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Open versus laparoscopic appendicectomy in children

Three Part Question

In [children with acute appendicitis] is [laparoscopic better than open appendicectomy] at [reducing operation time, post-operative recovery, complications, and costs]?

Clinical Scenario

A 14 year old boy presents to the paediatric assessment unit with a 24 hour history of right iliac fossa pain. After a full history and examination the clinical diagnosis is of acute appendicitis. He is booked for theatre as an emergency appendicectomy. Which is the best approach: laparoscopic or an open procedure?

Search Strategy

Pubmed search
"Child"[Mesh] AND ("Appendicitis"[Mesh] OR "Appendectomy"[Mesh] OR "Appendix"[Mesh]) AND "Laparoscopy"[Mesh] AND "open"
and a search of the BESTBet title: ‘open versus laparoscopic appendectomy (and appendicectomy) in children’
Cochrane library search
child AND appendicitis AND open AND laparoscopy

Relevant articles had their references searched for further articles.

Search Outcome

The Pubmed search produced 213 papers, of which 173 were irrelevant (last checked 07/03/10). A search of the Cochrane library search added no new papers. Of the 40 relevant papers, 14 were in English, of sufficient quality and provided additional data. The meta-analysis by Aziz et al reviewed 23 relevant articles from 1992 through to 2004.

All results are displayed as LA versus OA

LA = Laparoscopic appendicectomy; OA= Open appendicectomy; HES = Hospital Episode Statistics; NS = Not significant; m = minutes, h = hours, d = days

