Transumbilical Laparoscopic-assisted Appendectomy (Tulaa) for Acute Appendicitis in Children: to Bury or Not to Bury the Appendiceal Stump? – a Retrospective Cohort Study

Transumbilical Laparoscopic-assisted Appendectomy (Tulaa) for Acute Appendicitis in Children: to Bury or Not to Bury the Appendiceal Stump? – a Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Transumbilical Laparoscopic-assisted Appendectomy (Tulaa) for Acute Appendicitis in Children: to Bury or Not to Bury the Appendiceal Stump? – a Retrospective Cohort Study Stella Mazzarolo, Alessandro Boscarelli, Manuela Giangreco, Chiara Dobrinja, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6045734/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Acute appendicitis is one of the most common surgical conditions in pediatric and general surgery. To date, the management of the appendiceal stump during appendectomy remains controversial. The purpose of this study was to retrospectively investigate the management strategies of acute appendicitis in a tertiary children’s hospital in terms of surgical techniques and time, hospital length of stay, and postoperative complications. Methods: The records of patients < 18 years of age who were treated for acute appendicitis at our Pediatric Surgery Unit from December 2018 to January 2024 were retrospectively reviewed. Data were extrapolated from the departmental database, and clinical notes were reviewed. Results: The records of 278 patients who underwent appendectomy within a 5-year period at our institution were essentially used to compare appendiceal stump inversion and simple ligation. The two groups were similar in terms of sex (P = 0.05), age (P = 0.40), weight (P = 0.78), and associated pathologies (P = 0.12). Statistical analysis revealed no significant differences in length of hospital stay (P = 0.21) and postoperative complications (P = 0.15). Notably, 78.6% of appendicitis cases treated without stump invagination were uncomplicated, whereas 20% were complicated (4.3% abscess and 15.7% peritonitis cases). In contrast, AS invagination was performed in 87% of uncomplicated appendicitis and 13.1% of complicated appendicitis cases (6.8% abscess and 6.3% peritonitis cases). Therefore, simple ligation was also effective in complicated appendicitis cases (P=0.03), with no significant difference in postoperative complications (P = 0.15). Conclusions: Simple ligation does not compromise treatment efficacy nor increase postoperative complications, nor the length of hospital stay. Specifically, our data suggest that simple ligation is at least as effective as invaginating the appendiceal stump, and it might probably simplify the whole procedure. Pediatrics Appendicitis Children Transumbilical Laparoscopy Appendiceal Stump Figures Figure 1 1. INTRODUCTION Acute appendicitis (AA) is one of the most common surgical conditions in pediatric and general surgery [ 1 ]. To date, the management of the appendiceal stump (AS) during appendectomy remains controversial [ 2 ]. The conventional method for treating the AS is to ligate and bury it into the cecum after packing a tobacco pouch, as described by McBurney in 1894; this method is intended to prevent contamination of the abdominal cavity and surgical wound infections [ 3 ]. Recently, several studies have confirmed that in both open and laparoscopic appendectomy, simple ligation does not produce different results in terms of surgical efficacy and adverse outcomes [ 4 , 5 ] and is even preferred because of the shorter surgical time [ 6 – 10 ]. Furthermore, the literature has showed that stump invagination is an additional procedure that could alter the cecal anatomy and may potentially lead to related complications, including intramural abscesses, ileocecal intussusception, and fecal fistulas [ 11 , 12 ]. Despite these studies, many surgeons hesitate to avoid burying the AS, particularly in transumbilical laparoscopic-assisted appendectomy (TULAA) and open appendectomy. The purpose of this study was to retrospectively investigate the management strategies of acute appendicitis in a tertiary children’s hospital in terms of surgical techniques and time, hospital length of stay (LOS), and postoperative complications. 2. MATERIALS AND METHODS The records of patients < 18 years of age who were treated for AA at our Pediatric Surgery Unit from December 2018 to January 2024 were retrospectively reviewed. Data were extrapolated from the departmental database, and clinical notes were reviewed. Demographic data (age and sex), comorbidities at admission, laboratory investigations (white blood cells [WBCs], neutrophil percentage (%) and absolute count (#), and C-reactive protein [CRP] levels), diagnostic imaging, surgical details (surgical technique [particularly whether invagination of the appendiceal stump was performed], number of operators, and surgical time), histopathology, antibiotic therapy, and postoperative outcomes were examined. In all patients, surgery was initiated as TULAA and converted to videolaparoscopic surgery (VLS) and/or open surgery in the event of intraoperative difficulties. The continuous variables were described as medians and interquartile ranges (IQRs), while frequencies and percentages were employed to describe categorical variables. The chi-square test and Fisher’s exact test were used to analyze the relationships between categorical variables, while the Wilcoxon Mann–Whitney nonparametric test was used to analyze the relationships between continuous variables across the categories of qualitative variables. A significance level of P < 0.05 was chosen. All statistical analyses were conducted using SAS 9.4 software (SAS Institute Inc, Cary, NC, USA). 3. RESULTS A total of 278 patients underwent appendectomies at our Pediatric Surgery Department between December 2018 and January 2024, including 132 females (47.5%) and 146 males (52.5%). Of these patients, AS invagination was performed in 208 patients (74.8%), comprising 106 females (51.0%) and 102 males (49.0%), with a median age of 11 years (IQR 8–15) and a median weight of 36.5 kg (IQR 28–54). Twenty-six (12.5%) patients had associated conditions, including type 1 diabetes mellitus, obesity, Kawasaki syndrome, Ehlers–Danlos syndrome, and Klinefelter syndrome. Out of a total of 278 patients, the AS was not invaginated in 70 children (25.2%), consisting of 26 females (37.1%) and 44 males (62.9%), with a median age of 11 years (IQR 8–14) and a median weight of 38.3 kg (IQR 29.5–47). Fourteen patients (20%) had associated pathologies, including SARS-CoV-2 infection, Kawasaki syndrome, obesity, and anorexia. At admission, laboratory parameters were collected for all patients, revealing a general increase in inflammation marker levels. Specifically, for