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PII: S1055-8586(16)30052-X
DOI: http://dx.doi.org/10.1053/j.sempedsurg.2016.10.002
Reference: YSPSU50649
To appear in: Seminars in Pediatric Surgery
Cite this article as: Maria E. Linnaus and Daniel J. Ostlie, Complications in
common general pediatric surgery procedures, Seminars in Pediatric Surgery,
http://dx.doi.org/10.1053/j.sempedsurg.2016.10.002
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Complications in Common General Pediatric Surgery Procedures
Department of Surgery
Phoenix Children's Hospital
Corresponding Author:
Daniel J Ostlie, MD
Surgeon-in-Chief and Chair of Surgery
Phoenix Childrens Hospital
Professor of Surgery
Mayo Clinic Arizona
1919 E Thomas Road
Phoenix, AZ 85016
602-933-7003
dostlie@phoenixchildrens.com
Abstract
Complications related to general pediatric surgery procedures are a major concern for
pediatric surgeons and their patients. Although infrequent, when they occur the consequences
can lead to significant morbidity and psychosocial stress. The purpose of this article is to discuss
the common complications encountered during several common pediatric general surgery
procedures including inguinal hernia repair (open and laparoscopic), umbilical hernia repair,
Introduction
Complications after pediatric surgery are a relatively uncommon occurrence. Several of these
are unique to pediatric patients, and they can differ vastly from complications in the adult
population. Certain complications arise from the increased difficulty of operating on smaller
anatomic structures in infants and young children while others are unique to the pediatric
population simply because of the pathophysiology of the disease or specificity with which the
disease process affects the pediatric patient. This summary attempts to discuss complications of
Inguinal Hernia
Pediatric inguinal hernia is one of the most frequently encountered diagnoses in pediatric
surgery with an overall incidence of 0.8-4%[1] in term infants and children and increasing to nearly
30% in the premature infant[2]. Generally regarded as one of the most common operations a
pediatric surgeon will perform, the pediatric inguinal hernia repair can be particularly challenging
given the small anatomic structures and limited working space. Fortunately, the overall
complication rate for pediatric inguinal hernia repair is low regardless of approach (i.e. open or
laparoscopic) but does appear to increase with prematurity and need for emergent surgery[3,4].
While there appears to be a transition to performing inguinal hernia repair laparoscopically, the
open approach remains in common practice today. Both approaches will be described in this
summary.
There are several technical considerations that merit attention in order to limit intraoperative
complications during inguinal hernia repair. Given that majority of patients with inguinal hernia are
male[2], special attention should be given to protection of the gonadal structures. Injury to the vas
deferens, testis and testicular artery can have long term implications on future fertility and
function - particularly in the case of bilateral inguinal hernia repair. Additionally, injuries to gonadal
Direct insult to the spermatic cord is reported to occur in 0.06% to 0.6% in term infants and
children undergoing open surgery for inguinal hernia repair [2,3]. Premature babies may be at
increased risk of injury but this particular injury does not appear to be elevated during emergency
surgery for incarceration [3,4]. The common mechanisms of injury to the vas deferens include
unintentional cutting or tearing of this delicate structure during repair of the hernia [2]. Direct injury
to the testis may also occur. Although it is rarely reported in the literature the surgeon must be
cautious in handling the testicle during repair. Injury to the testis or the testicular artery/vein may
result in postoperative hematoma formation. Moreover, direct injury to the testicular artery can
occur in both the open and laparoscopic techniques and may result in subsequent testicular
atrophy. Proponents of both approaches cite testicular artery injury as a benefit of their selected
surgical approach. To date no significant difference has been found between techniques [5].
Overall, atrophy occurs in less than 1% of patients and appears to be more directly a result of
incarceration rather than direct injury during elective repair [2]. Several studies have noted that
while a transient decrease in testicular vascularization can occur with surgical manipulation, the
vast majority will return to baseline in the later postoperative period [5,6].
