Open Versus Laparoscopic Appendectomy in the Pediatric Population: A Literature Review and Analysis of Complications

Abstract

Background:

This study aims to compare the results of laparoscopic and open appendectomy (LA and OA, respectively) in a pediatric population with particular attention to complications analysis.

Subjects and Methods:

A literature search was performed using Medline, Cochrane, Embase, Sci Search, Lilacs, and PubMed databases on all studies published during the 14-year interval of 1997–2010. Comparative studies of LA versus OA in the pediatric population were included in these studies. Data concerning operative time, length of hospital stay, postoperative complications, postoperative pain, and surgical trauma were recorded.

Results:

We recorded 52 studies, but 26 of these were excluded from our analysis because they were neither relevant nor related to the adolescent population. The 26 studies analyzed showed a population of 123,628 children and adolescents (ages 0–18 years) who underwent appendectomy by laparoscopic (LA, 42,213 [34.1%]) and open (OA, 81,415 [65.9%]) techniques. Our analysis showed that patients undergoing LA presented a lower incidence of surgical wound infection, lower incidence of postoperative ileus, a lower use of analgesics in the postoperative period, an earlier resumption of normal diet, a shorter hospitalization, and a more rapid recovery to resume normal activities compared with patients undergoing OA. This study, comparing LA versus OA in children, failed to identify any major difference between the two techniques in terms of formation of intra-abdominal abscesses. As for operative time, our analysis showed globally a significant reduced operative time in OA versus LA in complicated appendicitis, but in simple appendicitis the operative time seems to be the same.

Conclusions:

Our analysis of the literature showed that the LA technique presents several advantages compared with the OA technique. For this reason, if a child is hospitalized today for appendicitis treatment in a pediatric center where the laparoscopic approach is unavailable, he or she should be placed on antibiotics and transferred to a center that offers the laparoscopic approach.

Introduction

Appendicitis is one of the most common surgical emergencies in childhood. Its incidence peaks between the ages of 11 and 12 years, and the lifetime risk is 7%–9%.¹ Perforation is a typical complication in children.¹ In fact, 55%–80% of patients younger than 6 years present to the surgeon with perforation, and perforated appendicitis remains in a highly morbid condition. Open appendectomy (OA), first reported by McBurney in 1894, has become the gold standard treatment for appendicitis. The operation remained virtually unchanged for 100 years owing to its proven efficacy and safety. The development of minimally invasive techniques for an increasing number of surgical conditions in adults has been followed by the utilization of these procedures in children. Since Semm performed the first laparoscopic appendectomy (LA) in 1983, this approach has gained popularity in the treatment of appendicitis over the last 20 years.¹ The advantages of laparoscopic techniques are clear: reduced postoperative pain, reduced length of hospital stay, reduced scarring, improved cosmetic, more rapid return to normal function, and great patient acceptance and demand. Controversy remains, however, regarding possible increases in length of operating time, cost, postoperative complications, and indications and contraindications. Whether LA is superior to OA for both simple appendicitis and perforated appendicitis continues to be debated. The aim of this study is to analyze the main literature databases to compare the results of LA versus OA in the pediatric population, with regard to operative time, length of hospital stay, postoperative complications, postoperative pain, and surgical trauma.

Subjects and Methods

Study selection

A literature search was performed using Medline, Cochrane, Embase, Sci Search, Lilacs, and PubMed databases on all studies published during the 14-year interval of 1997–2010 reporting on laparoscopic surgery for appendicitis and comparing its results with those of conventional OA. The following key words were used: “appendicitis in pediatric population,” “laparoscopic versus open appendectomy,” “minimally invasive versus conventional appendectomy,” and “complications.” Searches were also performed using the following as limit: clinical trials, randomized controlled trials, multicenter retrospective and prospective studies, and our analysis.

We recorded 52 studies, but 26 of these were excluded from our analysis using the following criteria:

1. Studies in which the outcomes of interest were not reported for the two techniques, or it was impossible to calculate these from the published results.

