Retrospective analysis of laparoscopic management for pediatric complicated appendicitis with concurrent inguinal hernia at a tertiary center
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Key findings
• Simultaneous laparoscopic surgery for complicated appendicitis with concurrent inguinal hernia in children is safe and effective. Compared to staged surgery, it shortens hospital stay and reduces postoperative antibiotic use, with no increase in complications or hernia recurrence.
What is known and what is new?
• Managing coexisting complicated appendicitis and inguinal hernia in children is controversial due to concerns about infection risk during hernia repair. Traditionally, hernia repair is delayed to avoid complications.
• This study shows that simultaneous laparoscopic management is feasible even in the presence of significant intra-abdominal contamination. The approach is associated with favorable perioperative outcomes and avoids the need for a second hospitalization.
What is the implications, and what should change now?
• This study supports the use of simultaneous laparoscopic surgery in pediatric patients with both complicated appendicitis and inguinal hernia, potentially streamlining treatment and improving resource efficiency. Surgeons may consider incorporating this approach into clinical decision-making, especially in tertiary centers with appropriate expertise.
Introduction
In recent years, the advancement of minimally invasive techniques has increased the use of laparoscopic approaches for treating pediatric patients with inguinal hernia (IH) and acute appendicitis (AA) (1,2). The laparoscopic approach offers a broader surgical field, facilitating the possibility of performing multiple procedures simultaneously. Prior studies in adults have demonstrated favorable outcomes for combined surgical interventions (3-6). In the pediatric population, during laparoscopic appendectomy, incidental detection of IH or just a patent processus vaginalis (PPV) which can lead to the development of an IH, raises the question of whether concurrent hernia repair should be performed. Traditionally, the separation of contaminated and clean procedures has been emphasized in surgical practice (7). Appendectomy, particularly for complicated appendicitis (CA) (e.g., suppurative, perforated, gangrenous, diffuse peritonitis, or peri-appendiceal abscess), may heighten the risk of infection and recurrence of the hernia (6,8,9). However, no established guidelines exist regarding concurrent surgical treatment of AA with IH in a pediatric patient. The limited literature on this topic primarily addresses early and uncomplicated cases of appendicitis (10,11). The aim of this study was to investigate the safety and effectiveness of concurrent laparoscopic treatment of CA combined with IH in pediatric patients. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2024-541/rc).
Methods
Study design
A retrospective review was conducted on pediatric patients diagnosed with AA who underwent laparoscopic surgery at Beijing Children’s Hospital between January 2016 and December 2022. The inclusion criteria for the study were: (I) a diagnosis of CA (defined as suppurative, perforated, gangrenous, diffuse peritonitis, or peri-appendiceal abscess) (8,9); (II) intraoperative diagnosis of concurrent IH or PPV; and (III) performance of either simultaneous laparoscopic surgery or staged surgery. Exclusion criteria included: (I) simple appendicitis (SA); (II) Amyand’s hernia; and (III) patients lost to follow-up. Classification of AA was based on clinical symptoms, laboratory examinations, preoperative ultrasound, laparoscopic exploration, and postoperative pathology. Routine intraoperative exploration of the internal ring on both sides was performed, and, in cases where a PPV was identified, the surgeon communicated the advantages and disadvantages of simultaneous hernia repair with the patients’ parents. Demographic data, perioperative findings, pathological results, and follow-up records were collected and analyzed retrospectively. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health (approval No. [2024]-E-060-R) and informed consent was obtained from all individual participants’ legal guardians.
Surgical technique
Laparoscopic surgery was performed under general anesthesia utilizing three ports: a 10 mm umbilical monitoring port and two 5 mm manipulating ports positioned to the left and below the umbilicus. A comprehensive examination of the abdominal cavity, including both bilateral internal rings, was conducted. The appendectomy was performed first, with surgical techniques tailored to the condition of the appendix. If a significant amount of pus was present in the abdominal cavity, saline was repeatedly used to irrigate the area until the effluent appeared clear. If IH was diagnosed, the surgeon assessed the abdominal cavity and the internal ring anatomy. When hernia repair was deemed necessary based on the surgeon’s experience, a 2-0 silk suture was introduced through a needle inserted into the abdominal wall at the projection of the internal ring and passed through the extraperitoneal space medial to the internal ring. In male patients, the silk suture traversed the vas deferens and spermatic vessels, with the needle puncturing the peritoneum to place the suture within the abdominal cavity. The needle was reinserted at the same location on the abdominal wall, passing laterally through the extraperitoneal space and puncturing into the abdominal cavity again, allowing the silk suture to be grasped and withdrawn through the abdominal wall alongside the needle. Prior to knotting the internal ring, gas and fluid within the hernia sac were expelled. The knots were secured beneath the skin. If contralateral repair was required, this surgical procedure was repeated at the corresponding internal ring. No abdominal drains were placed due to adequate irrigation.
