Journal of Pediatric Surgery (2013) 48, 555–561

www.elsevier.com/locate/jpedsurg

Laparoscopic appendectomy for perforated appendicitis in

children has complication rates comparable with those of
open appendectomy
Mohammad Reza Vahdad ⁎, Ralf-Bodo Troebs, Matthias Nissen,
Lars Benjamin Burkhardt, Svenja Hardwig, Grigore Cernaianu
Department of Pediatric Surgery, Marienhospital–Kinderchirurgische Klinik der Ruhr-Universität Bochum,
Widumerstr. 8, 44627 Herne, Germany

Received 13 January 2012; revised 23 July 2012; accepted 27 July 2012

Key words:
Abstract
Perforated appendicitis;
Purpose: To evaluate the outcome of laparoscopic (LA) vs. open appendectomy (OA) in children with
Children;
perforated appendicitis (PA).
Laparoscopic
Methods: We reviewed the medical files of 221 children who underwent LA (n=75), OA (n=122), and
appendectomy;
conversion (CO) (n=24), comparing duration of operation, re-admissions, re-operations, intra-
Open appendectomy;
abdominal abscesses (IAA), and wound infections.
Complications
Results: Compared to OA, LA resulted in fewer re-admissions (1.3% vs. 12.3%; P=.006), fewer re-
operations (4% vs. 17.2%; P=.006), and fewer wound infections (0% vs. 11.5%; P=.001). No
differences in the duration of operation (72.9±23.0 min vs. 77.7±48.0 min; P=.392) or IAA (4% vs.
11.5%; P=.114) were observed. Compared to LA, CO had more complications.
Conclusions: We report that LA is superior to OA with regard to incidence of re-admission, re-
operation, and wound infection.
© 2013 Elsevier Inc. All rights reserved.

Laparoscopic appendectomy (LA) is minimally invasive
and associated with less postoperative pain in children [1]. It
remains to be clarified whether LA is inferior to open
appendectomy (OA) in terms of postoperative complications,
since there is considerable discrepancy in the published data. A
2010 Cochrane study [2] performed on adults and children
reported that LA increases the rate of intra-abdominal abscess
(IAA) in adults and postulated a similar trend in children. Other
studies performed on children, however, found an equal [3] or
decreased [4] rate of IAA. This discrepancy prompted us to
investigate the impact of LA on duration of operation and
complications, in children with perforated appendicitis.

⁎ Corresponding author. Tel.: +49 2323 408; fax: +49 2323 499 328.
E-mail addresses: rvahdad@aol.com (M.R. Vahdad),
ralf-bodo.troebs@marienhospital-herne.de (R.-B. Troebs),
matthias.nissen@marienhospital-herne.de (M. Nissen),
lars.burkhardt@marienhospital-herne.de (L.B. Burkhardt),
svenja.hardwig@marienhospital-herne.de (S. Hardwig),
grigorec@hotmail.com (G. Cernaianu).
1. Methods
After obtaining institutional review board approval
(no. 3928-11), a retrospective review identified all
children less than 18 years of age with intraoperative
and histological confirmed perforated appendicitis who

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556 M.R. Vahdad et al.