Another commonly encountered problem with pediatric inguinal hernia repair is the presence
of a sliding component to the hernia sac. Sliding hernias occur in approximately 8 to 31% of
pediatric patients with an apparent predilection for female patients and patients under 1 year of
age [2,7,8]. In fact, reports assessing female inguinal hernia repair describe presence of the
fallopian tube or ovary in one-third to three-quarters of patients [7,9]. The pediatric surgeon must
be highly diligent in identifying a sliding hernia component as it may also incorporate a portion of
bladder or intestine. Injury to these organs may occur if the hernia sac is not inspected and
contents not reduced. While the incidence of a sliding hernia may be high, the reported overall
risk of injury to such structures is under 1%. In large retrospective series, no accounts of injury to
the internal organs were documented [2,7]. In these same studies, a few rare cases of ovarian
ischemia were noted as a result of incarceration independent of the sliding hernia. These were
Wound infection after open inguinal hernia repair is reported to be approximately 1% in most
large studies [2,7]. In meta-analysis, this reported risk in open repair has not been found to
significantly differ from laparoscopic repair and remains around 1% [10,11]. However, there exist
several other series that report a 0% incidence of wound infections using the laparoscopic
approach [1214]. Local wound care and antibiotics are sufficient in the treatment of wound
Hernia recurrence is considered the most definitive and most common quoted complication
related to inguinal hernia repair. It is the single most common complication compared between
the open and laparoscopic approaches. After open repair, the recurrence risk reported in
historical retrospective series is approximately 0.4% to 1.2% [2,7], which mirrors the reported
1.7% to 2.4% [15,16]. Several meta-analyses agree that the risk of recurrence is not significantly
different based on technique and is likely dependent on the comfort and training level of the
operating surgeon [10,17]. There may, however, be an increased predilection for recurrence in
teenagers undergoing open repair [2], in children with malnutrition, increased intraabdominal
One of the most highly debated discussions in the pediatric literature is the management of
the contralateral inguinal region during operative repair of a clinically apparent unilateral hernia.
Although the evaluation itself is not a complication, the decision based on the evaluation can lead
metachronous inguinal hernia is 2% to 11% after open repair in retrospective reports [2,7,1922].
Due to this high rate, many pediatric surgeons have advocated for contralateral exploration using
laparoscopy through the hernia sac during open repair or in highly suspicious cases, initial
laparoscopic evaluation through the umbilicus [1]. In studies employing laparoscopic exploration
of the contralateral groin through the ipsilateral hernia sac, the rate of a non-clinically detected
contralateral patent processus vaginalis (CPPV) is anywhere from 20% to 66% [11]. This rate
appears to be increased in premature patients [23], females greater than 2 years of age [24], and
perhaps even in patients with a left sided inguinal hernia [25]. However, the clinical significance of
this finding and the risk of true hernia development in the setting of CPPV are unknown.
Additionally, even in negative contralateral laparoscopic evaluations, there is still an inherent risk
of inguinal hernia development [26]. Those opposed to contralateral exploration cite increased risk
of injury, postoperative pain, and longer operative time [19,27,28] while those in favor opt to avoid a
second surgery for the development of a symptomatic hernia on the contralateral side. While the
authors mainly utilize laparoscopic hernia repair, in cases of open repair, we perform
laparoscopic evaluation of the contralateral internal ring through the ipsilateral hernia sac in all
patients less than 5 years of age. The reader should understand that this age limit is arbitrary
and chosen based on the decreasing potential of a patent processus becoming clinically
Postoperatively, there are a few acquired conditions that may result in parental or patient
distress, increased provider visits or even presentation to the emergency department (ED). In
particular, postoperative hematoma formation can present dramatically. Patients can develop
ecchymosis and swelling of the scrotum and groin which may even track up to the iliac crest. In
large retrospective studies the rate of reported hematoma formation after open inguinal hernia
repair is anywhere from 0.1% to 3.3% [7,29]. If there is no evidence of persistent hemorrhage,
management can be conservative and include comfort measures and reassurance to the patient
and/or family that the hematoma will spontaneously resolve and no intervention is necessary. In
the uncommon scenario where the hematoma becomes infected, drainage and antibiotic therapy
may be required.
