Pediatric laparoscopic appendectomy

Codes

Laparoscopic appendectomy CPT 44970

Background

In general and in our institution, pediatric surgeons are far more agressive with surgical treatment of appendicitis when compared to their adult counterparts.

Indications

Acute appendicitis with localized peritonitis without abscess (K35.30)

Preoperative workup

Calculate the PAS score

Follow Dr. Ham appendicitis algorithm in the pediatric surgery resident handbook.

Typically will have ultrasound done in the ED prior to calling us. Ultrasound score is 1-5 a/b.

If diagnosis is unclear after PAS score and ultrasound score, consider CT with IV and PO contrast.

Once diagnosis is confirmed, start IV antibiotics.

• Cefoxotin if acute non-perforated.
• Zosyn if suspicion for perforation is high.

Surgical technique

Our pediatric surgeons vary in their approaches to a laparoscopic appendectomy.

• In general you first identify the appendix.
• Take down the mesoappendix with cautery or some other energy device.
• Identify the base of the appendix where it starts to widen and spread out into the cecum.
• Resect the appendix at the base with a stapler or endoloop ligation (usually stapler in pediatric surgery).
• Washout out the abdomen with several liters of irrigation if there is significant contamination outside the RLQ/Pelvis.

Complications and post-op care

If acute, not ruptured, then stop antibiotics, liquid diet and advance as tolerated. Discharge later that day if feeling okay.

If ruptured in the pediatric patient population, needs 48 hours of Zosyn postoperatively. Typically await bowel function before starting diet

Surgeon specifics

Dr. Harmon

• Single site appendectomy.
• Triport through a single vertical umbilical incision
• He takes the mesoappendix down with hook cautery and transects the appendix at the base with a stapler.
• Then grab the appendix with a laparoscopic grasper and pull into the wound protector and hold tight as he takes everything out at once.
• Close the fascial incision with a running 0 Vicryl.

Dr. Ham

• Does a similar single site appendectomy as Harmon.
• However if the appendix is mobile, he may grab the appendix right away and pull it up into the umbilical wound protector and then preform appendectomy in an open fashion.

Dr. Vali

• Does a standard 3 port appy with the Harmonic scalpel and stapler.

Sample dictation

Dr. Harmon single site laparoscopic appendectomy

Laparoscopic appendectomy CPT 44970

The patient was met in the preoperative holding area with her mother. All questions answered. Site surgery and patient and informed consent confirmed. The patient was taken to the operating room, transferred to the table and placed in the supine position. General anesthesia was induced and the patient was intubated with endotracheal intubation without issue. Bony areas padded and both arms were tucked. The patient was prepped and draped in the usual sterile fashion. A timeout was performed and the correct patient, site, and procedure were verified.

A vertical incision was made through the umbilical skin and carried down to the fascia. Dissection was carried down to the fascia with Bovie electrocautery. The fascia was then opened and the abdominal cavity was entered. A Triport was inserted and the abdomen was insufflated. A laparoscope was inserted, the abdomen was inspected for injuries while obtaining access to the abdominal cavity and there was none.

The appendix was found to be in retrocecal position in the right lower quadrant. It was grasped with a bowel grasper and elevated up and towards the liver. It appeared firm and inflamed without gross gangrene or perforation. The mesoappendix was taken down with hook electrocautery. The appendix was transected with a 10 mm endo GIA stapler. The staple line was noted to be intact and hemostatic. The abdomen and pelvis were inspected and no free fluid was noted. The appendix and stump were removed along with the external part of the port and the wound protector portion.

The fascia was closed with a running 0 Vicryl. 10 mL of 0.25% Mercaine was injected into the fascia and skin. The skin was closed with three buried dermal 4-0 Monocryl sutures. 2 x 2 gauze dressing and a Tegaderm were placed.

At the conclusion of the case all instrument, sponges, and needle counts were correct. The patient was then liberated from anesthesia and extubated without issue and was transported to PACU in stable condition.

Dr. Harmon was present and scrubbed for the entire procedure