Surgical Endoscopy

, Volume 33, Issue 12, pp 4066–4077 | Cite as

Laparoscopic versus open appendectomy in pediatric patients with complicated appendicitis: a meta-analysis

  • Zhi Xuan LowEmail author
  • Glenn Kunnath Bonney
  • Jimmy Bok Yan So
  • Dale Lincoln Loh
  • Jun Jie Ng



Acute appendicitis is a common condition in the pediatric population. In patients with uncomplicated appendicitis, laparoscopic appendectomy (LA) is preferred as compared to open appendectomy (OA). However, in patients with complicated appendicitis (CA), as defined as suppurative, gangrenous or perforated appendicitis, or appendicitis with periappendicular abscess formation, the decision to perform OA or LA remains unclear.


The PRISMA guidelines were adhered to. An electronic database search from 1997 to 2017 was performed using the Cochrane, Medline, PubMed, Scopus, Ovid, Embase, and Web of Knowledge databases. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Assessment of methodological and statistical heterogeneity, as well as publication bias of the included studies, was performed.


Six randomized-control trials (296 LA versus 373 OA) and 33 case–control trials (3106 LA versus 4149 OA) were analyzed. Compared to OA, LA has a shorter length of stay (WMD = − 0.96, 95% CI − 1.47 to − 0.45) and a lower rate of surgical site infection (OR 0.37, 95% CI 0.25–0.54), although the rates of intraabdominal abscess formation were similar (OR 1.01, 95% CI 0.71–1.43). LA was also shown to have lower readmission rates, lower incidences of postoperative ileus or intestinal obstruction, lower incidence of reoperation, as well as a shorter time taken to oral intake. Operative time for OA was shorter than LA (WMD = 12.44, 95% CI 2.00–22.87).


While studies in the past have associated LA with higher rates of intraabdominal abscess in patients with CA, our meta-analysis has shown that they were similar. Considering this, together with other improved postoperative outcomes, LA should be the procedure of choice in pediatric patients presenting with CA.


Complicated appendicitis Laparoscopic appendectomy Open appendectomy Intraabdominal abscess 



There are no acknowledgements.

Compliance with Ethical Standards


Zhi Xuan Low, Glenn Kunnath Bonney, Jimmy Bok Yan So, Dale Lincoln Loh, and Jun Jie Ng have no conflicts of interest.

Supplementary material

464_2019_6709_MOESM1_ESM.docx (12 kb)
Supplementary material 1 (DOCX 12 KB)
464_2019_6709_MOESM2_ESM.docx (36 kb)
Supplementary material 2 (DOCX 36 KB)
464_2019_6709_MOESM3_ESM.docx (39 kb)
Supplementary material 3 (DOCX 38 KB)
464_2019_6709_MOESM4_ESM.docx (26 kb)
Supplementary material 4 (DOCX 25 KB)
464_2019_6709_MOESM5_ESM.docx (22 kb)
Supplementary material 5 (DOCX 21 KB)
464_2019_6709_MOESM6_ESM.eps (1.2 mb)
Supplementary Figure 6 Forest Plot of Postoperative Ileus or IO in the Meta-Analysis of LA versus OA (EPS 1211 KB)
464_2019_6709_MOESM7_ESM.eps (907 kb)
Supplementary Figure 7 Forest Plot of Readmission in the Meta-Analysis of LA versus OA (EPS 907 KB)
464_2019_6709_MOESM8_ESM.eps (910 kb)
Supplementary Figure 8 Forest Plot of Reoperation in the Meta-Analysis of LA versus OA (EPS 910 KB)
464_2019_6709_MOESM9_ESM.eps (813 kb)
Supplementary Figure 9 Forest Plot of Percutaneous Intervention in the Meta-Analysis of LA versus OA (EPS 812 KB)
464_2019_6709_MOESM10_ESM.eps (686 kb)
Supplementary Figure 10 Forest Plot of TTOI in the Meta-Analysis of LA versus OA (EPS 686 KB)
464_2019_6709_MOESM11_ESM.eps (78 kb)
Supplementary Figure 11 Funnel Plot of IAA between LA and OA (EPS 77 KB)
464_2019_6709_MOESM12_ESM.eps (78 kb)
Supplementary Figure 12 Funnel Plot of SSI between LA and OA (EPS 77 KB)