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Wang et al.
128 children who underwent LA (80) or OA (48) OA for acute complicated appendicitis (perforation, mass or intra-abdominal abscess) over 3 1/2 years (2005-2008)Single-centre retrospective cohort study (2b)Mean operative time (m)88.5vs71.8 P=0.002Retrospective study (particularly susceptible to selection bias). Small sample size. No age range included. No conversions from LA to OA.
Time to resume diet (d)1.8vs2.8 P=<0.001
Mean length of hospital stay (d)6.5vs7.8 P=0.005
Wound infections1.3%vs12.5% P=<0.05
Intra-abdominal abscess2.5%vs14.6% P=<0.05
Kaselas et al.
1684 children (1 month–14 years) with acute appendicitis who underwent LA (1175) or OA (509) over 15 years (1992-2007)Single-centre retrospective cohort study (2b)Post-op bowel obstructionRetrospective study. Rare complication. Does not describe LA/OA techniques used. No conversion rate included (groups based on initial approach attempted).
Non-perforated appendicitis 1.04%vs3.35% P=0.0057
Perforated appendicitis 1.8%vs9.78% P=0.0028
Jen et al.
95,806 children (1-18 years) who underwent LA (34%) or OA (66%) over 7 years (1999-2006) recorded on the California Patient Discharge Database (sourced from 386 hospitals)State-wide retrospective cohort study (2b) Non-perforated appendicitis Retrospective study. Susceptible to coding errors. Coding data provides limited information (e.g. no information on techniques used, basis for procedure selection and operating surgeons). Intra-operative complications not defined. Conversion rate from LA to OA 4.2%.
Mean length of hospital stay (d)1.9vs2.1 P=<0.001
Intra-operative complications0.5%vs0.2% P=<0.001
Intra-abdominal abscess0.6%vs0.3% P=<0.001
Wound infections1.1%vs1.4% P=0.08 (NS)
Post-operative bowel obstruction0.5%vs0.4% P=0.67 (NS)
Readmissions rate2%vs1.8% P=0.42 (NS)
Perforated appendicitis
Mean length of hospital stay (d)5.2vs5.5 P=<0.001
Intra-operative complications0.8%vs0.4% P=0.002
Intra-abdominal abscess4.9%vs3.8% P=<0.001
Wound infections5.5%vs6.4% P=0.02
Post-operative bowel obstruction2%vs2.6% P=0.02
Readmissions rate6.3%vs6.9% P=0.16 (NS)
Faiz et al.
89,497 children (under 15 years) who underwent emergency LA (3%) or OA (97%) over 10 years (1996-2006) in English NHS trusts National retrospective cohort study (2b)Mortality 30 dayP=1.000 (NS)Retrospective study. Inequality between LA and OA group size. Mortality is very rare. Coding data provides limited information (as above). Susceptible to coding errors notably the coding of LA requires an additional second code otherwise assumed to be OA. No information regarding conversion rates.
Mortality 365 dayP=0.406 (NS)
Readmission rates (28 d)7.2%vs6.3% P=0.072 (NS)
Comparison in length of hospital stayP=0.068 (NS)
Thambidorai et al.
112 children (<12 years) who underwent LA (51) or OA (61) for complicated appendicitis (perforated/gangrenous/mass) over 4 years (2002-2006)Single-centre retrospective cohort study (2b)Mean operating time (m)112vs72 P=<0.005Retrospective study. Small sample size. Open to operator bias, LA performed by single senior surgeon, OA by surgical trainees. Conversion from LA to OA in six cases.
Severe wound infection4%vs21% P=<0.005
Mean length of hospital stay (d)5.7vs7.4 P=<0.005
Intra-abdominal abscess12%vs11.5% P=>0.05 (NS)
Post-operative fever20%vs11.5 % P=>0.05 (NS)
Menezes et al.
118 children (2-16 years) who underwent LA (54) and OA (64) for complicated appendicitis (perforated/gangrenous) over 6 years (2000-2006)Single-centre retrospective cohort study (2b)Mean length of hospital stay (d)8.3vs7.1 P=>0.05 (NS)Retrospective study. Small sample size. Limited information included regarding surgical techniques used, operating surgeons and group selection. One case converted from LA to OA.
Complication rates: (Intra-abdominal abscess, wound infection, pleural effusion, prolonged ileus respectively)9.2%vs15.6% (LA: 3,2,0,0) (OA: 5,3,1,1) P=<0.05
Schmelzer et al.
223 patients (under 20 years) that underwent LA (44) and OA (179) over 2 yearsSingle-centre retrospective cohort study (2b)Mean operative time (m)62vs42 P=<0.0001 Retrospective study. Inequality between LA and OA group size. Author’s noted significant difference in mean weight between groups; LA 49kg compared to OA 38kg (P= 0.0003). Detailed information on operative techniques not included. Two cases converted from LA to OA.
Estimated blood loss (ml)21vs26 P=0.007
IV analgesia requirement (d)0.8vs1.9 P=0.0003
Mean length of hospital stay (d)2.2vs3.4 P=0.004