2. Studies not concerning the pediatric population.

Results

Twenty-six studies published between 1997 and 2010 matched the inclusion criteria, comparing appendicitis treatments in the pediatric population and reporting the incidence of complications. All the results are clearly analyzed in Tables 1 and 2. Of the analyzed studies, we found 5 multicenter studies, 4 randomized clinical trials, 14 clinical trials, and 3 meta-analyses. We first considered all studies that showed a population of 123,628 children and adolescents (ages 0–18 years) who underwent appendectomy by laparoscopic (LA, 42,213 [34.1%]) and open (OA, 81,415 [65.9%]) techniques and reporting the incidence of operative time, length of hospitalization, resumption to diet, postoperative complications, postoperative pain, or surgical trauma. A conversion rate was reported in 12 studies (range, 0%–20.5%). Two studies contained LA and OA only in simple appendicitis, six in complicated appendicitis, and 13 in simple and complicated appendicitis.

Table 1.

Patients' Surgical Data

Reference (year)	Study type	LA	OA	Conversion rate	Age (years)	Operative time (minutes)	Length of hospitalization (days)	Resumption of normal diet (days)
Horwitz et al.² (1997)	CT	34 (60.7%)	22 (39.2%)	7 (20.5%)	LA 10.3±0.6 OA 8.1±0.8	LA 87.0±4.7 OA 83.5±5.8	LA 7.0±1.0 OA 6.5±0.6
Paya et al.³ (2000)	CT	138 (27.6%)	362 (72.4%)	6 (4.3%)	10.8		LA 3.4/OA 6
Canty et al.⁴ (2000)	CT	955 (84.6%)[SA 653/PA 302]	173 (15.4%)[SA 86/PA 87]	10 (1.04%)		SA: LA 52/OA 50PA: LA 68/OA 58	SA: LA 2/OA 3PA: LA 7/OA 7
Lintula et al.⁵ (2001)	RCT	30 (49%)	31 (51%)	0 (0%)	LA 11±3OA 12±3	LA 34±18OA 30±11	LA 1.9±0.7OA 2.6±0.9
Lintula et al.⁶ (2002)	CT	13 (52%)	12 (48%)		LA 10±3OA 11±3	LA 63±31OA 37±18	LA 5.0±1.9OA 4.0±1.2
Meguerditchian et al.⁷ (2002)	CT	126 (32.2%)	265 (77.8%)	3 (2.4%)	LA 11.9OA 9.6	LA 45.7±14.9OA 40.6±14.7	LA 2.38±1.76OA 2.94±2.63
Little et al.⁸ (2002)	RCT	44 (50%)	44 (50%)	3 (7%)	LA 12.02OA 10.5	LA 75 (32–150)OA 51 (25–115)	SA: LA 3/OA 2PA: LA 6.5/OA 7	SA: LA 2/OA 2PA: LA 3/OA 4
Newman et al.⁹ (2003)	MA	1052 (31%)	2341 (69%)				SA: LA 2.3/OA 2PA: LA 5.5/OA 6.2
Vernon et al.¹⁰ (2004)	CT	106 (53%)	94 (47%)	0 (0%)	LA 11.6±3.7OA 10.7±3.6	LA 45.7±17.8OA 46.6±15.3	LA 42 hoursOA 45 hours
Nguyen et al.¹¹ (2004)	CT	5366 (29.6%)	12,726 (70.4%)				LA 2.49±2.46OA 3.42±3.39
Oka et al.¹² (2004)	CT	141 (27%)	376 (73%)		LA 11.0±4.3OA 10.6±3.5	LA 49.9±12.9OA 47.3±19.7	LA 4.3±3.2OA 5.2±3.5
Ikeda et al.¹³ (2004)	CT	53 (53%)	47 (47%)		LA 9 (2–15)OA 10 (2–15)	SA: LA 80 (42–215)/OA 50 (25–118)PA: LA 101 (73–170)/OA 61 (30–132)	SA: LA 6 (4–11)/OA 9 (4–10)PA: LA 11 (5–29)/OA 12 (7–35)
Li et al.¹⁴ (2005)	RCT	59 (36%)	101 (64%)	3 (5%)	LA 8.07±0.30OA 7.85±0.24	SA: LA 28.73±0.93/OA 43.87±0.68PA: LA 55.80±3.20/OA 57.94±0.77	SA: LA 3.91±0.12/OA 6.37±0.09PA: LA 6.33±0.37/OA 8.44±0.24
Yagmurlu et al.¹⁵ (2006)	CT	59 (53%)	52 (47%)		LA 10.2±0.5OA 8.60±0.5	LA 60±3OA 57±3	LA 189±15 hoursOA 210±15 hours	LA 104±7OA 127±11
Rai et al.¹⁶ (2007)	CT	91 (66%)	46 (34%)	9 (9.8%)	LA 9.6 (9–10.3)OA 8.7 (7.9–9.4)	LA 106.5 (100.2–112.8)OA 92.8 (82.9–102.7)	LA 6.5 (6.1–6.8)OA 8.2 (7.1–9.3)
Henry et al.¹⁷ (2007)	MS	109 (41.1%)	146 (55.1%)	10 (3.8%)	10.1±4.0		High early LA 76%OA 38%
Esposito et al.¹ (2007)	MS	1506 (64.5%)	826 (35.5%)	25 (1.6%)		LA 40 (15–150)OA 45 (23–160)	SA: LA 3/OA 4.3PA: LA 5.2/OA 8.3
Padankatti et al.¹⁸ (2008)	RCT	12 (40%)	18 (60%)		LA 7.5OA 6.5			LA 2.5OA 3.7
Menezes et al.¹⁹ (2008)	CT	54 (45.7%)	64 (54.3%)				LA 8.3 (4–12)OA 7.1 (4–17)
Wang et al.²⁰ (2009)	CT	80 (62.5%)	48 (37.5%)		LA 7.4±4.3OA 6.6±3.2	LA 88.5±28.8OA 71.8±30.6	LA 6.5±2.2OA 7.8±2.9	LA 1.8±0.6OA 2.8±0.8
Howard and Stephen²¹ (2010)	MS	32,185 (34%)	63,621 (66%)	1339 (4.2%)	LA 12.4±4.1OA 11.1±4.3		SA: LA 1.9±1.4/OA 2.1±1.3PA: LA 5.2±3.2/OA 5.5±3.4