  1. 1.
    Aarabi S, Sidhwa F, Riehle KJ, Chen Q, Mooney DP (2011) Pediatric appendicitis in New England: epidemiology and outcomes. J Pediatr Surg 46:1106–1114PubMedGoogle Scholar
  2. 2.
    Buckius MT, McGrath B, Monk J, Grim R, Bell T, Ahuja V (2012) Changing epidemiology of acute appendicitis in the United States: study period 1993–2008. J Surg Res 175:185–190PubMedGoogle Scholar
  3. 3.
    Addiss DG, Shaffer N, Fowler BS, Tauxe RV (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132:910–925PubMedGoogle Scholar
  4. 4.
    Brender JD, Marcuse EK, Koepsell TD, Hatch EI (1985) Childhood appendicitis: factors associated with perforation. Pediatrics 76:301–306PubMedGoogle Scholar
  5. 5.
    Semm K (1983) Endoscopic appendectomy. Endoscopy 15:59–64PubMedGoogle Scholar
  6. 6.
    McBURNEY C (1894) IV. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg 20:38PubMedPubMedCentralGoogle Scholar
  7. 7.
    Cheong LHA, Emil S (2014) Pediatric laparoscopic appendectomy: a population-based study of trends, associations, and outcomes. J Pediatr Surg 49:1714–1718PubMedGoogle Scholar
  8. 8.
    Vahdad MR, Troebs R-B, Nissen M, Burkhardt LB, Hardwig S, Cernaianu G (2013) Laparoscopic appendectomy for perforated appendicitis in children has complication rates comparable with those of open appendectomy. J Pediatr Surg 48:555–561PubMedGoogle Scholar
  9. 9.
    Esposito C, Calvo AI, Castagnetti M, Alicchio F, Suarez C, Giurin I, Settimi A (2012) Open versus laparoscopic appendectomy in the pediatric population: a literature review and analysis of complications. J Laparoendosc Adv Surg Tech A 22:834–839PubMedGoogle Scholar
  10. 10.
    Aziz O, Athanasiou T, Tekkis PP, Purkayastha S, Haddow J, Malinovski V, Paraskeva P, Darzi A (2006) Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg 243:17–27PubMedPubMedCentralGoogle Scholar
  11. 11.
    Markar SR, Blackburn S, Cobb R, Karthikesalingam A, Evans J, Kinross J, Faiz O (2012) Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children. J Gastrointest Surg 16:1993–2004PubMedGoogle Scholar
  12. 12.
    Dai L, Shuai J (2017) Laparoscopic versus open appendectomy in adults and children: a meta-analysis of randomized controlled trials. United Eur Gastroenterol J 5:542–553Google Scholar
  13. 13.
    Bennett J, Boddy A, Rhodes M (2007) Choice of approach for appendicectomy: a meta-analysis of open versus laparoscopic appendicectomy. Surg Laparosc Endosc Percutaneous Tech 17:245–255Google Scholar
  14. 14.
    Liu Z, Zhang P, Ma Y, Chen H, Zhou Y, Zhang M, Chu Z, Qin H (2010) Laparoscopy or not: a meta-analysis of the surgical effects of laparoscopic versus open appendicectomy. Surg Laparosc Endosc Percutaneous Tech 20:362–370Google Scholar
  15. 15.
    Malagon AM, Arteaga-Gonzalez I, Rodriguez-Ballester L (2009) Outcomes after laparoscopic treatment of complicated versus uncomplicated acute appendicitis: a prospective, comparative trial. J Laparoendosc Adv Surg Tech A 19:721–725PubMedGoogle Scholar
  16. 16.
    Tsai C-C, Lee S-Y, Huang F-C (2012) Laparoscopic versus open appendectomy in the management of all stages of acute appendicitis in children: a retrospective study. Pediatr Neonatol 53:289–294PubMedGoogle Scholar
  17. 17.
    Law D, Law R, Eiseman B (1976) The continuing challenge of acute and perforated appendicitis. Am J Surg 131:533–535PubMedGoogle Scholar
  18. 18.