Wound infections2.3%vs6.2% P=0.3 (NS)
Wound complications2%vs17% P=0.02
Intra-abdominal abscess4.5%vs5.6% P=0.8 (NS)
Post-op ileus0%vs2.2% P=0.3 (NS)
Tsao et al.
1105 children over 7 years who underwent LA (628) and OA (477) for acute appendicitis over 7 years (1998-2005)Single-centre retrospective cohort study (2b)Adhesive small bowel obstruction (in perforated appendicitis)0.5%vs3.1% P=0.03 Retrospective study. Rare complication. Upper age range not included. Noted by authors that LA had a significantly lower proportion of perforated appendicitis (LA 30 % vs OA 40%, P= 0.03). Conversion rate from LA to OA 1.3%.
Adhesive small bowel obstruction (for all appendicectomies)0.2%vs1.5% P=0.01
Esposito et al.
2332 children (1-17 years) who underwent LA (1506) and OA (826) over 3 years from 9 different paediatric surgical centres (multi-national)Multi-national retrospective cohort study (2b)Mean operating time (m)40vs45 (NS)Retrospective study. Three different laparoscopic techniques used, the IN, OUT and MIXED procedures. No statistical analysis included of individual complications. Conversion rate from LA to OA 1.6%.
Complication rates8.23%vs7.9% (NS)
Median length of hospital stay
Simple appendicitis (d)3.0vs4.3
Appendicitis +peritonitis (d)5.2vs8.3
Overall hospital stayP=<0.0001
Chauhan et al.
200 children (4-15 years) who underwent LA or OA (100 in each group) for acute appendicitisSingle-centre (?retrospective/?prospective) cohort study (2c)Mean operative time (m) 35.8vs45.66Only outcomes, no statistical analysis published (i.e. P values, SD). No information given as to procedure selection. Unable to determine whether a retrospective or prospective study. Dates not given for study period. No conversion rate from LA to OA included.
Post-op pain scale (0-10, 10 severe)4.2vs6.3
Mean time to first oral food (h)16.7vs24.7
Mean length of hospital stay (d)1.6vs2.55
Mean resumption of normal daily activities (d)10.8vs15.78
Post-op complications3%vs2%
Yagmurlu et al.
111 children (2-18 years) who underwent LA (59) or OA (52) with perforated appendicitis over 3 years by six paediatric surgeonsSingle-centre retrospective cohort study (2b)Mean operating time (m)60vs57 P=0.3 (NS)Retrospective study. Small sample size. Dates not given for study period. Three patients were converted from LA to OA.
Time to oral intake (h)104vs127 P=0.08 (NS)
Length of hospital stay (h)189vs210 P=0.3 (NS)
Wound infection rates6.8%vs23% P=<0.05
Intra-abdominal abscess13.6%vs15.4% (NS)
Post-operative bowel obstruction1.7%vs1.9% (NS)
Aziz et al.
23 comparative studies published between 1992-2004, OA vs LA in children (6477, 43% LA and 57% OA); 12 retrospective, 11 prospective and 7 randomised studiesMeta-analysis (2a)Mean difference in operative time (m) (11 studies)=+5.84 P=0.09 (NS)Meta-analysis susceptible to non-publication bias. Combining heterogeneous studies. Largest proportion of studies retrospective. Studies included from 1992 onwards, likely significant changes in costs since early data collected.
Mean difference in length of hospital stay (d) (10 studies)=–0.48 P=<0.00001
Wound infection rates (13 studies)1.5%vs5% P=0.002
Intra-abdominal abscess rates (16 studies)3.8%vs3.4% P=0.62 (NS)
Post-operative bowel obstruction /ileus (9 studies)1.3%vs2.8% P=0.01
Post-operative fever (3 studies)17.3%vs17.1% P=0.11 (NS)
Mean treatment costs (4 studies)$5801vs$4734
Li et al.
160 children (3-15 years) undergoing LA (69) or OA (91) over 2 years (2002 – 2004) with suspected appendicitisSingle-centre prospective non-randomised cohort study (2b)Mean op time (m)Small sample size. Non-randomised, patients and parents chose procedure. Data for rates of intra-abdominal abscesses not included. Three patients undergoing LA were converted to OA.
Normal appendix17.56vs29.63 P=<0.01
Suppurative appendix28.73vs43.87 P=<0.01
Gangrenous appendix55.80vs57.94 P=>0.05 (NS)
Mean length of hospital stay (d)
Normal appendix3vs5 P=<0.01
Suppurative appendix3.91vs6.37 P=<0.01
Gangrenous appendix6.33vs8.44 P=<0.01
Wound infection1.45%vs10.99% P=<0.05
Intra-abdominal abscess(NS)
Ikeda et al.
100 children (2-15 years) who underwent LA (53%) and OA (47%) over 3 years (2000-2003)Single-centre retrospective cohort study (2b)Median operating time (m)88vs59 P=<0.001Retrospective study. Small sample size. One patient undergoing LA was converted to OA.
Median length of hospital stay (d)7vs9 P=0.001
Complication rate <30 days13.2%vs12.8% P=1.000 (NS)
Median treatment costs $5820vs$4619 P=<0.001


