Appendicitis remains the most common surgical illness in children that is treated by both pediatric and adult general surgeons. It has an incidence of 70,000 pediatric cases per year with the highest rates occurring at 25 cases per 10,000 children per year between 10 and 17 years of age. Diagnosing acute appendicitis in children is very similar and perhaps more straightforward than in adults. A history of migrating abdominal pain in association with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. For instance, migrating abdominal pain for acute appendicitis has a positive predictive value (PPV) of 94.2 % in children and 89.6 % in adults [10]. In the absence of classic signs and symptoms, diagnostic imaging can be a helpful adjunct. Given the increased awareness and risk of radiation exposure in children, ultrasound is usually the preferred modality, although certain clinical situations require CT imaging as well.

Most commonly, pediatric laparoscopic appendectomy in the United States is performed through a three-port technique. We prefer to place a 12-mm port at the umbilicus and two additional working ports that range from 2.7 to 5 mm based on patient size. One is placed in the left lateral abdomen and another in the suprapubic region. In very small patients, the suprapubic port may be placed very low in the left lower abdomen to increase the distance between the trocar and the appendix. The surgeon stands to the left of the patient with the assistant initially on the patient’s right. After trocar placement, the assistant moves to the patient’s left as well in order to hold and manipulate the camera in-line with the working field. We prefer to use small graspers to sweep the bowel away from the operative field, taking care to avoid grasping and potentially injuring the bowel. We also avoid grasping the appendix where it is inflamed or visibly friable, grasping only the relatively healthy portion. Occasionally, a long Debakey grasper is needed for a very thick, inflamed appendix. We divide the mesoappendix with hook electrocautery regardless of patient size. Although residual bleeding is quite rare, a Maryland dissector can be used to grasp the area of concern to apply additional electrocautery. Other surgeons prefer various vessel-sealing devices for the mesoappendix such as the LigaSure™ (Covidien, Norwalk, CT) or Harmonic Scalpel (Ethicon, Cincinnati, OH), but we feel the added cost is unnecessary. Some surgeons also utilize an endostapler to control the mesoappendix, which often yields less than satisfactory results when there is significant inflammation. We prefer to use a 35-mm stapler with 2.5-mm staples to divide the appendix at its junction with the cecum. A cost-efficient, safe, and effective method has been validated using only electrocautery with a hook or Maryland dissector to divide the mesoappendix and three 0-PDS Endoloops (Ethicon Endo-Surgery, Cincinnati, OH) to ligate the base of the appendix with two proximal and one distal [11]. Although this gives the added advantage of a smaller 5-mm umbilical incision (the 12-mm incision is needed for the stapler), application of the Endoloops can be tedious and there can be a small amount of contamination when dividing an appendix with acute inflammation at the cecal junction. Furthermore, the appendix can usually be pulled out through the 12-mm trocar without needing a specimen retrieval bag.

Several early studies comparing open versus laparoscopic appendectomy were conflicted and resulted in little consensus among pediatric surgeons regarding the best operative approach. Other more recent studies suggest that laparoscopic appendectomy, in appropriately selected patients, can result in fewer postoperative complications. The rate of superficial wound infection is clearly reduced with laparoscopic appendectomy and patients may have slightly earlier discharge from the hospital [12–14]. Some earlier reports suggested that children with perforated appendicitis that underwent laparoscopic appendectomy had higher rates of abscess formation [15]. However, a recent study by Nadler and colleagues reported no difference in infectious complications and a lower overall rate of perioperative complications in their patients with perforated appendicitis treated with laparoscopy [16]. Pediatric subspecialty training also seems to have little impact on surgical outcomes with regard to readmission, wound infection, intra-abdominal infection, or mean hospital stay for appendicitis when compared against adult general surgeons and their outcomes [17]. These findings could be explained by the fact that laparoscopic appendectomy technique is similar across age groups, and most general surgeons are high-volume surgeons for adult appendectomy, even if they are low-volume for pediatric appendectomy.