    Bonanni F, Reed J, Hartzell G, Trostle D, Boorse R, Gittleman M, Cole A (1994) Laparoscopic versus conventional appendectomy. J Am Coll Surg 179:273–278PubMedGoogle Scholar
  19. 19.
    Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, Liu Y (2010) Laparoscopic versus conventional appendectomy–a meta-analysis of randomized controlled trials. BMC Gastroenterol 10:129PubMedPubMedCentralGoogle Scholar
  20. 20.
    Sauerland S, Jaschinski T, Neugebauer EA (2010) Laparoscopic versus open surgery for suspected appendicitis. The Cochrane database of systematic reviews,, October 12, 2010
  21. 21.
    Zhang S, Du T, Jiang X, Song C (2017) Laparoscopic appendectomy in children with perforated appendicitis: a meta-analysis. Surg Laparosc Endosc Percutaneous Tech 27:262–266Google Scholar
  22. 22.
    Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM (1988) CDC definitions for nosocomial infections, 1988. Am J Infect Control 16:128–140PubMedGoogle Scholar
  23. 23.
    Higgins J, Green S (2011) Cochrane handbook for systematic reviews of interventions version 5.1. 0. The Cochrane Collaboration and John Wiley & Sons Ltd., England, pp 1–674Google Scholar
  24. 24.
    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13PubMedPubMedCentralGoogle Scholar
  25. 25.
    Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg 73:712–716PubMedPubMedCentralGoogle Scholar
  26. 26.
    Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JA (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928PubMedPubMedCentralGoogle Scholar
  27. 27.
    Khirallah MG, Eldesouki NI, Elzanaty AA, Ismail KA, Arafa MA (2017) Laparoscopic versus open appendectomy in children with complicated appendicitis. Ann Pediatr Surg 13:17–20Google Scholar
  28. 28.
    Lintula H, Kokki H, Vanamo K, Antila P, Eskelinen M (2002) Laparoscopy in children with complicated appendicitis. J Pediatr Surg 37:1317–1320PubMedGoogle Scholar
  29. 29.
    Oka T, Kurkchubasche A, Bussey J, Wesselhoeft C, Tracy T, Luks F (2004) Open and laparoscopic appendectomy are equally safe and acceptable in children. Surg Endosc Other Interv Tech 18:242–245Google Scholar
  30. 30.
    Karakuş OZ, Ulusoy O, Ateş O, Hakgüder G, Olguner M, Akgür FM (2016) Conventional single-port laparoscopic appendectomy for complicated appendicitis in children: Efficient and cost-effective. J Minimal Access Surg 12:16PubMedPubMedCentralGoogle Scholar
  31. 31.
    Krisher SL, Browne A, Dibbins A, Tkacz N, Curci M (2001) Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis. Arch Surg 136:438–441PubMedGoogle Scholar
  32. 32.
    Lee SL, Yaghoubian A, Kaji A (2011) Laparoscopic vs open appendectomy in children: outcomes comparison based on age, sex, and perforation status. Arch Surg 146:1118–1121PubMedGoogle Scholar
  33. 33.
    Li P, Han Y, Yang Y, Guo H, Hao F, Tang Y, Guo C (2017) Retrospective review of laparoscopic versus open surgery in the treatment of appendiceal abscess in pediatric patients: Laparoscopic versus open surgery for appendiceal abscess. Med 96:30Google Scholar
  34. 34.
    Li P, Xu Q, Ji Z, Gao Y, Zhang X, Duan Y, Guo Z, Zheng B, Guo X, Wu X (2005) Comparison of surgical stress between laparoscopic and open appendectomy in children. J Pediatr Surg 40:1279–1283PubMedGoogle Scholar
  35. 35.
    McKinlay R, Neeleman S, Klein R, Stevens K, Greenfeld J, Ghory M, Cosentino C (2003) Intraabdominal abscess following open and laparoscopic appendectomy in the pediatric population. Surg Endosc Other Interv Tech 17:730–733Google Scholar
  36. 36.