patients who underwent AS invagination, the median WBC count (×10 3 /μL) was 14.7 (IQR 12.1–18.3), the median absolute neutrophil count (#) was 11.6 (IQR 8.4 – 15.2), the median neutrophil percentage (%) was 80.6 (IQR 72.6–85.2), and the median CRP value (mg/L) was 14.6 (IQR 3.5–48.4). Ninety patients (43.3%) had fever at admission. For patients who underwent simple ligation of the AS, the median WBC count (×10 3 /μL) was 14.9 (IQR 11.5–18.0), the median absolute neutrophil count (#) was 11.2 (IQR 8.1–13.9), the median neutrophil percentage (%) was 78.6 (IQR 71.1–86.0), and the median CRP value (mg/L) was 58.9 (IQR 13.8–111.0). Fever was present in 34 patients (48.6%) at admission. Regarding diagnosis, definitive visualization of the appendix was not possible in 75 (27%) of the patients undergoing stump invagination and 22 (7.92%) of the patients who underwent simple ligation of the stump. Furthermore, in the group of patients who underwent stump burying, 181 (87%) had uncomplicated AA, fourteen (6.8%) had an appendicular abscess, and 13 (6.3%) had perforated appendicitis with generalized peritonitis. On the other hand, in the group of children who underwent simple ligation, 55 (78.6%) had AA, three (4.3%) had an appendicular abscess, 11 (15.7%) had perforated appendicitis with generalized peritonitis, and one (1.4%) underwent surgery for stump appendicitis. Overall, 222 operations (79.86%) were performed using only the TULAA technique and four (1.44%) using the open technique as the first-line treatment, while 52 (18.70%) operations were converted. Specifically, 41 of these 52 operations (14.74%) were converted from TULAA to VLS, six (2.16%) were converted to open surgery, and five (1.8%) were converted from TULAA to VLS and then to open surgery. One hundred and seventy-four patients (83.65%) undergoing AS invagination underwent appendectomy using the TULAA technique. The addition of two trocars was necessary for 17 children (8.17%), while one more trocar was needed for five children (2.40%); three patients (1.44%) required conversion from TULAA to open surgery due to difficulties arising during the procedure, while three patients required conversion from TULAA plus one trocar (one patient, 0.48%) or two trocars (two patients, 0.96%) to open surgery. In two patients (0.96%), the open appendectomy technique was applied directly. Four cases (1.92%) were started with conservative treatment and subsequently treated with TULAA, adding one trocar for one patient (0.48%) and two trocars for three patients (1.44%). The procedure involved one surgeon in five cases (2.40%), two surgeons in 180 cases (86.54%), and three surgeons in 23 cases (11.06%). Forty-eight patients (68.57%) in whom the AS was not invaginated underwent appendectomy with the TULAA technique, while two children (2.86%) underwent appendectomy with the open technique. In some children, the TULAA technique was begun, but the addition of one trocar (five patients, 7.14%) or two trocars (10 patients, 14.29%) was needed. In three patients (4.29%), conversion from TULAA to open surgery was necessary. In two cases (2.86%), TULAA plus one trocar (one patient, 1.43%) or two trocars (one patient, 1.43%) was converted to open surgery. The procedure required one surgeon in two cases (2.86%), two surgeons in 51 cases (72.86%), and three surgeons in 17 cases (24.29%). The median surgical duration for patients undergoing AS invagination was 63.5 minutes, with a minimum of 20 minutes and a maximum of 325 minutes (IQR 46–90). In comparison, the median surgical duration for patients who underwent simple ligation was 69 minutes, with a minimum of 25 minutes and a maximum of 270 minutes (IQR 60–115). Appendicitis severity was evaluated based on the intra-abdominal findings during the procedures. In patients with AS invagination, the appendix was catarrhal in 34 patients (16.3%), phlegmonous in 117 patients (56.3%), phlegmonous with a gangrenous tip in eight patients (3.8%), gangrenous in 23 patients (11.1%), and perforated in 25 patients (12%), and one patient had an appendicular abscess (0.5%). In the other group, the appendix was catarrhal in 18 patients (25.7%), phlegmonous in 21 patients (30%), phlegmonous with an abscessed tip in one patient (1.4%), phlegmonous with a gangrenous tip in five patients (7.1%), gangrenous in nine patients (12.9%), and perforated in 15 patients (21.4%). All the patients were treated with antibiotics during and after surgery. In children undergoing stump invagination, different combinations of antibiotics were used in the hospital, including ampicillin (0.30%), ampicillin/sulbactam (56.20%), ciprofloxacin (0.30%), clindamycin (0.30%), fluconazole (0.30%), metronidazole (22.66%), meropenem (0.90%), piperacillin (0.30%), piperacillin/tazobactam (4.83%), tigecycline (0.30%), tobramycin (13.29%), and vancomycin (0.30%). The combinations used after discharge in these patients included amoxicillin-clavulanate (55.75%), ampicillin/sulbactam (0.44%), cefixime (0.44%), ciprofloxacin (3.98%), clarithromycin (0.44%), clindamycin (0.44%), fluconazole (0.44%), meropenem (0.44%), metronidazole (8.40%), tobramycin (0.44%), vancomycin (0.44%), and no antibiotics in 64 patients (28.32%). Patients who underwent simple ligation of the AS received the following antibiotics during hospitalization: ampicillin/sulbactam (44.19%), fluconazole (0.78%), metronidazole (28.81%), meropenem (1.55%), piperacillin/tazobactam (9.30%), tobramycin (18.60%), and vancomycin (0.78%). The combinations used after discharge in these patients included amoxicillin-clavulanate (65.82%), ciprofloxacin (1.27%), clindamycin (2.53%), levofloxacin (1.27%), metronidazole (12.66%), and no antibiotics in 13 patients (16.46%). The median LOS was 3 days for patients who underwent stump invagination, with values ranging from 1 to 34 days (IQR 2–4), and 3 days for patients who underwent simple ligation, with values ranging from 2 to 27 days (IQR 2–7). Regarding postoperative complications, 32 patients (15.4%) with the AS buried during surgery experienced complications, including intra-abdominal abscess (3.8%), wound infection (3.8%), fever (2.9%), gastrointestinal symptoms (0.5%), fever and gastrointestinal symptoms (1.0%), intra-abdominal abscess and fever (1.4%), fever and abdominal pain (1%), fever and wound infection (0.5%), and intra-abdominal abscess and abdominal pain (0.5%). In the other group, 16 patients (22.9%) experienced complications, including intra-appendicular abscess (4.3%), fever (5.7%), gastrointestinal symptoms (5.7%), wound infection (5.7%), and combined fever, intra-abdominal abscess, and wound infection (one patient, 1.4%). All analyzed variables are summarized in Tables 1 and 2. 