For the two-stage approach, laparoscopic appendectomy was performed initially, with IH repair scheduled for a later date based on parental preference. Consequently, variables such as operative time and length of hospital stay were specific to the initial appendectomy.
Antibiotic therapy consisting of cefoperazone/sulbactam combined with metronidazole was administered once prior to surgery and continued routinely in the postoperative period.
Statistical analysis
Categorical data were analyzed using the Chi-squared test or Fisher’s exact test, while continuous data were assessed with the t-test or Mann-Whitney U test. Specifically, the t-test was applied to variables following a normal distribution, with results presented as mean ± standard deviation. For non-normally distributed variables, the Mann-Whitney U test was used, and results were reported as median and interquartile range. All P values were two-tailed, with significance level defined as P<0.05. Analyses were conducted using the R programming language and environment for Windows (version 4.2.3, http://www.r-project.org).
Results
A total of 153 patients who underwent laparoscopic appendectomy at our institution between January 2016 and December 2022 were retrospectively reviewed. Of these, forty patients were identified with CA and included in the study. Based on whether IH repair was performed simultaneously, patients were divided into two groups: the simultaneous repair group (n=29) and the two-stage group (n=11). Two patients in each group presented with symptomatic IH prior to surgery; this may be attributed to school-age patients typically undergoing hernia repair during winter or summer vacations to minimize academic disruption. Asymptomatic IH was observed in over 80% of cases across both groups. A significant difference was observed in the proportion of bilateral IHs between the simultaneous group and the two-stage group (48.3% vs. 9.09%, P=0.03).
The median operative time was 84 minutes for the simultaneous group, slightly longer than the 68 minutes observed in the two-stage group, although this difference was not statistically significant. The duration of postoperative antibiotic treatment was longer in the two-stage group [5.00 (4.75; 8.00) vs. 4.00 (3.00; 6.00) days, P=0.04]. No significant difference was found in terms of length of stay between the two groups. Additionally, there were no statistical differences in demographics, including age, weight, and gender (Table 1).
Table 1
| Variables | Simultaneous group (n=29) | Two-stage group (n=11) | P value |
|---|---|---|---|
| Age (months) | 100±36.0 | 96.2±37.5 | 0.75 |
| Weight (kg) | 27.0 [20.0; 33.0] | 26.5 [22.0; 30.2] | 0.92 |
| Gender | 0.15 | ||
| Male | 8 (27.6) | 6 (54.5) | |
| Female | 21 (72.4) | 5 (45.5) | |
| Bilateral IH | 0.03 | ||
| No | 15 (51.7) | 10 (90.9) | |
| Yes | 14 (48.3) | 1 (9.09) | |
| Symptomatic IH | 0.30 | ||
| No | 27 (93.1) | 9 (81.8) | |
| Yes | 2 (6.9) | 2 (18.2) | |
| Operative time (min) | 84.0 [70.0; 105] | 68.0 [57.5; 102] | 0.32 |
| Postop antibiotic time (days) | 4.00 [3.00; 6.00] | 5.00 [4.75; 8.00] | 0.04 |
| Length of stay (days) | 5.00 [4.00; 6.00] | 6.00 [5.00; 9.00] | 0.056 |
| Follow-up duration (months) | 23.0 [16.0; 30.0] | 15.0 [13.5; 42.5] | 0.56 |
Continuous variables are presented as mean ± standard deviation or median [interquartile range]. Categorical variables are presented as n (%). IH, inguinal hernia; Postop, postoperative.
The follow-up duration ranged from 11 to 66 months, with postoperative complications compared in Table 2. The median follow-up time was 23 months for the simultaneous group and 15 months for the two-stage group. Only one patient in the two-stage group experienced postoperative complications. This patient had a symptomatic IH prior to surgery, and approximately 300 mL of purulent exudate was observed in the abdominal cavity during the operation. After thorough discussion, the decision was made not to perform simultaneous repair of the left-sided IH. The patient subsequently developed a scrotal infection one day after laparoscopic appendectomy, incomplete intestinal obstruction two days postoperatively, and an infraumbilical trocar wound infection three days after surgery. Conservative treatment was administered, and the patient was discharged following recovery. As of the last follow-up, no recurrence of IH was observed in the simultaneous group.