    Menezes M, Das L, Alagtal M, Haroun J, Puri P (2008) Laparoscopic appendectomy is recommended for the treatment of complicated appendicitis in children. Pediatr Surg Int 24:303–305PubMedGoogle Scholar
  37. 37.
    Miyano G, Okazaki T, Kato Y, Marusasa T, Takahashi T, Lane GJ, Yamataka A (2010) Open versus laparoscopic treatment for pan-peritonitis secondary to perforated appendicitis in children: a prospective analysis. J Laparoendosc Adv Surg Tech 20:655–657Google Scholar
  38. 38.
    Nadler EP, Reblock KK, Qureshi FG, Hackam DJ, Gaines BA, Kane TD (2006) Laparoscopic appendectomy in children with perforated appendicitis. J Laparoendosc Adv Surg Tech 16:159–163Google Scholar
  39. 39.
    Nwokoma NJ, Swindells MG, Pahl K, Mathur AB, Minocha A, Kulkarni M, Tsang T (2009) Pediatric advanced appendicitis: open versus laparoscopic approach. Surg Laparosc Endosc Percutaneous Tech 19:110–113Google Scholar
  40. 40.
    Rai R, Chui C, Low Y, Yap T, Jacobsen A (2007) Perforated appendicitis in children: benefits of early laparoscopic surgery. Ann Acad Med Singap 36:277PubMedGoogle Scholar
  41. 41.
    Taqi E, Al Hadher S, Ryckman J, Su W, Aspirot A, Puligandla P, Flageole H, Laberge J-M (2008) Outcome of laparoscopic appendectomy for perforated appendicitis in children. J Pediatr Surg 43:893–895PubMedGoogle Scholar
  42. 42.
    Thambidorai C, Aman FY (2008) Laparoscopic appendicectomy for complicated appendicitis in children. Singap Med J 49:994–997Google Scholar
  43. 43.
    Tirabassi MV, Tashjian DB, Moriarty KP, Konefal SH, Courtney RA, Sachs BF (2004) Perforated appendicitis: is laparoscopy safe? J Soc Laparoendosc Surg 8:147Google Scholar
  44. 44.
    Wang X, Zhang W, Yang X, Shao J, Zhou X, Yuan J (2009) Complicated appendicitis in children: is laparoscopic appendectomy appropriate? A comparative study with the open appendectomy—our experience. J Pediatr Surg 44:1924–1927PubMedGoogle Scholar
  45. 45.
    Yagmurlu A, Vernon A, Barnhart D, Georgeson K, Harmon C (2006) Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy. Surg Endosc Other Interv Tech 20:1051–1054Google Scholar
  46. 46.
    Bıçakcı Ü, Tander B, Günaydın M, Rızalar R, Aritürk E, Ayyıldız SH, Bernay F (2011) The comparison of open and laparoscopic appendectomy: is there any outcome difference between non-complicated and complicated appendicitis? Balkan Med J 28:304–306Google Scholar
  47. 47.
    Canty TG, Collins D, Losasso B, Lynch F, Brown C (2000) Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice? J Pediatr Surg 35:1582–1585PubMedGoogle Scholar
  48. 48.
    Chang HK, Han SJ, Choi SH, Oh J-T (2013) Feasibility of a laparoscopic approach for generalized peritonitis from perforated appendicitis in children. Yonsei Med J 54:1478–1483PubMedPubMedCentralGoogle Scholar
  49. 49.
    Esposito C, Borzi P, Valla JS, Mekki M, Nouri A, Becmeur F, Allal H, Settimi A, Shier F, Sabin MG (2007) Laparoscopic versus open appendectomy in children: a retrospective comparative study of 2,332 cases. World J Surgery 31:750–755Google Scholar
  50. 50.
    Groves LB, Ladd MR, Gallaher JR, Swanson J, Becher RD, Pranikoff T, Neff LP (2013) Comparing the cost and outcomes of laparoscopic versus open appendectomy for perforated appendicitis in children. Am Surg 79:861–864PubMedGoogle Scholar
  51. 51.
    Horwitz JR, Custer MD, May BH, Mehall JR, Lally KP (1997) Should laparoscopic appendectomy be avoided for complicated appendicitis in children? J Pediatr Surg 32:1601–1603PubMedGoogle Scholar