underwent appendectomy between January 2001 and by histopathology. Eleven otherwise eligible patients were
December 2010 at the Department of Pediatric Surgery of excluded during the duration of the study: 8 patients with
Ruhr-University in Bochum, Germany. For inclusion in our incomplete documentation, 1 patient with concomitant
study, patients had to fulfill the criteria of the definition for resection of a Meckel's diverticulum, and 2 patients referred
perforated appendicitis published in 2008 by St Peter et al. with complications after appendectomies in other hospitals.
[5]: intraoperative evidence of perforation or intra-abdominal Perforated appendicitis accounted for 221 (19.8%) of
fecalith and confirmation of the perforation during histopath- 1114 patients with appendicitis. Seventy-five (33.9%)
ological examination. Only data from those patients who children underwent LA, 122 (55.2%) underwent OA, and
fulfilled both criteria were included. All other patients with a in 24 patients (10.8%) the operative procedure was converted
surgical diagnosis of perforated appendicitis who did not intra-operatively from LA to OA (CO).
fulfill these strict criteria were excluded in order to rule out Mean patient age was 94 months (range, 15–212 months).
variation in the definition of perforation from 2001 to 2010. Twenty-five different surgeons performed the surgical pro-
Informed consent was obtained from each patient's cedures, and the same surgeons operated on patients from
guardian. The patients were divided into three groups: different treatment groups (Table 1). Several surgeons
patients who underwent LA, patients who underwent OA, performed operations both as residents and subsequently as
and patients who underwent a conversion (CO). LA was board-certified pediatric surgeons. Consequently, 136 patients
performed using 3 Endo-Loops® (Ethicon®, Norderstedt, (61.5%) were operated on by 8 board-certified pediatric
Germany). The decision of whether to perform LA or OA was surgeons, and 20 residents operated on the remaining
based on the surgeon's preference. Until 2007, COs were 85 patients (38.5%) under the supervision of a board-certified
performed routinely if suppuration was visualized intra- pediatric surgeon. The incidence of perforated appendicitis
abdominally. Since 2007, however, the only indication for (P=.137) did not significantly differ between boys (n=124)
CO is the inability to continue with LA. Surgical procedures and girls (n=97), and no deaths occurred. The median follow-
were performed by consultants and residents. Our antibiotic up period was 25 months (range, 12–127 months) for LA,
regimen consisted of daily intravenous administration of
cefuroxim (100 mg/kg body weight in three doses) for 7 days
Table 1 Count and type of surgical procedures performed by
and metronidazole (20 mg/kg body weight in two doses) for
each participating surgeon.
5 days starting at the onset of anesthesia. Some patients
received an adapted antibiotic therapy based on the results of Surgeon LA OA CO Total
their intraoperative microbiological smear. Patients' medical Count %
records were reviewed retrospectively, and the following data
1 1 0 0 1 0.5
were collected: age, sex, surgical procedure(s), duration of 2 3 0 0 3 1.4
operation, and incidence of re-admission, re-operation, intra- 3 0 7 0 7 3.2
abdominal abscess formation, adhesiolysis and wound 4 6 1 1 8 3.6
infection. We excluded children presenting with additional 5 3 0 0 3 1.4
diagnoses before the first admission. 6 9 4 2 15 6.8
Patients with a follow-up period less than 12 months, 7 3 0 0 3 1.4
incomplete documentation, concomitant operations, or re- 8 0 8 0 8 3.6
ferred after appendectomy in other hospitals were exclu- 9 0 13 0 13 5.9
ded.We chose 12 months for the minimum follow-up in order 10 0 3 0 3 1.4
to include late complications such as bowel obstruction that 11 4 21 5 30 13.6
12 1 0 0 1 0.5
required adhesiolysis in addition to the complications that
13 4 20 5 29 13.1
occurred within the first 30 postoperative days. 14 0 5 0 5 2.3
Comparative statistical analyses were undertaken using the 15 0 4 0 4 1.8
Fisher's exact test for qualitative data and the Mann–Whitney 16 0 4 0 4 1.8
U test for quantitative data. Qualitative and quantitative data are 17 0 5 0 5 2.3
presented as bars, illustrating mean±standard deviation (SD). 18 13 10 2 25 11.3
Statistical analyses were performed using SPSS® 20 (IBM®) 19 0 2 0 2 0.9
software. Differences were considered significant at Pb.05. 20 1 0 1 2 0.9
21 3 5 0 8 3.6
22 3 2 4 9 4.1
2. Results 23 16 6 3 25 11.3
24 1 2 0 3 1.4
25 4 0 1 5 2.3
2.1. Demographic data
Total 75 122 24 221 100
LA, laparoscopic appendectomy; OA, open appendectomy; CO,
Appendectomies were completed in 221 children with
conversion from LA to OA. %: percentage of all surgical procedures.
perforated appendicitis evident at operation and confirmed

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Laparoscopic appendectomy for perforated appendicitis 557

Fig. 1 Counts of conversions, laparoscopic, and open appendectomies per year for perforated appendicitis. The vertical line marks the cut-
off point between the two time frames of treatment (2001–2007 vs. 2008–2010).