4. DISCUSSION AA remains the most common abdominal surgical emergency in the second decade of life. Currently, TULAA is considered a valuable strategy for treating AA, especially in children [ 13 – 15 ]. Since 2006, at our Pediatric Surgery Department, TULAA has been adopted as the gold-standard treatment for complicated and uncomplicated appendicitis. It consists of a single intra-umbilical access site for an operative laparoscope to exteriorize the appendix, combining the advantages of laparoscopic visualization with the safety and speed of the open appendectomy. If necessary, this approach is supplemented with the addition of one or two trocars or converted to an open appendectomy. Ordinarily, immediate surgical intervention is considered crucial in cases of AA particularly when complicated by generalized peritonitis, while appendicular abscesses are initially treated conservatively with double (ceftriaxone and metronidazole) or triple (ampicillin plus sulbactam, metronidazole, and tobramycin) antibiotic therapy. In that event, after 48 hours of antibiotic treatment, patients are re-evaluated clinically and through laboratory tests (WBC count, neutrophil count and percentage, and CRP level), and in case the patient’s clinical condition has improved, deferred surgery (known as “interval appendectomy”) is scheduled after 8–12 weeks. If the patient does not respond to antibiotics within 48 hours, prompt appendectomy is indicated. Accordingly, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and Jerusalem guidelines suggest that pediatric patients with uncomplicated appendicitis should be managed surgically using TULAA and recommend that both adult and pediatric patients undergoing conservative treatment for complicated appendicitis should undergo interval appendectomy [ 14 , 15 ]. Figure 1 shows the management flowchart for AA in our tertiary-level pediatric surgical department. The records of 278 patients who underwent appendectomy within a 5-year period at our institution were essentially used to compare AS inversion and simple ligation. The two groups were similar in terms of sex (P = 0.05), age (P = 0.40), weight (P = 0.78), and associated pathologies (P = 0.12). In this study on children, statistical analysis also revealed no significant differences in length of hospital stay (P = 0.21) and postoperative complications (P = 0.15), which is consistent with previous trials [ 4 , 5 ]. On the other hand, the p-value for the duration of the intervention was statistically significant (P = 0.02) and, although the median values between the two groups were quite similar, a lower value (63.5 min) was observed in patients who experienced stump invagination than in patients in whom the stump was not invaginated (69 min). Nonetheless, this outcome may be influenced primarily by the unequal sample size of the two groups (70 vs. 208), and secondarily by the variety of surgeons performing the procedures. However, the maximum duration of the intervention was 270 minutes in the group that did not experience the burying of the AS and 325 minutes in patients who experienced the stump invagination. This finding suggests that probably patients who underwent stump invagination could require longer occupation of the operating room, potentially resulting in increased costs for the hospital. An additional factor that may have influenced the duration of surgery was the predominant number of cases of complicated appendicitis undergoing simple ligation, confirmed by a higher CRP value in these patients and a statistically significant P value (P < .0001). Indeed, 78.6% of appendicitis cases treated without stump invagination were uncomplicated, whereas 20% were complicated (4.3% abscess and 15.7% peritonitis cases). In contrast, AS invagination was performed in 87% of uncomplicated appendicitis and 13.1% of complicated appendicitis cases (6.8% abscess and 6.3% peritonitis cases). Therefore, simple ligation was also effective in complicated appendicitis cases (P = 0.03), with no significant difference in postoperative complications (P = 0.15). Our study presents several limitations, including its retrospective nature, the small patient cohort, and the comparison of two groups with different patient numbers (208 vs. 70). Prospective randomized studies with a higher number of patients are encouraged to strengthen our findings. 5. CONCLUSIONS In conclusion, burying the AS or not during appendectomy for AA remains a matter of debate between both general and pediatric surgeons. Based on our experience, simple ligation does not compromise treatment efficacy nor increase postoperative complications, nor the length of hospital stay. Specifically, our data suggest that simple ligation is at least as effective as invaginating the AS, and it might probably simplify the whole procedure. Therefore, although stump invagination is still widely used during appendectomies not performed laparoscopically, we strongly believe that simple ligation of the AS should be preferred during the surgical management of AA in both TULAA and open appendectomy. Abbreviations AA = Acute Appendicitis AS = Appendiceal Stump TULAA = Transumbilical Laparoscopic-Assisted Appendectomy LOS = Length of Stay WBC = White Blood Cell CRP = C-reactive protein VLS = VideoLaparoscopic Surgery IQR = Intrequartile Range Declarations The (IRCCS Burlo Garofolo) Institutional Research Committee approved the study. Conflicts of Interest: The authors declare no conflict of interest. Funding: This research received no external funding. Availability of data and material: The data that support the findings of this study are available on request from the corresponding author. Informed Consent Statement: Patient consent was waived due to the retrospective nature of the study. Statement of ethics approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (IRCCS Burlo Garofolo) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. References Bundy, D. G., Byerley, J. S., Liles, E. A., Perrin, E. M., Katznelson, J., Rice, H. E. Does this child have appendicitis? JAMA. 2007 Jul 25;298(4):438-51. doi: 10.1001/jama.298.4.438. PMID: 17652298; PMCID: PMC2703737. Aceti, V., Boscarelli, A. Burying the appendiceal stump during appendicectomy: state of art. Transl Pediatr. 