In 1988 the first laparoscopic appendicectomy was performed on a child at the Scottish Rite Children’s Medical Centre, Texas (Naffis); subsequently it has seen a steady growth in popularity. Both open and laparoscopic appendicectomies are now common practice and despite many studies the gold standard remains undetermined. Unfortunately these studies contain no recent high quality randomised control trials, and criticisms of the included studies are: they are predominantly retrospective in design; many use a small population; and the reliance upon coding data, which removes clinical context and is susceptible to error. Although establishing a gold standard is important, the choice of how to perform an appendicectomy is ultimately up to the operating surgeon (who may offer the choice to patient/parent). There may be factors which may influence their decision, e.g. laparoscopy is often preferred in obese children as it provides better visualisation of the abdominal cavity or ‘ambiguous’ cases where laparoscopy is thought to be more sensitive at detecting alternative pathology. If a child has had previous abdominal surgery or suspected complicated appendicitis, many surgeons will opt for an open approach. There are concerns that a laparoscopic procedure extends operating time; four out of the eight studies (Wang, Thambidorai, Schmelzer and Ikeda) found the laparoscopic approach to take significantly longer. The meta-analysis by Aziz et al did not find a statistically significant difference in operating times (+ 5.84min for LA, P=0.09). One group of very experienced laparoscopists, Li et al, found the laparoscopic approach shorter for both normal appendices (P<0.01) and suppurative appendicitis (P<0.01). Schmelzer and Ikeda et al also illustrated that operative times appreciably improved as laparoscopic experience grew. Schmelzer et al looked at their 11 most recent laparoscopic cases and found no statistical difference in operative times (LA 46min vs OA 42min) in contrast to the first 11 laparoscopic cases (LA 63min vs OA 42min). With respect to post-operative recovery, various outcomes were used but only the length of hospital stay was measured with some consistency. Seven of the eleven studies showed a significantly shorter hospital stay for children undergoing the laparoscopic appendicectomy (Wang, Jen, Thambidorai, Schmelzer, Esposito, Li and Ikeda). The meta-analysis by Aziz also reported the laparoscopic group spent less time in hospital (–0.48 days, P= <0.00001). No study found a significantly longer inpatient stay for the laparoscopic group. The independent findings regarding post-operative recovery were: Wang et al reported the time to first oral feed was considerably shorter in the laparoscopic group; Chauhan et al also noted that children returned to their normal daily activities sooner, as well as having better pain scores post-operatively; and Schmelzer et al found the laparoscopic group required a shorter period of IV analgesia. There have been studies linking the adult and paediatric laparoscopic appendicectomy with higher rates of intra-abdominal abscesses (Horwitz & Tang). Jen et al (n=95,806) found a higher rate amongst the laparoscopic group with a substantial sample, although it is drawn from coding data (4.9% vs 3.8%, P= 0.001). Four studies (Thambidorai, Schmelzer, Yagmurlu & Li) and the meta-analysis concluded no statistical difference between the groups. Wang et al (n=128) reported a significant reduction in intra-abdominal abscesses in the laparoscopic group (2.5% vs 14.6%, P= <0.05). Due to the shortcomings in the study designs, the risk of intra-abdominal abscesses remains inconclusive. Five of the six studies (Wang, Jen, Thambidorai, Yagmurlu & Li) and the meta-analysis established a significant reduction of wound infections in the laparoscopic group with none finding the contrary. Similarly, post-operative bowel obstruction was also significantly reduced after laparoscopy in three out of four studies (Kaselas, Jen & Tsao) and the meta-analysis, thought to be due to the reduction in handling of the bowel and subsequent adhesion formation. Jen and Faiz et al found no statistical differences between readmission rates. Overall, complication rates show little difference (Esposito and Ikeda), although Menezes et al reported a significant reduction in complications favouring the laparoscopic group. In terms of the total cost of admission, the comparative studies found laparoscopy to be significantly more expensive than the open procedure (Aziz and Ikeda). As laparoscopy is now fundamental to many surgical specialities, it has no doubt become more cost effective. The findings are all prior to 2004 and so an up to date review is needed. The open appendicectomy has been relied upon for over a century. For the laparoscopic appendicectomy to become the gold standard it must establish a tangible advantage. There is evidence favouring the laparoscopic approach, although questions over the increased risk of intra-abdominal abscesses, costs and the expertise required still linger, particularly in the paediatric population.

Clinical Bottom Line

On the evidence available, in children with acute appendicitis, laparoscopic is better than open appendicectomy at reducing length of hospital stay, wound infections and post-operative bowel obstruction. There are still concerns regarding longer operating times, possible increase in risk of intra-abdominal abscesses and costs.


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  2. Kaselas C, Molinaro F, Lacreuse I, Becmeur F. Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience. J Pediatr Surg 2009 Aug; 44(8):1581-5
  3. Howard C. Jen, M.D., and Stephen B. Shew, M.D. Laparoscopic Versus Open Appendectomy in Children: Outcomes Comparison Based on a State-wide Analysis. Journal of Surgical Research 1–5 (2009) doi:10.1016/j.jss.2009.06.033
  4. Faiz O, Blackburn SC, Clark J, Bottle A, Curry JI, Farrands P, Aylin P Laparoscopic and conventional appendicectomy in children: outcomes in English hospitals between 1996 and 2006. Pediatr Surg Int 2008 Nov;24(11):1223-7
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