Open versus laparoscopic appendicectomy in children

January 5, 2007

May 26, 2010

Dr Hannah Sellars, Dr Monteiro de Barros and Dr Grainne Gallagher , F2, F2 and F1 (Peterborough District Hospital)

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

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?

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.

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

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.

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.
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.
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