2018 Jan;7(1):73-74. doi: 10.21037/tp.2017.11.01. PMID: 29441286; PMCID: PMC5803017. McBurney C. IV. The Incision Made in the Abdominal Wall in Cases of Appendicitis, with a Description of a New Method of Operating. Ann Surg. 1894 Jul;20(1):38-43. doi: 10.1097/00000658-189407000-00004. PMID: 17860070; PMCID: PMC1493708. Kiran, K. S., Ramani, A. S., Math, S. K. (2023).Outcomes of Open Appendicectomy by Simple Ligation versus Invagination in Acute Appendicitis- A Prospective Observational Study, 12(1), SO21-SO23. https://www.doi.org/10.7860/JCDR/2023/59856/2871 Bekki, T., Abe, T., Namba, Y., Okimoto, S., Mukai, S., Saito, Y., et al. (2023). Validation of appendiceal stump invagination in laparoscopic appendectomy. Asian journal of endoscopic surgery, 16(2), 203–209. https://doi.org/10.1111/ases.13137 Afridi, N. G., Iqbal, Z., Nazeem, S., Ahmad, S. (2014). Simple ligation versus invagination of stump in open appendicectomy. Journal of Medical Sciences, 22(2), 93–95. Retrieved from https://jmedsci.com/index.php/Jmedsci/article/view/285 Qazi, S. R., Darokar, A. V., Bijwe, V. N., Mulmule, R. M., & Bele, K. K. (2016). A comparative study of simple ligation and simple ligation with invagination of appendicular stump. International Journal of Research in Medical Sciences, 4(5), 1485–1489. https://doi.org/10.18203/2320-6012.ijrms20161215 Qian, D., He, Z., Hua, J., Song, Z. (2015). Stump Invagination Versus Simple Ligation in Open Appendicectomy: A Systematic Review and Meta-Analysis. International surgery, 100(7-8), 1199–1206. https://doi.org/10.9738/INTSURG-D-15-00074.1 Bansal, A. R., Bansal, M., Lamba, R.K. (2020). 'Comparative Evaluation of Simple Ligation Versus Invagination of Stump in Open Appendicectomy' , International Journal of Current Advanced Research, 09(03), 21661-21663. doi: 10.24327/ijcar.2020.21663.4263 Sayyadinia, M., Hamadiyan, H., Mokaripoor, S., Azaad, M. (2016). Comparing the complications of purse-string and simple ligation of appendix stump in appendectomy: A randomized clinical trial. Int J Med Res Health Sci., 5(10):55-60 Gravante, G., Yahia, S., Sorge, R., Mathew, G., Kelkar, A. Back to basics: A meta-analysis of stump management during open appendicectomy for uncomplicated acute appendicitis. World J Surg Proced 2013;3:47-53 Machado, N. O. Ileocecal intussusception following appendectomy. Ann Saudi Med. 2006 Jul-Aug;26(4):315-7. doi: 10.5144/0256-4947.2006.315. PMID: 16885630; PMCID: PMC6074511. Klein, T., Diesbach, D., Boemers, T. M., Vahdad, R. M. Transumbilical laparoscopic-assisted appendectomy in children and adolescents: what have we learnt in more than 1200 cases?. Langenbecks Arch Surg 409, 263 (2024). https://doi.org/10.1007/s00423-024-03437-2 Di Saverio, S., Podda, M., De Simone, B., Ceresoli, M., Augustin, G., Gori, A., et al. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World journal of emergency surgery : WJES, 15(1), 27. https://doi.org/10.1186/s13017-020-00306-3 Kumar, S. S., Collings, A. T., Lamm, R., Haskins, I. N., Scholz, S., Nepal, P., et al. (2024). SAGES guideline for the diagnosis and treatment of appendicitis. Surgical endoscopy, 38(6), 2974–2994. https://doi.org/10.1007/s00464-024-10813-y Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files Table1and2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6045734","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":418220289,"identity":"76abb0b5-4eed-4183-bf7c-6473f04d759f","order_by":0,"name":"Stella Mazzarolo","email":"","orcid":"","institution":"University of Trieste, Faculty of Medicine and Surgery, Trieste, Italy.","correspondingAuthor":false,"prefix":"","firstName":"Stella","middleName":"","lastName":"Mazzarolo","suffix":""},{"id":418220290,"identity":"d1b9bce5-48c7-4376-8753-a78fd5c7cea7","order_by":1,"name":"Alessandro Boscarelli","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYDACCQglZwCmDCwY2Ajp4IFqMTZgYAZpkWBgI6QHpiVxA1gLyFJCWuylmw9/+FFzL307e//RDT8KJBj45BsI2CJzLE2y51hx7s6ew2w3e4hzWI4ZMwNbQu6GG8lsN3iI1GL8meFfQroBUMvNP0RqMZBmbEtIAGm5TZwtd4B+6e1LMNxw5rDZbRkDCR42tgT8Wthng0LsW4K8wfHGZzff/LGRk28+QMAaDGtJVD8KRsEoGAWjABsAADteOYC/dAhtAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-1934-1764","institution":"Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - 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IRCCS \"Burlo Garofolo\", 34137 Trieste, Italy.","correspondingAuthor":false,"prefix":"","firstName":"Daniela","middleName":"","lastName":"Codrich","suffix":""},{"id":418220294,"identity":"f4b1ec71-517a-4cbf-be3c-0e7e21302733","order_by":5,"name":"Maria-Grazia Scarpa","email":"","orcid":"","institution":"Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS \"Burlo Garofolo\", 34137 Trieste, Italy.","correspondingAuthor":false,"prefix":"","firstName":"Maria-Grazia","middleName":"","lastName":"Scarpa","suffix":""},{"id":418220295,"identity":"b2936486-4828-40cf-8969-2e3345f96118","order_by":6,"name":"Marianna Iaquinto","email":"","orcid":"","institution":"Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS \"Burlo Garofolo\", 34137 Trieste, Italy.","correspondingAuthor":false,"prefix":"","firstName":"Marianna","middleName":"","lastName":"Iaquinto","suffix":""},{"id":418220296,"identity":"27009af2-642a-4a6c-b145-43aea6ad538c","order_by":7,"name":"Matea Peric-Anicic","email":"","orcid":"","institution":"Department of Surgery, University Hospital of Mostar, Mostar, Bosnia and Herzegovina.","correspondingAuthor":false,"prefix":"","firstName":"Matea","middleName":"","lastName":"Peric-Anicic","suffix":""},{"id":418220297,"identity":"74a71bad-4708-4347-a62b-5dfeaaeea83d","order_by":8,"name":"Damiana Olenik","email":"","orcid":"","institution":"Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS \"Burlo Garofolo\", 34137 Trieste, Italy.","correspondingAuthor":false,"prefix":"","firstName":"Damiana","middleName":"","lastName":"Olenik","suffix":""},{"id":418220298,"identity":"34aae244-f43c-491c-934e-57cee189929a","order_by":9,"name":"Sonia Maita","email":"","orcid":"","institution":"Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS \"Burlo Garofolo\", 34137 Trieste, Italy.","correspondingAuthor":false,"prefix":"","firstName":"Sonia","middleName":"","lastName":"Maita","suffix":""},{"id":418220299,"identity":"801b97fb-b032-4dfb-b5f9-de05619fa829","order_by":10,"name":"Edoardo Guida","email":"","orcid":"https://orcid.org/0000-0003-4901-2515","institution":"Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS \"Burlo Garofolo\", 34137 Trieste, Italy.","correspondingAuthor":false,"prefix":"","firstName":"Edoardo","middleName":"","lastName":"Guida","suffix":""},{"id":418220300,"identity":"b9acd840-299c-4abb-99e9-11bc0ed06474","order_by":11,"name":"Jurgen Schleef","email":"","orcid":"https://orcid.org/0000-0001-9754-2479","institution":"Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS \"Burlo Garofolo\", 34137 Trieste, Italy.","correspondingAuthor":false,"prefix":"","firstName":"Jurgen","middleName":"","lastName":"Schleef","suffix":""}],"badges":[],"createdAt":"2025-02-17 08:12:44","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6045734/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6045734/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77354967,"identity":"017937ca-529a-4a08-b500-6b451002f6c2","added_by":"auto","created_at":"2025-02-27 17:53:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":132646,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6045734/v1/894d65a033c0b5305f8e142b.jpg"},{"id":77355959,"identity":"88b49096-41b3-48f4-9263-cad49526f32e","added_by":"auto","created_at":"2025-02-27 18:01:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":600203,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6045734/v1/fafd381a-faa4-43b2-bfe9-2abfcc335b70.pdf"},{"id":77354971,"identity":"0f83d268-73b8-4581-8924-d333dd00e471","added_by":"auto","created_at":"2025-02-27 17:53:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20645,"visible":true,"origin":"","legend":"","description":"","filename":"Table1and2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6045734/v1/55ab93cf34ae32f176e2d593.