Dingemann Jens, Metzelder Martin L, Szavay Philipp O
German Society for Pediatric Surgery, DGKCH, Task-force Minimally-Invasive Surgery, MIC-AG, Berlin, Germany.
Eur J Pediatr Surg. 2013 Jun;23(3):226-33. doi: 10.1055/s-0032-1333121. Epub 2013 Feb 26.
Management of appendicitis in children has changed remarkably over the last decade. The proven benefits of laparoscopic appendectomy (LA) over the open operation have made LA increasingly popular for pediatric patients. To date, no national clinical practice guideline is available for pediatric LA in Germany and the operation is not standardized. Thus, the aim of our study was to evaluate the current status of pediatric LA in Germany.
An internet-based survey was conducted on pediatric LA among all 98 registered pediatric surgical units in Germany, comprising 22 questions with regard to utilization and subjective appraisal of LA, technical standards, perioperative treatment, and training aspects.
The survey was completed by 71 of the 98 units (72%). Technical infrastructure for LA was provided in all units, but only in 79% of the units was LA, the standard approach for appendectomy. Overall quality of LA was rated better compared with open appendectomy by 52% units, equivalent by 38% and worse by 3%. The three-port technique was used by 90% of the units; 10% used a single-port approach. Dissection of the mesoappendix was done with bipolar coagulation in 55%, monopolar coagulation in 24%, harmonic knife in 6%, and endostaplers in 11% of the units. Closure of the appendiceal stump was performed using endoloops in 57%, ligations in 3%, endostaplers in 39%, and harmonic knife in 1%. Removal of the appendix was done through the port by 79%, using a retrieval bag by 18%, whereas in 3% it was removed directly through laparotomy. In case of appendiceal perforation, an intra-abdominal drain was placed in 65%. Perioperative antibiotic treatment for nonperforated appendicitis was given as a single shot in 33% of the units, for 24 hours in 17%, for 3 days in 39%, and for 5 to 7 days in 11%. LA was performed by a trainee under supervision in 87%, by a board approved pediatric surgeon in 2%, by an attending pediatric surgeon in 7%, and by the surgeon-in-chief in 4% of the units. For 93% of the sample, LA was an essential part of pediatric surgical training.
LA is the favored surgical method for pediatric appendectomy in Germany. However, technical details, perioperative therapy and implementation into training programs remain inconsistent. An effort has to be made to establish national clinical practice guidelines to achieve standardization of LA.
在过去十年中，儿童阑尾炎的治疗方法发生了显著变化。腹腔镜阑尾切除术（LA）相较于开放手术已被证实具有诸多益处，这使得LA在儿科患者中越来越受欢迎。迄今为止，德国尚无针对儿科LA的国家临床实践指南，且该手术尚未标准化。因此，我们研究的目的是评估德国儿科LA的现状。
对德国所有98个注册儿科手术科室进行了一项基于网络的儿科LA调查，包括22个关于LA的使用情况和主观评价、技术标准、围手术期治疗及培训方面的问题。
98个科室中有71个（72%）完成了调查。所有科室均具备LA的技术基础设施，但只有79%的科室将LA作为阑尾切除术的标准方法。52%的科室认为LA的总体质量优于开放阑尾切除术，38%认为相当，3%认为较差。90%的科室采用三孔技术；10%采用单孔方法。55%的科室在阑尾系膜解剖时使用双极电凝，24%使用单极电凝，6%使用超声刀，11%使用腔内吻合器。57%的科室使用圈套器闭合阑尾残端，3%使用结扎，39%使用腔内吻合器，1%使用超声刀。79%的科室通过切口取出阑尾，18%使用取物袋，3%直接通过剖腹手术取出。阑尾穿孔时，65%的科室放置腹腔引流管。33%的科室对非穿孔性阑尾炎围手术期抗生素治疗采用单次给药，17%为24小时给药，39%为3天给药，11%为5至7天给药。87%的科室由受训人员在监督下进行LA，2%由委员会认可的儿科外科医生进行，7%由主治儿科外科医生进行，4%由外科主任进行。对于93%的样本，LA是儿科外科培训的重要组成部分。
在德国，LA是儿科阑尾切除术最常用的手术方法。然而，技术细节、围手术期治疗以及在培训项目中的实施仍不一致。必须努力制定国家临床实践指南以实现LA的标准化。