Injury to the lymphatic drainage of the testis within the spermatic cord can also result in
postoperative hydrocele formation in up to 2.9% of patients, particularly if the patient had a large
hydrocele preoperatively [3]. Hydrocele formation also occurs more frequently in premature
patients [3]. In general, postoperative hydroceles should be observed for spontaneous regression
which occurs in the majority of cases by one year [3]. Large persistent hydroceles are infrequent
(0.06% in large retrospective reports) [2] and aspiration of the hydrocele may be needed for
cryptorchidism which can result from failure to return the testis to its anatomic position. Particular
care must be given to ensuring that the testis remains in the scrotum after repair of the hernia has
been performed. Secondary cryptorchidism is rarely reported ( 0.1% to 0.5%) [2,7] in large
retrospective studies assessing open pediatric inguinal hernia repair, but may be as high as 4.5%
when emergent surgery is needed [4]. If its occurrence is clinically detected in the postoperative
period, it can often be resolved with manual testicular traction in the office, however, in the rare
event that the testis cannot be returned to the scrotum, patients may require orchidopexy at a
Inguinal abscess formation is a rare event in the pediatric literature and occurs in less than
0.5% of open repairs [31]. When it is encountered it is generally associated with the suture chosen
for repair (also known as stitch abscess/granuloma). This risk appears to be associated with
utilization of silk suture or other braided nonabsorbable sutures during open repair of inguinal
hernia [32]. Even in the rare cases of paravesicle abscess development described in the literature,
silk suture appears to have been implicated [33]. Antibiotics alone may not resolve the issue and
in most cases aspiration or open incision and drainage along with removal of the foreign material
Laparoscopic repair
The initial criticism of laparoscopic inguinal hernia repair in the pediatric population was its
reported higher recurrence rate. However, over the last decade, many pediatric surgeons have
embraced the laparoscopic repair and with changes in surgical technique the recurrence rates
have decreased from an initial recurrence rate of 3-4% to 1% [3436]. Several recent studies
utilizing varying laparoscopic techniques demonstrate recurrence rates from 0.3 to 1.1% [12,3742].
Additionally, recent randomized trials and meta-analyses have shown no difference in recurrence
rates between the laparoscopic and open approaches in term infants and children [15,16,10,17,11,43,44],
and two recent small series have reported a 0% incidence of hernia recurrence [45,46]. There may
patients with incarceration, and children with connective tissue disorders and ventriculoperitoneal
shunts [47,48]. However, laparoscopy is still regarded as an appropriate method of repair for these
patients in experienced hands. Based on these data, cosmesis and surgeon preference have
been driving the technical approach, and no strict recommendations have been made regarding
an optimal repair method since none has been shown to be superior. The authors prefer
laparoscopic hernia repair and hypothesize that the addition of peritoneal suturing around the
internal ring may lead to a more durable repair with decreased recurrence rates [49,50].
As with the open repair, injury to the spermatic cord is another consideration while performing
laparoscopic repair of inguinal hernia. This can most often be avoided by careful recognition of
the anatomy and meticulous placement of transperitoneal sutures. A distinct difference between
the open and laparoscopic repair is that during laparoscopic repair the spermatic cord is not
directly manipulated as in open repair. However, during intracorporeal suturing, the spermatic
cord lies directly adjacent to the hernia defect. A practiced technique to decrease the risk of
injury to these structures includes hydrodissection with saline or local anesthesia to lift the
peritoneum away from the vas deferens and testicular vessels, thus creating a working space for
Umbilical port site hernia is a complication unique to the laparoscopic repair of the inguinal
hernia. Few studies report on the incidence of umbilical port site hernia after laparoscopic inguinal
hernia repair. In one study assessing utility of laparoscopic hernia repair in children under 1 year
of age, the authors noted a 2.6% occurrence rate of umbilical hernia 4 months postoperatively,
however, all closed spontaneously without intervention [42]. Numerous retrospective studies have
reported the rate of port site hernia after laparoscopic hernia repair from 0-1.6% regardless of
Similar to the open approach to inguinal hernia repair, laparoscopic repair can result in
delayed persistent hydrocele formation. However, this occurrence appears particularly rare in the
laparoscopic literature despite most laparoscopic techniques leaving the distal hernia sac in situ.
