Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
Even if abscess can be managed for 2 weeks non-operatively, that operation is much easier than going in early through dense inflammation and purulent material — Whit Holcomb, Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb · 51:01
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
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Dr. Whit Holcomb discusses current concepts and controversies of appendicitis.Dr. Ponsky: Perfect. I know today we’re going to be talking about appendicitis, and I know that you’ve built a pretty robust research center there and I think tha
podcast58:22 · Dec 2020
Nonoperative Management of Uncomplicated Appendicitis: Practice Gap...
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At the 6th Annual Pediatric Surgery Update Course, Drs Charles Snyder, Craig Lillehei and David Powell discussthe top ten practice gaps of 2018. Here they discuss nonoperative management of uncomplicated appendicitis, focusing on rate of re
video · Sep 2018
IPEG Academy: Single Incision Laparoscopic Appendectomy
video · Jul 2021Private
The postoperative antibiotic study did not report postoperative abscess rates, which is a more clinically relevant outcome than surgical site infections for uncomplicated appendectomy. Journal Club: Appendicitis in 2021 · 11:20
Journal Club: Appendicitis in 2021
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We all know how commonly pediatric surgeons see patients with appendicitis and how frequently new literature is published on its management. Dr. Jose Campos helped us find some of the latest publications on appendicitis management and we di
podcast15:06 · Aug 2021
Acute Appendicitis 2020 Update
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Dr. Beth Rymeski, Dr. Rod Gerardo, and Dr. Todd Ponsky discuss the recent Midwest Pediatric Surgery Consortium publication on acute appendicitis and how it might change management in 2020 and on. "Association of Nonoperative Management Usin
podcast · Dec 2020
Update Course Rewind: Perforated Appendicitis 2019
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Did you miss our annual Update Course? Don't worry, we are summarizing our favorite sessions from years past. In this episode, Dr. Whit Holcomb talks us through the diagnosis and management of perforated appendicitis. Mark your calendars fo
podcast12:08 · Apr 2021
Appendicitis: conservative vs. operative treatment
video · Dec 2021Private
Povidone-iodine Irrigation for Pediatric Perforated Appendicitis May Be Protective: A Bayesian Pilot Randomized Controlled Trial
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Objectives: A randomized controlled trial was conducted to test the hypothesis that povidone-iodine (PVI) irrigation versus no irrigation (NI) reduces postoperative intra-abdominal abscess (IAA) in children with perforated appendicitis.Meth
article · Jul 2020
Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic
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AbstractObjectiveEarly presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed presentation of acute appendiciti
article · Oct 2020
Clinical Pathway for Suspected Appendicitis
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Dr. Ponsky shares the findings from the Pediatrics' article, “Prospective Evaluation of a Clinical Pathway for Suspected Appendicitis.” Link to full article: https://gcmd.co/2Qzy6MH
video · Jan 2020
Too Much Variability in Opioid Prescriptions for Pediatric Operations
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Do you routinely give your pediatric patients narcotics after a laparoscopic appendectomy for simple appendicitis? Dr. K. Tinsley Anderson and Dr. KuoJen Tsao evaluated their appendectomy patients at Children's Memorial Hermann Hospital in
video · Apr 2019
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Expert statements from the recordings in this collection.
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
Classic acute appendicitis presentation (pain migration to right lower quadrant, McBurney's point tenderness, elevated WBC and CRP, low-grade fever in thin patient with short symptom duration) can proceed directly to laparoscopic appendectomy without imaging
Whit Holcomb3:25
At Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction
Whit Holcomb4:00
Symptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound
Whit Holcomb5:11
If ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed
Whit Holcomb6:25
Non-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; absence of both findings makes appendicitis unlikely though not zero
Whit Holcomb7:28
Children's Mercy uses IV contrast for CT and performs limited/focused CT scans to minimize radiation exposure; rectal contrast protocol was attempted but not adopted by ED physicians
Whit Holcomb8:40
Ceftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens
Whit Holcomb11:11
In 2008 Journal of Pediatric Surgery randomized trial of 100 patients, daily ceftriaxone/metronidazole showed no difference in abscess rate or wound infections versus ampicillin/gentamicin/clindamycin but resulted in lower antibiotic charges
Whit Holcomb14:18
Ceftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis
Whit Holcomb15:11
Non-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics
Whit Holcomb12:58
Once-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities
Whit Holcomb13:29
Single-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis
Whit Holcomb16:35
In double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy
Whit Holcomb17:51
Locking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen
Whit Holcomb19:40
Fascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp
Whit Holcomb20:53
Perforation is strictly defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix; without these findings the patient does not have perforation
Whit Holcomb21:58
This strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons
Whit Holcomb21:58
In Ponsky's inter-observer variation study published in Journal of Laparoendoscopic and Advanced Surgical Techniques, attending surgeons viewing same images agreed on perforation status only 25% of the time without defined criteria
Children's Mercy has been sending non-perforated appendicitis patients home the same day (within 6 hours of surgery) for over a year with over 100 patients managed this way
Whit Holcomb25:46
Same-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics
Whit Holcomb25:46
Rationale for same-day discharge includes patient satisfaction, opening hospital beds for patients who need them, and preparing for potential future trials of antibiotics versus day-surgery appendectomy
October 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis
Whit Holcomb28:30
Single-incision appendectomy showed no difference versus three-port in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity
Whit Holcomb28:30
Single-incision approach had longer operative time (5 minutes, statistically significant but not clinically relevant), more narcotic doses, greater surgical difficulty, and higher hospital charges than three-port
Whit Holcomb28:30
Wound infection rate was 3.3% (6/180) for single-incision versus 1.7% (3/180) for three-port, p=0.5, not statistically different
Host summaryTodd Ponsky summarizes what Dr. Whit Holcomb said — not the host's own clinical position30:23
For single-incision approach, umbilical fascia is closed and interrupted plain sutures placed in umbilical skin; for three-port, umbilical incision closed similarly and 5mm port sites closed with 5-0 Vicryl in U-fashion
Whit Holcomb31:32
Interrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm
Whit Holcomb32:09
St. Peter study compared irrigation plus suction versus suction-only for perforated appendicitis and found no difference in abscess rate or location; both groups had approximately 20% postoperative abscess rate
Whit Holcomb33:00
Study used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix
Whit Holcomb33:00
Across 6-7 appendectomy studies for perforated disease at Children's Mercy, abscess rate has consistently been 15-20%; Holcomb counsels families on 20% abscess risk
Whit Holcomb34:28