CT, clinical trial; LA, laparoscopic appendectomy; MA, meta-analysis; MS, multicenter studies; OA, open appendectomy; PA, complicated (perforated) appendicitis; RCT, randomized clinical trial; SA, simple appendicitis.

Table 2.

Patients' Follow-Up and Complications

Reference (year)	Study type	Postoperative analgesia for pain/surgical trauma	Postoperative complications	Wound infection	Intra-abdominal abscess	Intestinal obstruction	Other	Surgical reintervention
Horwitz et al.² (1997)	CT		LA 44.1%OA 18.8%	LA 11.7%OA 4.5%	LA 32.3%OA 9.1%
Paya et al.³ (2000)	CT	LA 0.9OA 2.6	LA 12.8%OA 22.7%	LA 2.8%OA 1.9%	LA 0%OA 1%	LA 0.7%OA 3.3%		OA 0.8%
Canty et al.⁴ (2000)	CT		LA 4.1%OA 4.6%	SA: LA 0.4%/OA 0%PA: LA 0%/OA 1%	SA: LA 0.7%/OA 1.1%PA: LA 6%/OA 6%	SA: LA 0%/OA 0%PA: LA 3%/OA 0%	LA: 1 bladder perforation, 4 umbilical incisional hernias
Lintula et al.⁵ (2001)	RCT		LA 1OA 3	LA 0OA 3			LA 1OA 0
Lintula et al.⁶ (2002)	CT			LA 0%/OA 16.6%	LA 7.7%/OA 0%			LA: 7.7% fecal fistula
Meguerditchian et al.⁷ (2002)	CT	LA 1.16 daysOA 1.29 days	LA 10.3%OA 8.02%	NS	NS			LA 1.6%OA 3.4%
Little et al.⁸ (2002)	RCT	LA 91%–39%OA 86%-48%		LA 2 (5%)OA 1 (3%)	LA 1 (3%)OA 1 (3%)		Fever:LA 21 (48%)OA 25 (57%)
Nguyen et al.¹¹ (2004)	CT		A 6.1%OA 9.6%	LA 0.81%OA 1.76%	LA 0.20%OA 0.21%		Re-admission:LA 1.01%OA 1.27%
Oka et al.¹² (2004)	CT		LA 9.2%OA 9.6%	SA: LA 2.1%/OA 3.4PA: LA 2.3%/OA 5.3%	SA: LA 2.1%/OA 1.5%PA: LA 16.3%/OA 9%	SA: LA 0%/OA 0%PA: LA 0%/OA 0.9%	Re-admission:LA 2.3%OA 3.8%
Ikeda et al.¹³ (2004)	CT		LA 6.52%OA 0%PA: 22.7%/OA 27.3%	SA: LA 3.2%/OA 9.1%PA: LA 0%/OA 22.7%	SA: LA 0%/OA 0%PA: LA 18.2%/OA 0%	SA: PA 0%/OA 0%PA: LA 0%/OA 4.5%
Li et al.¹⁴ (2005)	RCT	SA: LA<OAPA: LA<OA		LA 1.44%OA 11%	LA 2.88%OA 3.3%
Yagmurlu et al.¹⁵ (2006)	CT			LA (6.8%)OA 23%	LA 8 (13.6%)OA 8 (15.4%)	LA 1.7%OA 1.9%
Rai et al.¹⁶ (2007)	CT	LA 2.5 (2.2–2.7)OA 3.2 (2.9–3.6)	LA 5.6%OA 19.6%	LA 0%OA 10.8%	LA 2.4%OA 4.3%		Bowel obstruction:LA 3.2%OA 2.2%	LA 5.6%OA 6.5%
Henry et al.¹⁷ (2007)	MS				13.2%
Esposito et al.¹ (2007)	MS		LA 8.2%OA 7.9%	SA: LA 0.13%/OA 0.24%PA: LA 0%/OA 0.6%	SA: LA 0%/OA 0.24%PA: LA 0.2%/OA 0.7%	SA: LA 0%/OA 0%PA: LA 0%/OA 0.36%		OA: 0.36% small bowel obstructions
Padankatti et al.¹⁸ (2008)	RCT	LA 16.6%OA 33.3%		LA 16.6%OA 16.6%	LA 0%OA 0%		OA: 5.5% wound dehiscence	OA: 5.5% fecal fistula
Menezes et al.¹⁹ (2008)	CT		LA 9.2%OA 15.6%	LA 2 (1.7%)OA 3 (2.5%)	LA 3 (2.5%)OA 5 (4.2%)	LA 0 (0%)OA 1 (0.8%)
Wang et al.²⁰ (2009)	CT			LA 1 (1.3%)OA 6 (12.5%)	LA 2 (2.5%)OA 7 (14.6%)
Howard and Stephens²¹ (2010)	MS			SA: LA 1.1%/OA 1.4%PA: LA 5.5%/OA 6.4%	SA: LA 0.6%/OA 0.3%PA: LA 4.9%/OA 3.8%	SA: LA 0.5%/OA 0.4%PA: LA 2%/OA 2.6%		SA: LA 2%/OA 1.8%PA: LA 6.3%/OA 6.9%