There is an increasing frequency of inflammatory bowel diseases (IBD) such as ulcerative colitis (UC), Crohn’s disease (CD), and indeterminate colitis (IC) in both pediatric and adult populations [18]. Ulcerative colitis and IC are most frequently diagnosed in children between the ages of 3 and 5, while CD increases during the adolescent years, peaking at 15 years of age. Pediatric surgeons become involved as the disease worsens and becomes refractory to medical management or when complications arise. The peak incidence of IBD occurs between the ages of 15 and 25 years, or a time when adolescents and young adults may traverse both pediatric and adult hospital settings when seeking surgical consultation [18]. Interestingly, a study by Jan et al. revealed that both hospital type and surgeon specialty within hospital type influenced the likelihood of surgical complications among adolescents and young adults with IBD requiring surgical intervention [19]. Despite higher complications among children’s hospitals, pediatric surgeons had the lowest predicated probabilities of surgical complication or 30-day readmission (24 %) compared with general surgeons (39 %) and colorectal surgeons (35 %). The lifetime risk of surgery for IBD complications, such as extraintestinal manifestations, bowel obstruction, enteric fistulas, abscess formation, toxic megacolon, or massive hemorrhage, ranges from 40 to 70 % with a surgical complication rate of 13–55 % [20–24]. Other surgical indications unique to the pediatric population include more chronic symptoms such as delayed puberty or growth retardation as demonstrated by a failure to follow normal growth curves.

Laparoscopic ileocecectomy for irreversible obstruction of the terminal ileum in patients with Crohn’s disease can be performed through a four-trocar approach. A stapled intracorporeal or extracorporeal anastomosis can be performed through an enlarged right lower quadrant port incision depending on preference. We prefer extracorporeal anastomosis. Ileocecal resection for Crohn’s disease is much less common in the pediatric population, but the adult experience has demonstrated this to be a safe technique with obvious cosmetic advantages, shorter length of stay, and fewer complications [25–27]. Therefore, additional instruction regarding operative technique will be deferred to the discussion found elsewhere in this text.

Surgery remains the definitive cure for patients with ulcerative colitis after failure of medical management or neoplastic degeneration. There are several notable differences in the surgical techniques that are usually applied to the pediatric patient. Patients usually undergo either a two-stage or a three-stage approach, depending on their clinical condition at the time of total abdominal colectomy. If patients are critically ill with toxic megacolon or on high-dose steroids, completion proctectomy and J-pouch creation are performed later in a staged approach with end ileostomy done at the time of the total abdominal colectomy. In patients who can tolerate it, we perform this laparoscopically in a manner quite similar to the adult operation (See Chap. 13). Although the specimen can be removed through the eventual ileostomy site, the specimen is often friable and dilated. The authors prefer to avoid making the ileostomy site incision any larger than required and alternatively use a relatively small transverse suprapubic incision for removal of the colectomy specimen.

The most notable disparity between typical adult and pediatric techniques involves the dissection and approach on the perineum. The ileal pouch-anal anastomosis (IPAA) is now commonly performed with a very low (end-to-end) EEA-stapled anastomosis in adults. This operation evolved after studies discovered that up to 50 % of patients undergoing endorectal mucosa resection and hand-sewn IPAA were left with early postoperative nighttime stool incontinence [28]. Despite preserving the richly innervated anal transition zone (ATZ), stapled IPAA has been shown to confer no early advantage with regard to decreased stool frequency or fewer episodes of fecal incontinence compared to hand-sewn IPAA [29]. Despite the results of a large meta-analysis that suggested stapled IPAA offered improved early nocturnal continence with coinciding higher anorectal resting and squeeze pressures, both procedures are acceptable with different benefits [30]. The stapled technique leaves several centimeters of anorectal mucosa at risk for the development of ulcerative colitis, polyposis, and in the long run, dysplastic conversion and malignant degeneration. Most practitioners recommend routine endoscopic surveillance for this cuff. Since most pediatric patients have significantly greater life expectancy, tedious surveillance of this at-risk mucosa can be avoided by performing a mucosectomy with a hand-sewn ileoanal anastomosis, with a reduced risk of eventual malignancy given that the life expectancy for these patients is longer.

A trans-abdominal low-anterior dissection of the rectum can be performed laparoscopically or via the small transverse suprapubic incision followed by the transanal mucosectomy on the perineum. For the mucosectomy, a circumferential incision is made just above the dentate line (Fig. 32.4), and multiple sutures are placed in this mucosal sleeve circumferentially to provide traction (Fig. 32.5). Pop-off sutures are preferred due to their ease of use and identical length. A Colorado needle-tip Bovie electrocautery is then used to dissect the muscularis layer proximally off of the mucosal sleeve (Fig. 32.6). At first, the plane can be somewhat difficult to create, but this often becomes easier and more apparent as the dissection is carried proximally. If the dissection becomes too facile at this stage, the surgeon may have inadvertently created a full-thickness dissection instead of remaining in the submucosal plane. If any defects are created in the mucosal tube, sutures are placed to repair them. Unfortunately, this may plicate the mucosa, making it more difficult to get back into the right plane as the proximal dissection continues. Fine, cotton-tipped swabs can be used as pushers to help create the plane as well, although small bleeding vessels will require electrocautery.