Most reports cite early development of a postoperative hydrocele that resolves with aspiration or
observation [39,54]. In the rare circumstance that the hydrocele is recurrent and unresolving,
consideration should be given to repeat laparoscopy to rule out recurrent hernia [36]. Additionally,
for those that are without recurrence and still unresolved, surgical obliteration of the hydrocele
Complication avoidance during inguinal hernia repair primarily rests on meticulous surgical
ligation of the hernia sac during open repair, and through precise suture placement around the
internal ring during the laparoscopic repair. Many surgeons will also use hydrodissection of the
peritoneum to elevate it away from the cord structures during the laparoscopic repair to aid in
Identification of the presence of a sliding hernia is paramount for avoiding injury to other
organs during its repair. In all female patients, and unless it is clearly evident that there is no
sliding component to the hernia in a boy, the hernia sac should be opened and the internal ring
inspected through the sac to ensure that there is intestinal or ovarian sliding component. If
present, the sliding component should be reduced if possible. If it is not possible to reduce the
Postoperative hydrocele formation can be essentially eliminated by widely opening the distal
hernia sac. In circumstances where the sac is significantly thickened, eversion of the sac with
Umbilical Hernia
estimated 10-20% of infants are born with a hernia of the umbilicus [55], with increased numbers in
premature infants, but the majority of these resolve spontaneously throughout early childhood.
Operative repair is indicated in patients if the umbilical defect fails to close by 2-5 years of age.
Most surgeons elect to repair umbilical hernia defects through an open approach although
minimally invasive techniques involving injection of polymer into the hernia sac have been
described [56]. For this review we will focus on the open approach to umbilical hernia repair.
The major concern for patients, parents, and surgeons is the risk of recurrence of an
umbilical hernia after operative repair. In a large fifty-year retrospective study comprised of nearly
500 patients, the overall recurrence rate was 2% [57]. However, older reports indicate that rate of
recurrence may be around 1% [58]. Interestingly, no modern studies have assessed the long term
recurrence rate of pediatric umbilical hernia repair. Typically, time to recurrence is less than 1
year [57]. Additionally, the rate of recurrence appears higher with closure using nonabsorbable
Wound infection is another consideration when proceeding with operative repair of umbilical
hernia. It is estimated that less than 1% of umbilical hernia repairs develop postoperative wound
infections [59] and the majority of these can be managed with antibiotics and local wound care.
While there are no modern studies that assess the rates of wound infection after umbilical hernia
Finally, there has been significant focus on limiting the potential development of hematoma or
seroma after umbilical hernia repair. These two complications are similarly very rare (0.1-
0.5%)[57]. Interestingly, arguments have been made suggesting that dressing type and duration
will decrease this risk. In a prospective randomized trial of 96 patients, there was no difference in
the development of either hematoma or seroma suggesting that dressing type/duration is not a
factor.
Recurrence is the concerning complication related to umbilical hernia repair. Perhaps most
important in avoiding this complication is timing of surgery. Delaying repair until after 2 years of
age allows for fascial development and potential partial closure of the defect. If either or both of
these occur recurrence is less likely. Additionally, adequate fascial dissection and suture/tissue
Pyloromyotomy
Hypertrophic pyloric stenosis (HPS) was originally recognized as a surgical disease in the
1800s [60]. The initial operative management was invasive and despite success in its treatment,
pyloromyotomy has been shown to be superior to the open approach. Randomized controlled
trials and meta-analyses have shown that laparoscopic pyloromyotomy has decreased length of
hospital stay, and shorter time to full feeds although the effect on overall complications remains
debatable [6163]. It has been suggested that laparoscopic pyloromyotomy may have the potential
for an increase in the risk of incomplete pyloromyotomy [64]. However, numerous reports have
laparoscopic pyloromyotomy compared to open [67]. It is the view of the authors that laparoscopic
pyloromyotomy should be pursued during this current era of laparoscopy and therefore this
Intraoperative complications
shown to have decreased operative times compared with the open approach [61,68]. The most
of initial operation. There have been some reports that indicate this risk may be elevated in
laparoscopy [69] but others show no difference [64,65]. In general, the incidence of mucosal injury is
anywhere between 0.8% to 2.2% [61,64,65,68,70]. This rate appears to be consistent regardless of
study found that there was no difference in risk of mucosal perforation between open and
randomized controlled trial found no difference in complications between laparoscopic and open
pyloromyotomy including mucosal perforation. In the event of a mucosal perforation, most may be
treated with laparoscopic interventions. In a survey looking at surgeon preferences for repair of
mucosal injury, the majority report preference for primary repair with nearly one-quarter of those
same surgeons utilizing an omental patch which can be done laparoscopically [71]. In these
regimen and using a nasogastric tube for decompression in the initial postoperative period.