A, appendicitis; CT, clinical trial; RCT, randomized clinical trial; LA, laparoscopic appendectomy; MA, meta-analysis; MS, multicenter studies; OA, open appendectomy; PA, complicated (perforated) appendicitis; SA, simple appendicitis; NS, not significant.

Operative time

Fourteen of the 26 studies included in our analysis reported operative time in LA versus OA groups.^{1,2,4–8,10,12–16,20} The results showed a significant reduced operative time in the OA versus LA in complicated appendicitis, but in simple appendicitis the operative time is quite the same (no significant differences).

Length of hospitalization

Twenty studies reported length of hospitalization.^{1–17,19–21} The results, considered globally, demonstrated a decrease in the length of stay of patients undergoing laparoscopic surgery for both simple and complicated appendicitis.

Resumption of normal diet

Only five studies reported data for the resumption of normal diet,^{8,15,16,18,20} and two^16,20 showed a statistically significant reduction in the LA compared with the OA group.

Postoperative analgesia

Five studies reported the incidence of pain, analgesia, and surgical trauma.^{3,7,8,14,16,18} In four of these,^3,14,16,18 laparoscopic access showed a significant decrease in the use of postsurgical painkillers and stress levels.

Postoperative complications

There are three main complications observed after an appendectomy, either laparoscopic or open access: surgical wound infection, intra-abdominal abscess, and intestinal obstruction. Most of the articles reported lower rates of complications in LA, principally as regards surgical wound infection and bowel obstruction. Twenty studies reported the incidence of postoperative wound infection,^{1–8,11–16,18–23} with 7^{11,14–16,20,21,24} showing a statistically significant reduction in the LA compared with the OA group. Post-appendectomy intra-abdominal abscess is one of the most serious complications; in two^16,20 of the 18 works^{1–4,-6–8,11–21} that studied the issue, the percentage was lower after laparoscopic surgery, in two other articles^2,21 open access gave a lower percentage of intra-abdominal abscesses, and in the 14 studies results were similar. Two Cochrane studies, published in 2002 and 2010, reported that in the case of gangrenous appendicitis, the abscess rate seems to be higher for LA; however, these studies focused only on adult patients.^25,26 Eight studies reported the incidence of postoperative ileus,^{1,3,4,12,13,15,19,21} and only in one of them²¹ was there a gap significantly lower for laparoscopy; in the others no significant difference was found. Seven articles reported reoperations (laparotomy or laparoscopic access),^{1,3,6,7,16,18,21} with none individually showing a statistically significant reduction in LA versus OA.