Table 2
| Complications | Simultaneous group (n=29) | Two-stage group (n=11) |
|---|---|---|
| Leakage | 0 | 0 |
| Peritonitis | 0 | 0 |
| Intraabdominal abscess | 0 | 0 |
| Intestinal obstruction | 0 | 1 |
| Wound infection | 0 | 1 |
| Postoperative scrotal/vulvar infection | 0 | 1 |
| Recurrent inguinal hernia | 0 | – |
| Total | 0 | 3 |
Data are presented as n.
Discussion
The increasing adoption of minimally invasive methods and technological advances has enhanced the role of laparoscopic surgery in treating pediatric AA and IH. Laparoscopic techniques offer not only therapeutic benefits but also diagnostic value. The ability to explore the entire abdominal cavity allows for the detection of asymptomatic IH during appendectomy. However, the contaminated nature of appendectomy, especially in cases of CA, which accounts for approximately 30% of AA in pediatric patients, has raised concerns regarding the feasibility of performing a concurrent, typically clean IH repairs (8,12,13). Consequently, only a limited number of studies have reported on simultaneous approaches, while the prevailing preference remains staged surgeries (10,11). The aim of this study was to investigate the outcomes associated with simultaneous versus two-stage management of CA and IH. The findings suggest that concurrent surgery is both safe and effective, associated with lower rates of hernia recurrence and scrotal infections.
The categories of appendicitis included in this study were carefully selected to address the conventional concern that a contaminated abdominal environment is unsuitable for concurrent hernia repair. This investigation specifically focused on the pathological classifications of CA, encompassing all subtypes that can lead to intra-abdominal inflammation. The aim of this study was to assess whether simultaneous hernia repair is safe and effective in various scenarios potentially leading to intra-abdominal contamination.
Previously, Li et al. conducted a multicenter study excluding cases that could have resulted in intra-abdominal infection, such as perforated appendicitis, gangrenous appendicitis, and peritoneal abscesses, focusing solely on acute SA and suppurative appendicitis for analysis (10). However, it is important to consider that suppurative appendicitis may still present some degree of exudate, and there remains a risk of leakage during resection, which could increase the risk of abdominal cavity contamination.
Additionally, Dayı et al. included 293 cases of laparoscopic appendectomy in their study, but they did not specify the pathological classification of appendicitis (11). They did report two cases—AA and phlegmonous appendicitis—where hernia repair was conducted, suggesting that both SA and CA were likely included in their cohort. In contrast, this study employed more standardized and stringent inclusion and exclusion criteria ensuring a focused assessment of cases with clearly defined pathological classifications.
Current surgical techniques for laparoscopic appendectomy are generally consistent, while approaches for hernia repair in pediatric patients vary. Li et al. reported continuous suturing of the internal ring in the extraperitoneal space using a 2-0 silk suture needle (10). In contrast, Dayı et al. described the use of the Burnia method in the treatment of two female patients (11). The surgical approach for hernia repair in this study closely resembled that of Li et al., though with a notable difference: the 2-0 silk suture penetrated the peritoneum during ligation of the internal ring (10). Regarding the outcomes of hernia repair, Li et al. observed no cases of inguinal infection in their study group, which underwent simultaneous laparoscopic appendectomy and hernia repair (10). However, they reported one case of hernia recurrence three months postoperatively, requiring additional laparoscopic hernia repair. In Dayı et al.’s study, only five of 293 laparoscopic appendectomy cases were combined with PPV, with hernia repair performed in two cases, while the remaining three asymptomatic cases were not addressed (11). Both patients in their study experienced no postoperative complications or hernia recurrence during the two-year follow-up period. The findings of our study showed similar, if not superior results. None of the 29 patients in the simultaneous repair group experienced postoperative complications or hernia recurrence by the last follow-up (median follow-up duration: 23 months). In the two-stage group, only one patient developed a complication, and there was no significant difference in complication rates between the two groups, aligning with previous studies (10,11).
There is currently no consensus on the optimal sequence for performing appendectomy and hernia repair in the same operation. Li et al. conducted hernia repair prior to appendectomy, while Dayı et al. opted to perform appendectomy first (10,11). Notably, both studies included patients with appendicitis types that posed a risk of abdominal cavity contamination. In this study, only patients with CA were included, with simpler, relatively clean cases excluded. To minimize the risk of intra-abdominal contamination, appendectomy was prioritized, followed by thorough irrigation of the abdominal cavity with saline to eliminate residual contaminants, creating a relatively clean environment for hernia repair. Additionally, antibiotics were routinely administered to both groups. However, the duration of postoperative antibiotic use (in days) was significantly longer in the two-stage group. This difference may be attributed to selection bias, as the decision to perform the procedure in one or two stages was made by the surgeon and the patient’s parents based on the severity of the infection observed during surgery. Consequently, patients in the staged group were more likely to have severe infections, necessitating prolonged antibiotic use, whereas those in the simultaneous group had less severe infections, leading to shorter antibiotic durations. The findings indicate that, despite the inherent risks of intra-abdominal contamination and inflammatory stimulation that may lead to peritoneal swelling near the internal ring, hernia recurrence and scrotal infection can be effectively managed through individualized assessments and surgical planning.