the laparoscopic repair, the duodenum is often grasped with the laparoscopic grasper, placing the
duodenum at risk of injury. However, the risk of this complication is quite rare. One recent
occurrence [65]. However, this was in a single patient in an overall laparoscopic cohort of 50
patients. Another large cohort study of pyloromyotomy noted an incidence of 0.9% in all
pyloromyotomy procedures but this study didnt specify whether the cases were performed in
open or laparoscopic fashion [72]. There have been retrospective studies that include duodenal
injury as a secondary outcome for laparoscopic pyloromyotomy and some report no injuries
compared to around a 1% rate of duodenal injury in open pyloromyotomy [73]. Finally, in a meta-
analysis performed in 2009, only one reported patient out of 294 (0.3%) had a duodenal serosal
injury [62]. Based on this lack of data, the authors suggest that the operating pediatric surgeon
should be cognizant of this slight risk and utilize caution when grasping the duodenum and
performing the distal myotomy. After complete pyloromyotomy has been performed careful
inspection of the duodenum, gastric serosa and pyloric submucosa should be performed in
addition to insufflation of the stomach utilizing a nasogastric tube despite less than 100%
Postoperative complications
Fortunately, most patients who have undergone pyloromyotomy do well. Wound infections
antibiotic usage [75]. While wound infections may become a nuisance the majority can be treated
More concerning in the postoperative period may be the presence of prolonged emesis,
pyloromyotomy. Benign postoperative emesis may occur in as many as 48% to 64% of infants
feeding regimens have emerged with studies reporting no correlation between regimens and
development of postoperative emesis [77]. Additionally, no reliable factors have been identified to
predict risk of postoperative emesis. In the majority of infants, some transient postoperative
emesis is within the range of normal. However, in a small subset of patients it may persist for
several days or weeks which can be concerning to the surgeon for incomplete pyloromyotomy. In
a large randomized trial assessing outcomes between laparoscopic and open pyloromyotomy,
3.4% of patients had significant emesis to warrant evaluation [61]. However, given that many of
these patients may also have concomitant gastroesophageal reflux, determining the etiology of
the prolonged emesis may be difficult. In these cases, swallow studies or upper GI examinations
may be beneficial.
There has been an increased association with the laparoscopic approach and incomplete
the laparoscopic group reported in the literature remains low and many have questioned the
clinical relevance of the small difference [61,64,65,70] with some studies reporting no cases of
incomplete pyloromyotomy [66,79]. This trend also appears to be decreasing as more surgeons
Incisional hernia after laparoscopic pyloromyotomy is also a rare event, but appears to be
more related to the open repair than the laparoscopic. In a large randomized controlled trial
assessing open versus laparoscopic pyloromyotomy, zero patients developed an incisional hernia
after laparoscopic intervention compared to a 1% rate in the open group [66]. Similarly, a
prospective randomized trial performed just a year later revealed that they had no incidences of
incisional hernia again with laparoscopic intervention [65]. Another large retrospective study also
noted a zero-event rate of incisional hernia in the laparoscopic group [68]. In a general review of
pediatric laparoscopic surgery the incidence of incisional hernia with 5mm trocar sites was 1.2%
[80]
. In infants undergoing laparoscopic pyloromyotomy, 3mm instruments are used and many
surgeons use trocarless entry for the lateral incisions which again likely decreases the risk of
Specific to the laparoscopic approach is the development of umbilical port site hernia. No
reports specifically targeting the umbilical port site hernia have been noted in the authors review
of the literature. Since many of the infants undergoing laparoscopic pyloromyotomy already have
a natural orifice at the umbilicus, this risk certainly is less than 1%. Most surgeons close the 5-
mm defect with an absorbable suture which aids in preventing herniation at the umbilical port site.
incomplete pyloromyotomy and duodenal injury. All are addressed via appropriate technique.
