JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 16, Number 2, 2006

© Mary Ann Liebert, Inc.

Laparoscopic Appendectomy in Children with

Perforated Appendicitis

EVAN P. NADLER, MD,1 KIMBERLY K. REBLOCK, RN,2 FAISAL G. QURESHI, MD,2

DAVID J. HACKAM, MD, PhD,2 BARBARA A. GAINES, MD,2
and TIMOTHY D. KANE, MD2

ABSTRACT

Purpose: There is persistent controversy regarding the optimal surgical therapy for children with
appendicitis. We have recently adopted laparoscopic appendectomy in lieu of the open technique
for children with perforated appendicitis. We hypothesized that laparoscopic appendectomy would
be as effective as open appendectomy in preventing postoperative complications.
Materials and Methods: We reviewed the medical records of children admitted to our hospital
over a 5-year period with the diagnosis of perforated appendicitis. Patients were divided into two
groups based on the operative approach: laparoscopic vs. open appendectomy. Demographic data,
duration of presenting symptoms, initial white blood cell (WBC) count, length of stay, and compli-
cations were abstracted. Data were compared using appropriate statistical analyses.
Results: There was no difference between the laparoscopic (n
43) and open (n
77) groups
with respect to gender, duration of presenting symptoms, initial WBC, or length of stay. However,
patients in the laparoscopic group had a significantly lower complication rate than those in the open
group (6/43 vs. 23/77, P
0.05). Infectious complications were no different between groups. Patients
in the laparoscopic group tended to be older than patients in the open group (10.6  3.3 years vs.
8.5  4.1 years, P
0.003).
Conclusion: Laparoscopic appendectomy for children with perforated appendicitis has the same
infectious complication rate and a lower overall complication rate than open appendectomy. A
prospective study with standardized postoperative care would be needed to determine whether lap-
aroscopic appendectomy for children with perforated appendicitis is the treatment of choice, but
until then it remains an attractive alternative.

INTRODUCTION series.1–5 There remains controversy regarding the surgi-

cal therapy that may best limit the relatively high mor-

P ERFORATED APPENDICITIS IN THE PEDIATRIC POPULA-

TION continues to be significant source of prolonged
hospitalization, and is characterized by a hospital course
that is often complicated by wound infections and intra-
abdominal abscesses.1 Most series report complication
rates
10%, although there is variation among different
bidity for children with perforated appendicitis. While
many have adopted laparoscopic appendectomy as the
standard of care,6 there are few data to support this ap-
proach.7 In fact, some suggest that laparoscopic appen-
dectomy (LA) is no more efficacious than open appen-
dectomy (OA), and is perhaps associated with a higher

1Division of Pediatric Surgery and Department of Surgery, New York University School of Medicine, New York, New York.
2Department of Surgery, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsyl-
vania.
Presented at the 13th Annual Congress for Endosurgery in Children, Maui, Hawaii, May 2004.