Discussion

Although appendectomy is one of the first general surgical operations in laparoscopy and was described over 20 years ago, it has not gained widespread acceptance among pediatric surgeons.^4,6,13 As such, LA was described¹ in 1983 by Semm. The first report of LA in children goes back to 1991, when Ure and co-workers presented a small prospective series of 43 patients, concluding that it was a safe procedure.^1,14 Numerous prospective randomized studies, meta-analyses, and systematic critical reviews have been published on the subject of LA in adult patients, but scanty reports exist in the pediatric population.^24,26 To date, there is controversy over the management of appendicitis in pediatric patients. The variety of treatment options indicates that the ideal techniques to manage this pathologic condition have not yet been determined.

One of the great advantages of the laparoscopic approach is the possibility of a good abdominal semiology, especially in those patients in whom diagnostic doubt exists, allowing definition of the therapeutic approach more clearly.^8,19,23 As for the pediatric literature on appendectomy it seems that in the period from 1997 to 2010 the majority of patients with an acute appendicitis were still operated on using an open approach; in fact, of 123,628 children and adolescents (ages 0–18 years) analyzed in the 21 studies, 81,415 (65.9%) underwent an OA and 42,213 (34.1%) an LA. However, if you analyze only data from the last 5–6 years, there is a change; in fact, after 2006 LA overtook OA for children with appendicitis.^1,17,18

The results of our analysis of 26 studies (retrospective, prospective, and randomized) suggest that the postoperative complications of wound infection and ileus are reduced in children undergoing LA compared with OA.

The incidence of intra-abdominal abscess when all studies were considered was similar. The reason why the surgical wound infection is lower with the laparoscopic access may be due to the removal of the appendix in endobags or a laparoscopic port, unlike open surgery, in which the appendix comes into direct contact with the surgical wound in its production as well as the smaller incisions. As for adult results, two Cochrane reviews of 2002 and 2010 report that in cases of gangrenous appendicitis in adults, LA has a higher rate of intra-abdominal abscesses compared with OA.^25,26

LA presents a lower incidence of postsurgical ileus compared with OA; in addition, it presents an earlier mobilization of the child due to the presence of less postsurgical pain.^6,10,13 The results of our analysis as regards length of hospitalization stay showed that LA significantly reduced length of hospital stay compared with OA, and this has an impact not only in terms of hospital costs but also in terms of familial organization around the sick child and less psychological impact for the child.

Operative time resulting from the included studies showed that, although LA took longer than OA, this was not statistically significant in simple appendicitis but not so in complicated appendicitis, in which the time difference was significantly higher for the laparoscopic approach.

However, old data focused on length of surgery in the case of LA should be viewed with caution because recent articles showed that also that thanks to the use of the new hemostatic devices used for dissection, laparoscopy seems to be faster than the open approach compared with the data published more than 5–10 years ago.^1,17,18

In conclusion, our literature analysis shows that laparoscopy seems to offer some advantages compared with open surgery in cases of pediatric appendicitis. Patients undergoing LA present a lower incidence of surgical wound infection, lower incidence of postoperative ileus, a lower use of analgesics in the postoperative period, an earlier resumption of normal diet, a shorter hospitalization, and a more rapid recovery to resume normal activities compared with patients undergoing OA. On the contrary, this study, comparing LA versus OA in children, failed to identify any major difference between the two techniques in terms of intra-abdominal abscesses. As for operative time, our analysis shows a reduced operative time in OA versus LA in complicated appendicitis, but in simple appendicitis the operative time seems to be the same.

Considering the superior cosmetic results of LA compared with OA and all the advantages reported in the literature, our study shows that if a child is hospitalized today for appendicitis treatment in a pediatric center where the laparoscopic approach is unavailable, he or she should be placed on antibiotics and transferred to a center that offers the laparoscopic approach.

Footnotes

Disclosure Statement

No competing financial interests exist.

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