Identification of the Optimal Treatment Strategy for Complex Appendicitis in the Pediatric Population

"Laparoscopic appendectomy is performed according to daily practice but with the following standardized key points:~1. Conventional laparoscopy (three-trocar technique)~2. In case of purulent fluid: Suction and no peritoneal lavage procedure~3. Skelletizing of the mesoappendix (coagulation/clips according to routine practice locally)~4. Appendiceal stump closure: with two endoloops and dissected between the endoloops. In case of involvement of the appendiceal base, the use of endostapler is recommended.~5. Withdrawal of appendix: principle of abdominal wall protection is followed (trocar technique / endobag)~6. No drain placement, no nasogastric tube, and no urinary catheter routinely, only on indication.~7. Closure of wounds as appropriate"

"Open appendectomy will be performed according to the following standardized key points:~1. Gridiron incision at the right lower quadrant. (McBurney's point)~2. After obtaining access to the abdominal cavity the principle of abdominal wall protection will be followed.~3. The appendiceal stump will be closed by ligation, not a purse string suture.~4. Closure of wounds as appropriate"

"Non-operative treatment consisting of administration of intravenous antibiotics with or without drainage procedures (in case of an abscess), reserving an appendectomy for those not responding or with recurrent disease.~One of the two antibiotic regiments:~1. Combination A:~ 1. Amoxicillin/clavulanic acid 25/2.5mg/kg 6 hourly (total 100/10 mg/kg daily. Maximum 6000/600mg a day) for children \<40 kg OR Amoxicillin/clavulanic acid 1000/200mg/kg 8 hourly (total 3000/6000 mg/kg daily) for children \> 40 kg~ 2. Gentamicin 7mg/kg once daily~2. Combination B:~ 1. Cefuroxim 25 mg/kg 6 hourly (total 100 mg/kg/day. Maximum 6gram/day)~ 2. Metronidazole 10mg/kg 8hourly (total 30 mg/kg/day. Maximum 4000 mg/day) In case of peri-appendicular abscess the decision can be made to perform a drainage procedure either percutaneously or surgical."

laparoscopic or open appendectomy as described