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eTransumbilical Laparoscopic-assisted Appendectomy (Tulaa) for Acute Appendicitis in Children: to Bury or Not to Bury the Appendiceal Stump? – a Retrospective Cohort Study\u003c/p\u003e","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eAcute appendicitis (AA) is one of the most common surgical conditions in pediatric and general surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To date, the management of the appendiceal stump (AS) during appendectomy remains controversial [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The conventional method for treating the AS is to ligate and bury it into the cecum after packing a tobacco pouch, as described by McBurney in 1894; this method is intended to prevent contamination of the abdominal cavity and surgical wound infections [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recently, several studies have confirmed that in both open and laparoscopic appendectomy, simple ligation does not produce different results in terms of surgical efficacy and adverse outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and is even preferred because of the shorter surgical time [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, the literature has showed that stump invagination is an additional procedure that could alter the cecal anatomy and may potentially lead to related complications, including intramural abscesses, ileocecal intussusception, and fecal fistulas [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these studies, many surgeons hesitate to avoid burying the AS, particularly in transumbilical laparoscopic-assisted appendectomy (TULAA) and open appendectomy. The purpose of this study was to retrospectively investigate the management strategies of acute appendicitis in a tertiary children\u0026rsquo;s hospital in terms of surgical techniques and time, hospital length of stay (LOS), and postoperative complications.\u003c/p\u003e"},{"header":"2. MATERIALS AND METHODS","content":"\u003cp\u003eThe records of patients\u0026thinsp;\u0026lt;\u0026thinsp;18 years of age who were treated for AA at our Pediatric Surgery Unit from December 2018 to January 2024 were retrospectively reviewed. Data were extrapolated from the departmental database, and clinical notes were reviewed. Demographic data (age and sex), comorbidities at admission, laboratory investigations (white blood cells [WBCs], neutrophil percentage (%) and absolute count (#), and C-reactive protein [CRP] levels), diagnostic imaging, surgical details (surgical technique [particularly whether invagination of the appendiceal stump was performed], number of operators, and surgical time), histopathology, antibiotic therapy, and postoperative outcomes were examined.\u003c/p\u003e \u003cp\u003eIn all patients, surgery was initiated as TULAA and converted to videolaparoscopic surgery (VLS) and/or open surgery in the event of intraoperative difficulties.\u003c/p\u003e \u003cp\u003eThe continuous variables were described as medians and interquartile ranges (IQRs), while frequencies and percentages were employed to describe categorical variables.\u003c/p\u003e \u003cp\u003eThe chi-square test and Fisher\u0026rsquo;s exact test were used to analyze the relationships between categorical variables, while the Wilcoxon Mann\u0026ndash;Whitney nonparametric test was used to analyze the relationships between continuous variables across the categories of qualitative variables. A significance level of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was chosen. All statistical analyses were conducted using SAS 9.4 software (SAS Institute Inc, Cary, NC, USA).\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eA total of 278 patients underwent appendectomies at our Pediatric Surgery Department between December 2018 and January 2024, including 132 females (47.5%) and 146 males (52.5%). Of these patients, AS invagination was performed in 208 patients (74.8%), comprising 106 females (51.0%) and 102 males (49.0%), with a median age of 11 years (IQR 8\u0026ndash;15) and a median weight of 36.5 kg (IQR 28\u0026ndash;54). Twenty-six (12.5%) patients had associated conditions, including type 1 diabetes mellitus, obesity, Kawasaki syndrome, Ehlers\u0026ndash;Danlos syndrome, and Klinefelter syndrome. Out of a total of 278 patients, the AS was not invaginated in 70 children (25.2%), consisting of 26 females (37.1%) and 44 males (62.9%), with a median age of 11 years (IQR 8\u0026ndash;14) and a median weight of 38.3 kg (IQR 29.5\u0026ndash;47). Fourteen patients (20%) had associated pathologies, including SARS-CoV-2 infection, Kawasaki syndrome, obesity, and anorexia.\u003c/p\u003e\n\u003cp\u003eAt admission, laboratory parameters were collected for all patients, revealing a general increase in inflammation marker levels. Specifically, for patients who underwent AS invagination, the median WBC count (\u0026times;10\u003csup\u003e3\u003c/sup\u003e/\u0026mu;L) was 14.7 (IQR 12.1\u0026ndash;18.3), the median absolute neutrophil count (#) was 11.6 (IQR 8.4 \u0026ndash; 15.2), the median neutrophil percentage (%) was 80.6 (IQR 72.6\u0026ndash;85.2), and the median CRP value (mg/L) was 14.6 (IQR 3.5\u0026ndash;48.4). Ninety patients (43.3%) had fever at admission. For patients who underwent simple ligation of the AS, the median WBC count (\u0026times;10\u003csup\u003e3\u003c/sup\u003e/\u0026mu;L) was 14.9 (IQR 11.5\u0026ndash;18.0), the median absolute neutrophil count (#) was 11.2 (IQR 8.1\u0026ndash;13.9), the median neutrophil percentage (%) was 78.6 (IQR 71.1\u0026ndash;86.0), and the median CRP value (mg/L) was 58.9 (IQR 13.8\u0026ndash;111.0). Fever was present in 34 patients (48.6%) at admission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding diagnosis, definitive visualization of the appendix was not possible in 75 (27%) of the patients undergoing stump invagination and 22 (7.92%) of the patients who underwent