbilical appear-
1403 ance; however, with experience we have rarely had concerns expressed in our last 600 cases. In fact, a fairly common experience is for the parent of one of our SIPES children who has had a traditional 3 port appendectomy (or 4 port cholecystectomy) to praise their child's hidden incision; often times demonstrating their own extra trocar scars in the clinic. Regarding obesity, making an incision and entering the peritoneal cavity in the deep umbilicus of an obese patient may present a technical challenge; however the post operative cosmetic appearance is even more dramatic than perhaps in a thin patient. Certainly, a systematic evaluation of the patient and/or parents view of the potential benefit of SIPES procedures is needed in the future. Concerns have been raised of increased risk of ventral hernia in patients, especially obese patients, undergoing single site laparoscopic surgery (adults or children) because of the single larger incision compared to multiple smaller trocar incisions. There was one study, comparing rate of incisional hernia after SIPES procedures with conventional laparoscopy in adults. After a median postoperative follow-up time of 16 months, the incidence of incisional hernia was 2.4% after 211 SIPES procedures for gynecological indication and obesity was the only factor associated with this complication [22]. To date, there have been no reports of this complication after SIPES procedures in children, and we did not encounter this complication in our appendectomy study population. The risk for a ventral hernia appears negligible as we have encountered only a single case of incisional hernia (after a fundoplication in a malnourished child) in over 800 SIPES procedures (unpublished data). As with any retrospective clinical trial, there were some limitations with this study. A significant percent of children have follow-up limited to one postoperative visit, prohibiting the ability to assess long-term complications such as incisional hernia and cosmetic benefit in a definitive way. In addition, there is the possibility that the outcomes were affected by either different types of trocars used or the fact that 7 different surgeons performed the procedures. However, we expect any bias resulting from trocar type or surgeon performance to be no differential between obese and nonobese children. We did not assess postoperative pain and cosmesis using standard instruments. Based on our large experience, SIPES appendectomy has become the procedure of choice for any appendiceal pathology at our institution. Our study suggests that obesity was not a contraindication for SIPES appendectomy and body habitus does not adversely affect the intraoperative or short-term postoperative outcomes.
Acknowledgments Authors acknowledge the help of Ms. Kristi Parker, Ms. Donna Bartle and Dr Benjamin Tuanama, MD in the preparation of manuscript.
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