159
160
incidence of intra-abdominal abscess formation.8,9 How-
ever, few of these reports focus solely on children with
complicated appendicitis, or they have small numbers of
patients with true perforations. We have recently adopted
LA in lieu of OA for children with perforated appen-
dicitis. We hypothesized that LA would be as effective
as OA in preventing postoperative complications.
MATERIALS AND METHODS
We reviewed the medical records of all children ad-
mitted to our hospital between January 1998 and March
2003 with the diagnosis of perforated appendicitis con-
firmed at appendectomy. Only patients who underwent
an operation within 24 hours of admission were included
in the analysis. Patients who were initially treated via a
nonoperative strategy, and thus had surgery later than 24
hours after admission, were omitted in an attempt to min-
imize patient variability. Operative approach was based
on surgeon preference for laparoscopic appendectomy
(LA) or open appendectomy (OA).
All incisions were closed. The standard approach for
perforated appendicitis at our institution does not include
the use of intraoperative cultures or intra-abdominal
drains.
Antibiotic management consisted of either monother-
apy with piperacillin/tazobactam, or triple therapy with
ampicillin, gentamicin, and clindamycin or metronida-
zole, depending on surgeon preference and the presence
of a penicillin allergy. We have previously proven the
equivalence of these two antibiotic regimens in children
with perforated appendicitis.10 Patients with penicillin al-
lergies were treated with gentamicin and clindamycin
alone. Antibiotics were started once the diagnosis of ap-
pendicitis was established, and were continued for up to
10 to 14 days until the white blood cells (WBC) and tem-
perature had returned to within normal limits. If the WBC
remained elevated or the patient was still febrile, then ab-
dominal and pelvic CT scan was obtained no sooner than
postoperative day (POD) 7 to look for an abscess. Pa-
TABLE 1. CHARACTERISTICS OF CHILDREN WITH PERFORATED APPENDICITIS WHO
UNDERWENT SURGERY WITHIN FIRST 24 HOURS OF ADMISSION
Age (years)
% Male
Duration of symptoms (hours)
Initial white blood cells (WBC)
Length of stay (days)
aP  0.003, Student’s t-test.
Data are presented as the mean  standard deviation (SD) for normally distributed data and as the median for skewed data.
NADLER ET AL.
tients were discharged from the hospital when they tol-
erated liquids and were allowed to complete their course
of antibiotics at home via a peripherally inserted central
catheter.
Patients were divided into two groups based on the op-
erative approach: LA vs. OA. The three patients who
were converted from a laparoscopic to an open approach
were included in the OA group. Demographic data, du-
ration of presenting symptoms, initial WBC, length of
stay (LOS), and complications were abstracted. Compli-
cations were further divided into infectious and nonin-
fectious categories.
Standard statistical software (StatgraphicsPlus v. 3.1,
Manguistics Inc., Rockville, Maryland) was used to ob-
tain summary statistics, including means and standard de-
viations for all continuous variables. Frequency distri-
butions were determined for categorical variables.
Continuous variables were compared using Student’s t-
test when the data were normally distributed and the
Mann-Whitney test when the data were skewed. Cate-
gorical data were compared using Chi-square analysis. If
the expected value of any cell was less than 5, then
Fisher’s exact test was used. Statistical significance was
assigned to P
0.05.
RESULTS
During the three-year study period, a total of 120 pa-
tients were diagnosed with perforated appendicitis and
underwent operative appendectomy within 24 hours of
diagnosis. There was no difference between the LA and
OA groups with respect to gender, duration of present-
ing symptoms, initial WBC, or LOS (Table 1). Patients
who underwent OA were slightly younger than those who
underwent LA (8.5  4.1 years vs. 10.6  3.3 years; P 
0.003, Student’s t-test).
In order to assess the efficacy of the two operative ap-
proaches, we abstracted all complications either prior to
or after leaving the hospital for the first year after surgery.
The overall complication rate was
14% in the LA group
Laparoscopic Open
appendectomy appendectomy
(n  43) (n  77)
10.6  3.3 8.5  4.1a
65.1% 70.1%
48 48
17.7  6.2 18.1  7.0
6.6  2.8 7.1  3.5
LA IN PERFORATED APPENDICITIS
FIG. 1. Patients were divided into 2 groups based on the op-
erative approach to appendectomy: laparoscopic vs. open. Over-
all complication rates and infectious complication rates were
recorded. Infectious complications included line infections,
wound infections, and intra-abdominal abscesses. Patients in
the open appendectomy group had a significantly higher over-
all complication rate than those in the laparoscopic appendec-
tomy group. *p  0.05, Chi-square analysis vs. laparoscopic
appendectomy.
and
30% in the OA group (Fig. 1). Patients in the LA
group were significantly less likely to suffer from a com-
plication than those in the OA group (6/43 vs. 24/77, P 
0.05, Chi-square analysis). Infectious complications, in-
cluding wound infections, line infections, and intra-ab-
dominal abscesses, were no different between the two
groups (6/43 vs. 15/77). Intra-abdominal abscess was the
most common complication in both groups (Table 2). Ab-
scesses that were deemed amenable to percutaneous
drainage were managed by either simple aspiration or
placement of a pigtail drain. Abscesses that were smaller
than 2 cm were treated with continued antibiotic therapy.
There were 4 readmissions in the LA group: 3 patients
with abscesses, and 1 with a wound infection at the um-
bilical port site. There were 7 readmissions in the OA
group: 3 children with abscesses, 2 children with small
bowel obstruction requiring an operation, 1 child with a
partial small bowel obstruction that responded to naso-
TABLE 2. ANALYSIS
Abscess
Wound infection
Line infection
Small bowel obstruction
Fistula
Drug reaction
Other
Clostridium difficile colitis
Gastrointestinal bleeding
161
gastric decompression, and 1 child with a fecal fistula.
There was no statistical difference in the readmission rate
between the two groups.
DISCUSSION
There is no consensus regarding the optimal surgical
treatment for children with perforated appendicitis, nor
for almost all aspects of patient care.3,4 While there has