simple ligation of the stump. Furthermore, in the group of patients who underwent stump burying, 181 (87%) had uncomplicated AA, fourteen (6.8%) had an appendicular abscess, and 13 (6.3%) had perforated appendicitis with generalized peritonitis. On the other hand, in the group of children who underwent simple ligation, 55 (78.6%) had AA, three (4.3%) had an appendicular abscess, 11 (15.7%) had perforated appendicitis with generalized peritonitis, and one (1.4%) underwent surgery for stump appendicitis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, 222 operations (79.86%) were performed using only the TULAA technique and four (1.44%) using the open technique as the first-line treatment, while 52 (18.70%) operations were converted. Specifically, 41 of these 52 operations (14.74%) were converted from TULAA to VLS, six (2.16%) were converted to open surgery, and five (1.8%) were converted from TULAA to VLS and then to open surgery. One hundred and seventy-four patients (83.65%) undergoing AS invagination underwent appendectomy using the TULAA technique. The addition of two trocars was necessary for 17 children (8.17%), while one more trocar was needed for five children (2.40%); three patients (1.44%) required conversion from TULAA to open surgery due to difficulties arising during the procedure, while three patients required conversion from TULAA plus one trocar (one patient, 0.48%) or two trocars (two patients, 0.96%) to open surgery. In two patients (0.96%), the open appendectomy technique was applied directly. Four cases (1.92%) were started with conservative treatment and subsequently treated with TULAA, adding one trocar for one patient (0.48%) and two trocars for three patients (1.44%). The procedure involved one surgeon in five cases (2.40%), two surgeons in 180 cases (86.54%), and three surgeons in 23 cases (11.06%). Forty-eight patients (68.57%) in whom the AS was not invaginated underwent appendectomy with the TULAA technique, while two children (2.86%) underwent appendectomy with the open technique. In some children, the TULAA technique was begun, but the addition of one trocar (five patients, 7.14%) or two trocars (10 patients, 14.29%) was needed. In three patients (4.29%), conversion from TULAA to open surgery was necessary. In two cases (2.86%), TULAA plus one trocar (one patient, 1.43%) or two trocars (one patient, 1.43%) was converted to open surgery. The procedure required one surgeon in two cases (2.86%), two surgeons in 51 cases (72.86%), and three surgeons in 17 cases (24.29%).\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe median surgical duration for patients undergoing AS invagination was 63.5 minutes, with a minimum of 20 minutes and a maximum of 325 minutes (IQR 46\u0026ndash;90). In comparison, the median surgical duration for patients who underwent simple ligation was 69 minutes, with a minimum of 25 minutes and a maximum of 270 minutes (IQR 60\u0026ndash;115).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAppendicitis severity was evaluated based on the intra-abdominal findings during the procedures. In patients with AS invagination, the appendix was catarrhal in 34 patients (16.3%), phlegmonous in 117 patients (56.3%), phlegmonous with a gangrenous tip in eight patients (3.8%), gangrenous in 23 patients (11.1%), and perforated in 25 patients (12%), and one patient had an appendicular abscess (0.5%). In the other group, the appendix was catarrhal in 18 patients (25.7%), phlegmonous in 21 patients (30%), phlegmonous with an abscessed tip in one patient (1.4%), phlegmonous with a gangrenous tip in five patients (7.1%), gangrenous in nine patients (12.9%), and perforated in 15 patients (21.4%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the patients were treated with antibiotics during and after surgery. In children undergoing stump invagination, different combinations of antibiotics were used in the hospital, including ampicillin (0.30%), ampicillin/sulbactam (56.20%), ciprofloxacin (0.30%), clindamycin (0.30%), fluconazole (0.30%), metronidazole (22.66%), meropenem (0.90%), piperacillin (0.30%), piperacillin/tazobactam (4.83%), tigecycline (0.30%), tobramycin (13.29%), and vancomycin (0.30%). The combinations used after discharge in these patients included amoxicillin-clavulanate (55.75%), ampicillin/sulbactam (0.44%), cefixime (0.44%), ciprofloxacin (3.98%), clarithromycin (0.44%), clindamycin (0.44%), fluconazole (0.44%), meropenem (0.44%), metronidazole (8.40%), tobramycin (0.44%), vancomycin (0.44%), and no antibiotics in 64 patients (28.32%). Patients who underwent simple ligation of the AS received the following antibiotics during hospitalization: ampicillin/sulbactam (44.19%), fluconazole (0.78%), metronidazole (28.81%), meropenem (1.55%), piperacillin/tazobactam (9.30%), tobramycin (18.60%), and vancomycin (0.78%). The combinations used after discharge in these patients included amoxicillin-clavulanate (65.82%), ciprofloxacin (1.27%), clindamycin (2.53%), levofloxacin (1.27%), metronidazole (12.66%), and no antibiotics in 13 patients (16.46%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe median LOS was 3 days for patients who underwent stump invagination, with values ranging from 1 to 34 days (IQR 2\u0026ndash;4), and 3 days for patients who underwent simple ligation, with values ranging from 2 to 27 days (IQR 2\u0026ndash;7).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding postoperative complications, 32 patients (15.4%) with the AS buried during surgery experienced complications, including intra-abdominal abscess (3.8%), wound infection (3.8%), fever (2.9%), gastrointestinal symptoms (0.5%), fever and gastrointestinal symptoms (1.0%), intra-abdominal abscess and fever (1.4%), fever and abdominal pain (1%), fever and wound infection (0.5%), and intra-abdominal abscess and abdominal pain (0.5%). In the other group, 16 patients (22.9%) experienced complications, including intra-appendicular abscess (4.3%), fever (5.7%), gastrointestinal symptoms (5.7%), wound infection (5.7%), and combined fever, intra-abdominal abscess, and wound infection (one patient, 1.4%). All analyzed variables are summarized in Tables 1 and 2.