  52. 52.
    Ikeda H, Ishimaru Y, Takayasu H, Okamura K, Kisaki Y, Fujino J (2004) Laparoscopic versus open appendectomy in children with uncomplicated and complicated appendicitis. J Pediatr Surg 39:1680–1685PubMedGoogle Scholar
  53. 53.
    Padankatti L, Pramod RK, Gupta A, Ramachandran P (2008) Laparoscopic versus open appendicectomy for complicated appendicitis: a prospective study. J Indian Assoc Pediatr Surg 13:104PubMedPubMedCentralGoogle Scholar
  54. 54.
    Little DC, Custer MD, May BH, Blalock SE, Cooney DR (2002) Laparoscopic appendectomy: an unnecessary and expensive procedure in children? J Pediatr Surg 37:310–317PubMedGoogle Scholar
  55. 55.
    Kaselas C, Molinaro F, Lacreuse I, Becmeur F (2009) Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience. J Pediatr Surg 44:1581–1585PubMedGoogle Scholar
  56. 56.
    Paya K, Rauhofer U, Rebhandl W, Horcher E (2000) Perforating appendicitis. Surg Endosc 14:182–184PubMedGoogle Scholar
  57. 57.
    Tsao KJ, St Peter SD, Valusek PA, Keckler SJ, Sharp S, Holcomb GW, Snyder CL, Ostlie DJ (2007) Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach. J Pediatr Surg 42:939–942PubMedGoogle Scholar
  58. 58.
    Valla J, Steyaert H, Alain L (1996) Management of appendicular peritonitis in children: traditional surgery vs. laparoscopy. Retrospective comparative study of pediatric video surgery group. Int J Pediatr Surg Sci 10:13–16Google Scholar
  59. 59.
    Athanasiou C, Lockwood S, Markides GA (2017) Systematic review and meta-analysis of laparoscopic versus open appendicectomy in adults with complicated appendicitis: an update of the literature. World J Surg 41:3083–3099PubMedGoogle Scholar
  60. 60.
    Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, Pietrobon R (2004) Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 239:43PubMedPubMedCentralGoogle Scholar
  61. 61.
    Masoomi H, Mills S, Dolich MO, Ketana N, Carmichael JC, Nguyen NT, Stamos MJ (2012) Comparison of outcomes of laparoscopic versus open appendectomy in children: data from the Nationwide Inpatient Sample (NIS), 2006–2008. World J Surgery 36:573–578Google Scholar
  62. 62.
    Tashiro J, Einstein SA, Perez EA, Bronson SN, Lasko DS, Sola JE (2016) Hospital preference of laparoscopic versus open appendectomy: effects on outcomes in simple and complicated appendicitis. J Pediatr Surg 51:804–809PubMedGoogle Scholar
  63. 63.
    Romy S, Eisenring M-C, Bettschart V, Petignat C, Francioli P, Troillet N (2008) Laparoscope use and surgical site infections in digestive surgery. Ann Surg 247:627–632PubMedGoogle Scholar
  64. 64.
    Fleming FJ, Kim MJ, Messing S, Gunzler D, Salloum R, Monson JR (2010) Balancing the risk of postoperative surgical infections: a multivariate analysis of factors associated with laparoscopic appendectomy from the NSQIP database. Ann Surg 252:895–900PubMedGoogle Scholar
  65. 65.
    Nataraja RM, Loukogeorgakis SP, Sherwood WJ, Clarke SA, Haddad MJ (2013) The incidence of intraabdominal abscess formation following laparoscopic appendicectomy in children: a systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A 23:795–802PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
  2. 2.Department of Surgery, University Surgical ClusterNational University HospitalSingaporeSingapore
  3. 3.Department of Paediatric SurgeryKhoo Teck Puat - National University Children’s MedicalSingaporeSingapore

Personalised recommendations