been increasing enthusiasm for LA in children for acute
or perforated appendicitis,6 there are few data supporting
its routine use.7 There are perceived social benefits with
LA in children that have led many institutions to adopt
this technique and evaluate its results.11 While some au-
thors have found that LA is safe and effective for the
treatment of appendicitis in children, others have sug-
gested that there may be a higher postoperative abscess
rate when compared to OA.5,8,9 The cost of LA may also
be higher than the open approach unless postoperative
LOS is decreased.12 Studies to date that have advocated
the use of laparoscopy for children with perforated ap-
pendicitis have had relatively few patients.13,14
The demographic data for patients reviewed in our
study was nearly identical in the LA and OA groups ex-
cept that patients in the OA group were younger by ap-
proximately 2 years. This is likely secondary to the bias
in our group toward OA in smaller children due to the
comparable incision sizes. However, the difference in age
is unlikely to impact patient outcome in the two groups.
The rest of the demographic data included a median du-
ration of symptoms prior to coming to the hospital of 2
days, a presenting WBC of
18,000, and an average hos-
pital LOS of about 7 days. These data are consistent with
other large series.1–5 Despite the fact that the two groups
were nearly equivalent, patients who underwent OA were
more than twice as likely to suffer from a complication
of any type than patients who underwent LA. This dif-
ference did not hold true when considering only infec-
OF ALL COMPLICATIONS
Laparoscopic Open
appendectomy appendectomy
(n  6) (n  24)
4 9
1 4
0 1
0 3
1 2
0 3
0 1
0 1
162
tious complications (wound infections, line infections,
and intra-abdominal abscesses).
Drug reactions were only encountered in the OA group,
however this was not statistically significant (P  0.2,
Chi-square analysis). The reason for this is unclear, but
may be due to a bias to using triple therapy in the open
group, as all 3 drug reactions were to ampicillin. There
was also no statistical difference in the readmission rate
between the two groups, despite the increased complica-
tion rate in the OA group. We did not evaluate cost or
charge data since our mean LOS and readmission rates
were no different between the two groups.
Many authors have tried to address the question
whether LA is suitable or even preferred for children with
appendicitis. The largest series is from the Children’s
Hospital of San Diego.15 They reported their results in
both simple and perforated appendicitis over 6 years dur-
ing which they were transitioning from OA to LA. There
was no difference in the incidence of abscess formation
or bowel obstruction between the two operative tech-
niques, even with subset analysis including only compli-
cated appendicitis. The overall complication rate was
higher in the laparoscopic group, although not signifi-
cantly, which was likely due to the learning curve for
these surgeons. On the contrary, we have found that the
overall complication rate was lower in children who un-
derwent LA. The difference may be that our study was
conducted after all surgeons were comfortable with the
laparoscopic technique. Other authors have compared
outcomes for laparoscopic and open appendectomy in
children with perforated appendicitis recently, but these
studies lack sufficient numbers to draw any concrete con-
clusions.5,13,14
When we undertook this review, we hypothesized that
LA and OA would be equally efficacious in regard to
postoperative complications. Our data suggest that LA
may actually be better. The reasons for the potentially
improved outcomes are unclear. The overall complica-
tion rate of 30% for the OA group is somewhat higher
than that reported in the literature, but is the same as the
complication rate for OA reported by Vegunta et al.5 If
we were to include only major complications (abscess,
small bowel obstruction, fistula, gastrointestinal bleed),
the complication rate for the OA group would be 19%,
which is not significantly different than most studies.1–5
This rate would still be higher than the major complica-
tion rate of
12% of our LA group.
Since infectious complications were equally prevalent
in the two groups, we assume that source control was
similar using either technique. Thus it is possible that the
difference between the two groups could be due to the
operative technique itself, that the open manipulation of
the abdominal contents carries a higher risk of compli-
cation. Indeed, it is interesting that there were no post-
operative bowel obstructions in the LA group. However,
NADLER ET AL.
it is also possible that there was an inherent bias of the
surgeons to perform the more difficult cases using the
open technique, leading to the higher complication rate,
although this theory is not supported by the similar days
of symptoms prior to presentation and initial WBC counts
in the two groups. An alternative possibility is that with
larger numbers we would see no difference in complica-
tion rates between open and laparoscopic appendectomy.
This was our original hypothesis, and is more likely to
be the case.
In summary, our data show that children with perfo-
rated appendicitis can be effectively managed with LA.
Our data suggest that LA is potentially more efficacious
than OA in preventing postoperative complications al-
though this conclusion is limited by the number of pa-
tients in our review. A prospective trial with standard-
ized postoperative care would be needed to determine
definitively whether LA for children with perforated ap-
pendicitis should be considered the treatment of choice,
but until then it remains an attractive and viable alterna-
tive.
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1. Soo Youn Bae, Ik Jin Yun, Kyung Yung Lee, Moo Kyung Seong, Young Bum Yoo, Seong Hwan Chang, Jee Soo Kim. 2009. A
Comparative Study about Complications of Laparoscopic Appendectomy in Children and Adults. Journal of the Korean Surgical
Society 76:2, 90. [CrossRef]
2. J. Gillick, N. Mohanan, L. Das, P. Puri. 2008. Laparoscopic appendectomy after conservative management of appendix mass.
Pediatric Surgery International 24:3, 299-301. [CrossRef]
3. Peter Mattei. 2007. Minimally invasive surgery in the diagnosis and treatment of abdominal pain in children. Current Opinion
in Pediatrics 19:3, 338-343. [CrossRef]