\u0026nbsp;\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eAA remains the most common abdominal surgical emergency in the second decade of life. Currently, TULAA is considered a valuable strategy for treating AA, especially in children [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince 2006, at our Pediatric Surgery Department, TULAA has been adopted as the gold-standard treatment for complicated and uncomplicated appendicitis. It consists of a single intra-umbilical access site for an operative laparoscope to exteriorize the appendix, combining the advantages of laparoscopic visualization with the safety and speed of the open appendectomy. If necessary, this approach is supplemented with the addition of one or two trocars or converted to an open appendectomy. Ordinarily, immediate surgical intervention is considered crucial in cases of AA particularly when complicated by generalized peritonitis, while appendicular abscesses are initially treated conservatively with double (ceftriaxone and metronidazole) or triple (ampicillin plus sulbactam, metronidazole, and tobramycin) antibiotic therapy. In that event, after 48 hours of antibiotic treatment, patients are re-evaluated clinically and through laboratory tests (WBC count, neutrophil count and percentage, and CRP level), and in case the patient\u0026rsquo;s clinical condition has improved, deferred surgery (known as \u0026ldquo;interval appendectomy\u0026rdquo;) is scheduled after 8\u0026ndash;12 weeks. If the patient does not respond to antibiotics within 48 hours, prompt appendectomy is indicated. Accordingly, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and Jerusalem guidelines suggest that pediatric patients with uncomplicated appendicitis should be managed surgically using TULAA and recommend that both adult and pediatric patients undergoing conservative treatment for complicated appendicitis should undergo interval appendectomy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Figure\u0026nbsp;1 shows the management flowchart for AA in our tertiary-level pediatric surgical department.\u003c/p\u003e \u003cp\u003eThe records of 278 patients who underwent appendectomy within a 5-year period at our institution were essentially used to compare AS inversion and simple ligation. The two groups were similar in terms of sex (P\u0026thinsp;=\u0026thinsp;0.05), age (P\u0026thinsp;=\u0026thinsp;0.40), weight (P\u0026thinsp;=\u0026thinsp;0.78), and associated pathologies (P\u0026thinsp;=\u0026thinsp;0.12). In this study on children, statistical analysis also revealed no significant differences in length of hospital stay (P\u0026thinsp;=\u0026thinsp;0.21) and postoperative complications (P\u0026thinsp;=\u0026thinsp;0.15), which is consistent with previous trials [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, the p-value for the duration of the intervention was statistically significant (P\u0026thinsp;=\u0026thinsp;0.02) and, although the median values between the two groups were quite similar, a lower value (63.5 min) was observed in patients who experienced stump invagination than in patients in whom the stump was not invaginated (69 min). Nonetheless, this outcome may be influenced primarily by the unequal sample size of the two groups (70 vs. 208), and secondarily by the variety of surgeons performing the procedures. However, the maximum duration of the intervention was 270 minutes in the group that did not experience the burying of the AS and 325 minutes in patients who experienced the stump invagination. This finding suggests that probably patients who underwent stump invagination could require longer occupation of the operating room, potentially resulting in increased costs for the hospital. An additional factor that may have influenced the duration of surgery was the predominant number of cases of complicated appendicitis undergoing simple ligation, confirmed by a higher CRP value in these patients and a statistically significant P value (P\u0026thinsp;\u0026lt;\u0026thinsp;.0001). Indeed, 78.6% of appendicitis cases treated without stump invagination were uncomplicated, whereas 20% were complicated (4.3% abscess and 15.7% peritonitis cases). In contrast, AS invagination was performed in 87% of uncomplicated appendicitis and 13.1% of complicated appendicitis cases (6.8% abscess and 6.3% peritonitis cases). Therefore, simple ligation was also effective in complicated appendicitis cases (P\u0026thinsp;=\u0026thinsp;0.03), with no significant difference in postoperative complications (P\u0026thinsp;=\u0026thinsp;0.15).\u003c/p\u003e \u003cp\u003eOur study presents several limitations, including its retrospective nature, the small patient cohort, and the comparison of two groups with different patient numbers (208 vs. 70). Prospective randomized studies with a higher number of patients are encouraged to strengthen our findings.\u003c/p\u003e"},{"header":"5. CONCLUSIONS","content":"\u003cp\u003eIn conclusion, burying the AS or not during appendectomy for AA remains a matter of debate between both general and pediatric surgeons. Based on our experience, simple ligation does not compromise treatment efficacy nor increase postoperative complications, nor the length of hospital stay. Specifically, our data suggest that simple ligation is at least as effective as invaginating the AS, and it might probably simplify the whole procedure. Therefore, although stump invagination is still widely used during appendectomies not performed laparoscopically, we strongly believe that simple ligation of the AS should be preferred during the surgical management of AA in both TULAA and open appendectomy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAA = Acute Appendicitis\u003c/p\u003e\n\u003cp\u003eAS = Appendiceal Stump\u003c/p\u003e\n\u003cp\u003eTULAA = Transumbilical Laparoscopic-Assisted Appendectomy\u003c/p\u003e\n\u003cp\u003eLOS = Length of Stay\u003c/p\u003e\n\u003cp\u003eWBC = White Blood Cell\u003c/p\u003e\n\u003cp\u003eCRP = C-reactive protein\u003c/p\u003e\n\u003cp\u003eVLS = VideoLaparoscopic Surgery\u003c/p\u003e\n\u003cp\u003eIQR = Intrequartile Range\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eThe (IRCCS Burlo Garofolo) Institutional Research Committee approved the study.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no external funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e The data that support the findings of this study are available on request from the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u003c/strong\u003e Patient consent was waived due to the retrospective nature of the study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of ethics approval:\u003c/strong\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (IRCCS Burlo Garofolo) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eBundy, D. G., Byerley, J. S., Liles, E. A., Perrin, E. M., Katznelson, J., Rice, H. E. Does this child have appendicitis? JAMA. 2007 Jul 25;298(4):438-51. doi: 10.1001/jama.298.4.438. PMID: 17652298; PMCID: PMC2703737.\u003c/li\u003e\n\u003cli\u003eAceti, V., Boscarelli, A. Burying the appendiceal stump during appendicectomy: state of art. Transl Pediatr. 2018 Jan;7(1):73-74. doi: 10.21037/tp.2017.11.01. PMID: 29441286; PMCID: PMC5803017.