In the two-stage group, several factors influenced the decision not to perform concurrent hernia repair. First, parents of patients with asymptomatic PPV discovered during surgery sometimes opted against concurrent treatment. For instance, in one case involving a relatively mild intra-abdominal infection, the parents decided, after thorough discussions, to defer hernia repair. Second, in cases with severe intra-abdominal infection, edema may develop around the internal ring due to inflammatory stimulation, obscuring the anatomical relationships. This can render critical structures, such as the vas deferens and spermatic vessels, vulnerable to injury. After assessing the risks and benefits, surgeons and the parents collaboratively decided to proceed with a staged approach to prioritize safety.
There are several limitations in this study. First, as a retrospective analysis, it is subject to recall bias, which may influence the accuracy of the data. Selection bias and other factors are also inevitable. Second, parameters related to elective hernia repair in the two-stage group, such as operative time and length of hospital stay were not included in the statistical analysis. Third, while this study is the largest to date focusing on the simultaneous laparoscopic approach for pediatric patients with CA and IH, the sample size remains relatively small, indicating a need for future studies with larger cohorts to validate these findings. Lastly, long-term follow-up is necessary to assess the efficacy of simultaneous hernia repair in this population.
Conclusions
The results of this study demonstrate that laparoscopic simultaneous treatment for pediatric patients with AA and IH is feasible, promising safety and efficacy, even in cases involving relatively contaminated CA. Key factors for success include the sequence of surgical procedures, management of contamination, and individualized assessments based on the patient’s condition. Future research should focus on longer follow-up periods and randomized controlled trials involving larger sample sizes to further validate these findings.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2024-541/rc
Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2024-541/dss
Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2024-541/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2024-541/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health (approval No. [2024]-E-060-R) and informed consent was obtained from all individual participants’ legal guardians.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Khan FA, Jancelewicz T, Kieran K, et al. Assessment and Management of Inguinal Hernias in Children. Pediatrics 2023;152:e2023062510. [Crossref] [PubMed]
- Lamm R, Kumar SS, Collings AT, et al. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023;37:8933-90. [Crossref] [PubMed]
- Claus CMP, Ruggeri JRB, Ramos EB, et al. Simultaneous laparoscopic inguinal hernia repair and cholecystectomy: does it cause mesh infection? Arq Bras Cir Dig 2021;34:e1600. [Crossref] [PubMed]
- Kahraman D, Uyar IS, Duman U, et al. Clinical Outcomes of Synchronous Laparoscopic Cholecystectomy with Coronary Artery Revascularization. Heart Surg Forum 2019;22:E229-33. [Crossref] [PubMed]
- Orr NT, Davenport DL, Roth JS. Outcomes of simultaneous laparoscopic cholecystectomy and ventral hernia repair compared to that of laparoscopic cholecystectomy alone. Surg Endosc 2013;27:67-73. [Crossref] [PubMed]
- Quezada N, Maturana G, Pimentel E, et al. Simultaneous TAPP inguinal repair and laparoscopic cholecystectomy: results of a case series. Hernia 2019;23:119-23. [Crossref] [PubMed]
- Gonzalez KW, Dalton BG, Kurtz B, et al. Operative wound classification: an inaccurate measure of pediatric surgical morbidity. J Pediatr Surg 2016;51:1900-3. [Crossref] [PubMed]
- Cameron DB, Anandalwar SP, Graham DA, et al. Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children. Ann Surg 2020;271:962-8. [Crossref] [PubMed]
- Neogi S, Banerjee A, Panda SS, et al. Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis. J Pediatr Surg 2022;57:394-405. [Crossref] [PubMed]
- Li Y, Guo Z, Qu Z, et al. Laparoscopic simultaneous inguinal hernia repair and appendectomy in children: A multicenter study. J Pediatr Surg 2022;57:1480-5. [Crossref] [PubMed]
- Dayı S, Anayurt M, Çınar F, et al. Approach to concurrent inguinal hernias during laparoscopic appendectomy for early appendicitis. Langenbecks Arch Surg 2024;409:84. [Crossref] [PubMed]
- Snyder MJ, Guthrie M, Cagle S. Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician 2018;98:25-33. [PubMed]
- Davies GM, Dasbach EJ, Teutsch S. The burden of appendicitis-related hospitalizations in the United States in 1997. Surg Infect (Larchmt) 2004;5:160-5. [Crossref] [PubMed]