Careful handling of the distal duodenum should be emphasized to eliminate risk of duodenal
injury. Additionally, the Geiger grasper, which was developed specifically for this operation,
securely fixes the entire duodenum and pylorus while the myotomy is being performed, thus
eliminating the single grasper on the distal duodenum or proximal stomach, depending on the
surgeons preference. We have exclusively used this grasper for the last several years and find it
Regarding mucosal perforation, careful spreading of the submucosal layers is essential. The
most common site of perforation is at the duodenal margin, and special attention should be taken
including the use of length alone (2 cm), the ability to move the superior and inferior
pyloromyotomy edges independently and the ability to bring the superior and inferior edges over
each other. In our experience all of these approaches are effective, and the surgeon should
Laparoscopic Appendectomy
Approximately 30% of pediatric patients will present with perforated appendicitis [81,82] which
may present simultaneously with intraabdominal abscess, free air, feculent peritonitis or, if
advanced, septic shock. Most surgeons perform urgent appendectomy on presentation unless the
symptoms are consistent with development of an organized abscess and the risk of injury to other
structures outweighs need for appendectomy at that time. Traditional open appendectomy has
been replaced in the majority of centers with laparoscopic appendectomy and more recently
single incision laparoscopic surgery. Since its introduction, the rate of laparoscopic
appendectomy has tripled [83] and most pediatric surgeons have adopted laparoscopic
infection, hospital stay, postoperative ileus, and time to normal activity postoperatively [84,85] with
Intraoperative complications
Intraoperatively, acute appendicitis has a wide spectrum of complexity and can become a
more challenging operation when perforation has occurred or the appendix is in a retrocecal
position. Iatrogenic bowel injury, while uncommon, can occur during laparoscopic
appendectomy. The appendix may form adhesions with adjacent bowel which may be injured
during adhesiolysis or during dissection of the mesoappendix and in search of the base of the
appendix. Direct manipulation of the friable adjacent bowel may lead to serosal injury or even full-
thickness perforation and use of electrocautery may lead to thermal injury. A large retrospective
study demonstrated a 0.8% risk of iatrogenic bowel injury during laparoscopic appendectomy [86].
Very few other studies even comment on the incidence of bowel injury during appendectomy
likely secondary to low incidence. In the case of superficial thermal injury or serosal tear, an
imbricating stitch on the site is satisfactory in preventing a postoperative leak. In the case of a full-
location of bleeding is the appendiceal artery. Techniques for ligation of the appendiceal blood
supply vary (e.g. staple device versus electrocautery, versus suture ligation/loop) and inadequate
ligation can lead to oozing or even hemorrhage. Most slow venous oozing ceases with brief
electrocautery to the site or even without intervention in a patient with normal coagulation.
However, steady or pulsatile bleeding indicates that repeat intervention is necessary. The
incidence of this complication is not well documented but in a large retrospective study bleeding
from the mesoappendix was reported in 1.2% of laparoscopic cases [86]. The authors did not
attempt to stratify based on technique for ligation of the artery nor did they describe the
management of the bleeding. However, most often use of electrocautery or a suture ligation/loop
Bleeding may also be encountered during instrument and trocar insertion during laparoscopic
surgery. Caution must be maintained to avoid the epigastric arteries which may be encountered
upon left lower quadrant trocar entry in a classic three-port appendectomy. While this
complication is generally not reported, the authors estimate the incidence to be low, certainly less
than 1%. Frequently, this can be managed laparoscopically by tying off the epigastric artery with
a suture passer. This complication, when recognized intraoperatively, is often with minimal
sequelae, most commonly pain and hematoma formation near the trocar site. In a large
was 2.4% in the laparoscopic group [86] but this is likely not specific to the epigastric artery and
may indicate simple peritoneal oozing or muscular bleeding. Finally, even less frequent is injury to
a major blood vessel such as the aorta, inferior vena cava or iliac artery or vein. Again, this is
most likely to occur during trocar insertion and has been reported with use of the Veress,
disposable and reusable trocars [87]. Also, it is likely correlated with children who are obese with a
thickened abdominal wall leading to difficulty with pneumoperitoneum or need for excessive force
to be applied during trocar insertion [87]. Very rarely, device malfunction may contribute to these
types of injuries but in the large series of major vascular injuries from trocar insertion the majority
of trocars reported were functionally normal [87]. There are no pediatric studies that describe this
complication in the setting of laparoscopic appendectomy and in fact, most of the literature is from
adult gynecologic surgery. However, extreme caution must be given to Veress entry, optical entry
Postoperative complications
After appendectomy, there are several infectious complications that must be considered.
