New Primaly Management for Appendiceal Abscess in Children: Laparoscopic Drainage

Purpose: The management of appendiceal abscess (AA) in children remains controversial. We evaluated primary laparoscopic treatment for efficacy. Methods: Eleven consecutive cases of AA (mean age: 8.1 2.8) between 2000 and 2004 were the subjects for this study. All had laparoscopic drainage (LD) at presentation (two Penrose drains were used; one within the abscess wall and the other within the pouch of Douglas). If the appendix was easily seen after LD, laparoscopic appendectomy (LA) was also performed. Results: Eight patients underwent LD alone (LD-group) and 3 underwent LD/LA (LA-group). In the LD-group, mean operating time was 87.9 23.2 minutes, oral feeding commenced after a mean of 2.3 0.8 days, patients became afebrile within 4.3 3.1 days, intravenous antibiotics were ceased after 5.3 3.1 days, C-reactive protein normalized within 13.6 4.2 days, drains were removed within 4.0 1.3 days, and hospital stay ranged from 7-15 days. There were no intraor post-operative complications related to the LD procedure. In 6 of the 8 LD patients, interval LA was performed at 6.8 5.8 months after LD, but was not performed in the remaining 2 due to parental refusal. In the LA-group, operating time ranged from 125-150 minutes, and oral feeding commenced 4, 5, and 5 days after LA, respectively. One patient developed an adhesive bowel obstruction after LA, which resolved with conservative therapy; in the remaining 2, there were no complications. All 11 patients are well after a mean follow-up period of 3.1 1.1 years. Histological examination of the excised appendices showed mild to severe inflammation. Conclusion: We recommend that laparoscopy be adopted for the primary management of AA as it would appear to be simple, safe, and effective. LAPAROSCOPIC TREATMENT OF A SMALL BOWEL VOLVULUS SECONDARY TO AN OMPHALO-MESENTERIC REMNANT Mario Mendoza-Sagaon MD, Rudolf Leuthardt MD, Servizio Cantonale di Chirurgia Pediatrica, Ospedale Regionale di Bellinzona e Valli, Switzerland Omphalo-mesenteric remnants such as Meckel diverticulum, fistulas and fibrous or vascular cords are common causes of small bowel obstruction in children. We present a case of a child with a small bowel volvulus secondary to a vascular omphalo-mesenteric remnant that was diagnosed and operated with a laparoscopic approach. A 9 year-old boy known for chronic episodes of abdominal pain with spontaneous resolution and a glandular hypospadias arrived in our institution with acute abdominal pain in the right hemiabdomen associated to biliar vomiting and abdominal distension. Clinical exam showed a painful distended abdomen with a palpable mass in the right hemiabdomen. The abdominal scanner showed data compatible with small bowel obstruction and a vascular structure coming from the umbilicus to the area of the intestinal obstruction. The child underwent laparoscopic exploration and a small bowel volvulus with intestinal ischemia was diagnosed. A vascular remnant coming from the umbilicus to the mesentery was at the base of the volvulus. After bowel detorsion and resection of the vascular cord the color and peristalsis of the bowel recovered and the intestinal resection was not necessary. The child was discharged on postoperative day 3. Exploratory laparoscopy is a safe and feasible option to evaluate children with intestinal obstruction and depending on the findings and the surgeon laparoscopic skills, a full surgical correction without open conversion could be achieved.