\u003c/li\u003e\n\u003cli\u003eMcBurney C. IV. The Incision Made in the Abdominal Wall in Cases of Appendicitis, with a Description of a New Method of Operating. Ann Surg. 1894 Jul;20(1):38-43. doi: 10.1097/00000658-189407000-00004. PMID: 17860070; PMCID: PMC1493708.\u003c/li\u003e\n\u003cli\u003eKiran, K. S., Ramani, A. S., Math, S. K. (2023).Outcomes of Open Appendicectomy by Simple Ligation versus Invagination in Acute Appendicitis- A Prospective Observational Study, 12(1), SO21-SO23. https://www.doi.org/10.7860/JCDR/2023/59856/2871\u003c/li\u003e\n\u003cli\u003eBekki, T., Abe, T., Namba, Y., Okimoto, S., Mukai, S., Saito, Y., et al. (2023). Validation of appendiceal stump invagination in laparoscopic appendectomy. Asian journal of endoscopic surgery, 16(2), 203\u0026ndash;209. https://doi.org/10.1111/ases.13137\u003c/li\u003e\n\u003cli\u003eAfridi, N. G., Iqbal, Z., Nazeem, S., Ahmad, S. (2014). Simple ligation versus invagination of stump in open appendicectomy. Journal of Medical Sciences, 22(2), 93\u0026ndash;95. Retrieved from https://jmedsci.com/index.php/Jmedsci/article/view/285\u003c/li\u003e\n\u003cli\u003eQazi, S. R., Darokar, A. V., Bijwe, V. N., Mulmule, R. M., \u0026amp; Bele, K. K. (2016). A comparative study of simple ligation and simple ligation with invagination of appendicular stump. International Journal of Research in Medical Sciences, 4(5), 1485\u0026ndash;1489. https://doi.org/10.18203/2320-6012.ijrms20161215\u003c/li\u003e\n\u003cli\u003eQian, D., He, Z., Hua, J., Song, Z. (2015). Stump Invagination Versus Simple Ligation in Open Appendicectomy: A Systematic Review and Meta-Analysis. International surgery, 100(7-8), 1199\u0026ndash;1206. https://doi.org/10.9738/INTSURG-D-15-00074.1\u003c/li\u003e\n\u003cli\u003eBansal, A. R., Bansal, M., Lamba, R.K. (2020). \u0026apos;Comparative Evaluation of Simple Ligation Versus Invagination of Stump in Open Appendicectomy\u0026apos;\u003cem\u003e,\u003c/em\u003e International Journal of Current Advanced Research, 09(03), 21661-21663. doi: 10.24327/ijcar.2020.21663.4263 \u003c/li\u003e\n\u003cli\u003eSayyadinia, M., Hamadiyan, H., Mokaripoor, S., Azaad, M. (2016). Comparing the complications of purse-string and simple ligation of appendix stump in appendectomy: A randomized clinical trial. Int J Med Res Health Sci., 5(10):55-60 \u003c/li\u003e\n\u003cli\u003eGravante, G., Yahia, S., Sorge, R., Mathew, G., Kelkar, A. Back to basics: A meta-analysis of stump management during open appendicectomy for uncomplicated acute appendicitis. World J Surg Proced 2013;3:47-53\u003c/li\u003e\n\u003cli\u003eMachado, N. O. Ileocecal intussusception following appendectomy. Ann Saudi Med. 2006 Jul-Aug;26(4):315-7. doi: 10.5144/0256-4947.2006.315. PMID: 16885630; PMCID: PMC6074511.\u003c/li\u003e\n\u003cli\u003eKlein, T., Diesbach, D., Boemers, T. M., Vahdad, R. M. Transumbilical laparoscopic-assisted appendectomy in children and adolescents: what have we learnt in more than 1200 cases?. Langenbecks Arch Surg 409, 263 (2024). https://doi.org/10.1007/s00423-024-03437-2\u003c/li\u003e\n\u003cli\u003eDi Saverio, S., Podda, M., De Simone, B., Ceresoli, M., Augustin, G., Gori, A., et al. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World journal of emergency surgery : WJES, 15(1), 27. https://doi.org/10.1186/s13017-020-00306-3\u003c/li\u003e\n\u003cli\u003eKumar, S. S., Collings, A. T., Lamm, R., Haskins, I. N., Scholz, S., Nepal, P., et al. (2024). SAGES guideline for the diagnosis and treatment of appendicitis. Surgical endoscopy, 38(6), 2974\u0026ndash;2994. https://doi.org/10.1007/s00464-024-10813-y\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"IRCCS Materno Infantile Burlo Garofolo","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Appendicitis, Children, Transumbilical, Laparoscopy, Appendiceal Stump","lastPublishedDoi":"10.21203/rs.3.rs-6045734/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6045734/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Acute appendicitis is one of the most common surgical conditions in pediatric and general surgery. To date, the management of the appendiceal stump during appendectomy remains controversial. The purpose of this study was to retrospectively investigate the management strategies of acute appendicitis in a tertiary children’s hospital in terms of surgical techniques and time, hospital length of stay, and postoperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe records of patients \u0026lt; 18 years of age who were treated for acute appendicitis at our Pediatric Surgery Unit from December 2018 to January 2024 were retrospectively reviewed. Data were extrapolated from the departmental database, and clinical notes were reviewed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe records of 278 patients who underwent appendectomy within a 5-year period at our institution were essentially used to compare appendiceal stump inversion and simple ligation. The two groups were similar in terms of sex (P = 0.05), age (P = 0.40), weight (P = 0.78), and associated pathologies (P = 0.12). Statistical analysis revealed no significant differences in length of hospital stay (P = 0.21) and postoperative complications (P = 0.15). Notably, 78.6% of appendicitis cases treated without stump invagination were uncomplicated, whereas 20% were complicated (4.3% abscess and 15.7% peritonitis cases). In contrast, AS invagination was performed in 87% of uncomplicated appendicitis and 13.1% of complicated appendicitis cases (6.8% abscess and 6.3% peritonitis cases). Therefore, simple ligation was also effective in complicated appendicitis cases (P=0.03), with no significant difference in postoperative complications (P = 0.15).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eSimple ligation does not compromise treatment efficacy nor increase postoperative complications, nor the length of hospital stay. Specifically, our data suggest that simple ligation is at least as effective as invaginating the appendiceal stump, and it might probably simplify the whole procedure.\u003c/p\u003e","manuscriptTitle":"Transumbilical Laparoscopic-assisted Appendectomy (Tulaa) for Acute Appendicitis in Children: to Bury or Not to Bury the Appendiceal Stump? – a Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-27 17:52:55","doi":"10.21203/rs.3.rs-6045734/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4bacb0c8-b2b4-415d-be57-2d1dd352f863","owner":[],"postedDate":"February 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":44937057,"name":"Pediatrics"}],"tags":[],"updatedAt":"2025-02-27T17:52:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-27 17:52:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6045734","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6045734","identity":"rs-6045734","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}