Postoperative abscess rates vary within studies and are dependent on the status of the appendix
abscess is extraordinarily low, 0-0.7%. In a large study utilizing the Nationwide Inpatient Sample,
the rates of intraabdominal abscess formation after laparoscopic appendectomy for nonperforated
appendicitis was around 0.1% [81]. This risk increases with perforation of the appendix and may
be anywhere from 5.7 to 20% [8992]. Management of the postoperative abscess includes
drainage with administration of antibiotics in the vast majority of cases. Occasionally, the
abscess may not be amenable to interventional guided drainage and in these cases antibiotics
alone should be utilized reserving repeat operative intervention for the rare case in which this
The overall rate of wound infection appears to be less than 2.0% in both retrospective reports and
appendectomy [83,84,9395]. However, this risk is increased in perforated appendicitis where rates
reach as high as 5.7% after laparoscopic appendectomy [83]. As in most cases of wound infection,
a short course of antibiotics and local wound care are often satisfactory in management; less
appendicitis treated with laparoscopic surgery. In large national database studies, the risk of true
bowel obstruction appears to be less than 0.1% for nonperforated appendicitis [81]. Overall,
perforated appendicitis and often requires less manipulation of adjacent structures which results
in decreased adhesion formation. The risk of ileus, however, is around 1.2% to 1.3% [81,84]. The
increased risk of postoperative bowel obstruction and ileus results from the presence of
perforation. Reported rates of postoperative bowel obstruction range from 0.2 to 1.2 in large
The risk of prolonged ileus after perforated appendicitis is much higher than true bowel
obstruction but is less frequently reported in the literature. A large discharge database study
appendicitis [81]. However, the rate of abdominal distention and vomiting with or without paralytic
perforated appendicitis or appendicitis with abscess [98]. In patients with prolonged paralytic ileus,
management should be conservative with bowel rest and total parenteral nutrition (TPN) if
necessary. Paralytic ileus may be prolonged for several weeks in rare instances.
population. The risk of VTE after laparoscopic appendectomy is less than 0.1% [81]. This risk may
be slightly increased in perforated appendicitis. Additionally, while patient factors such as obesity
and postoperative activity level may affect this rate, it is more likely that this rare rate of VTE is
deficiency. For the typical pediatric patient requiring laparoscopy for appendicitis the risk is so
Even rarer in the pediatric literature is the occurrence of portal vein or splenic vein thrombosis
portal venous system known as pylephlebitis. Historically, this condition had a <0.4% incidence
[99]
and now is reported in a few case reports only [100103]. One review noted that in all cases
reported since 1971 nearly one-quarter are in the pediatric population [104]. Other reports indicate
that this risk may be higher in perforated appendicitis as well [100] although there are no large
scale studies to prove this since the incidence is so rare. This condition can be fatal if left
undiagnosed or untreated. Initial presentation may include fevers, often nausea and diarrhea with
or without vague abdominal pain and longer history of appendicitis-like symptoms. Sometimes
weight loss and poor appetite may accompany these symptoms as well. Diagnosis is often made
and may extend into the splenic vein or mesenteric veins. In the event of thrombophlebitis of the
portal system or splenic vein, broad spectrum antibiotics targeting gram-negative bacteria and
anaerobes are a staple in management and therapeutic anticoagulation should be utilized if the
thrombus is extensive [105]. Sequelae of pylephlebitis may include the development of hepatic
abscesses which may require percutaneous drainage if antibiotics alone do not treat.
Anticoagulation is indicated in these cases to limit extension of the thrombus and to allow natural
fibrinolysis to occur.
Infectious complications are difficult to avoid in perforated appendicitis and suggestions for
limiting these include removal of as much of the contaminated material as possible and careful
generally related to intense adhesions secondary to perforation. Two timeframes during the
procedure are at greatest risk, entering the abdomen and dissection of the inflammatory mass.
Our technique of entering the abdomen is via an open cutdown and insertion of a blunt cannula.
Once the abdomen has been insufflated the working space can be developed through gentle
dissection with the laparoscope until adequate exposure has be obtained to allow insertion of the
mass, the mobilization of the cecum from the right lower quadrant will greatly aid in identification
of normal distal colon and proximal bowel. Often, once the cecum/ascending colon is mobilized,
the abscess is encountered, and the appendix and its base can be identified and divided without
significant manipulation of the proximal ileum, thus limiting potential small bowel injury.
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