Fig. 2 Impact of surgical procedure on duration of operation. The duration of operation in minutes was compared across three surgical
procedures. Patients underwent laparoscopic appendectomy (LA), open appendectomy (OA), or a conversion from laparoscopic to open
appendectomy (CO). Data are plotted as bars with SD. ***Pb.001.

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558 M.R. Vahdad et al.

Table 2 Distribution and statistical analysis of duration of operation and complications for the surgical procedures divided in the time
frames of treatment: 2001–2007 and 2008–2010.
Parameter 2001–2007 2001–2007 vs. 2008–2010
N Mean± LA vs. LA vs. OA vs. 2008–2010 N Mean± LA vs. LA vs. OA vs.
SD OA P CO P CO P SD OA P CO P CO P
Duration of operation (min)
LA 8 75±30 .81 b.001 b.001 .77 67 72±22 .46 b.001 .04
OA 116 76±44 .65 6 100±99
CO 8 115±19 .29 16 140±44
N % LA vs. LA vs. OA vs. N % LA vs. LA vs. OA vs.
OA P CO P CO P OA P CO P CO P
Re-admission
LA 8 0 .59 .07 .01 1.00 67 1.5 1 b.001 .13
OA 116 12.9 1.00 6 0
CO 8 50 .67 16 37.5
Re-operation
LA 8 12.5 1 1 .63 .29 67 3.0 .23 b.001 .35
OA 116 17.2 1.00 6 16.7
CO 8 25 .65 16 43.8
Abscess
LA 8 12.5 1 1 1 .29 67 3.0 1 .16 1
OA 116 12.1 1.00 6 0
CO 8 12.5 1.00 16 12.5
Wound infection
LA 8 0 1 .46 .24 n.a. 67 0 .82 b.001 .63
OA 116 11.2 .52 6 16.7
CO 8 25.0 1.00 16 31.2
Mean±SD duration of operation in minutes, and % of all patients who underwent the same surgical procedure demonstrating the following complications: re-
admission, re-operation, intra-abdominal abscess formation, and wound infection. LA, laparoscopic appendectomy; OA, open appendectomy; CO,
conversion from laparoscopic to open appendectomy; n=number of patients. Statistical analysis was performed for every surgical procedure between both
time frames and also between different surgical procedures within each time frame. Not applicable (n.a.), no wound infections occurred for LA during both
time frames.

89.5 months (range, 13–131 months) for OA, and 34 months
(range, 12–130 months) for CO. A significant increase in the
frequency of LA occurred from 2007 onward (Fig. 1).
2.2. Impact of surgical procedure on duration
of operation
LA and OA did not significantly differ (P = .392)
concerning the mean duration of the operations (72.9 ±
23.0 min for LA, 77.6±48.0 min for OA) (Fig. 2). In contrast,
CO resulted in a significantly longer operation (132.0±
39.4 min) in comparison to either LA (Pb.001) or OA
(P b.001). The results were consistent within both time
frames 2001–2007 and 2008–2010 (Table 2).
2.3. Impact of surgical procedure on adhesiolysis
caused by bowel obstruction
Redo surgery for adhesiolysis due to bowel obstruction
was necessary after 3 OA at 37, 1771 and 1859 days and in
only 1 CO at 21 days postoperatively (Fig. 3A). In our series,
adhesiolysis did not occur after LA. In contrast, most re-
admissions for observation due to abdominal pain as well as
for redo surgery as a consequence of intra-abdominal abscess
or wound infection occurred within the first 30 postoperative
days (Fig. 3B).
2.4. Impact of surgical procedure on re-admission,
re-operation, abscess formation, and wound infection
We analyzed the incidence of LA and OA per year between
2001 and 2010 (Fig. 1) and, as expected found a decrease in
OA and increase in LA from 2007 to 2010. Subsequently, the
data were divided in two time frames: 2001–2007 and 2008–
2010 (Table 2) and compared with respect to the incidence of
complications (re-admissions, re-operations, intra-abdominal
abscesses, and wound infections) for LA vs. OA, LA vs. CO,
and OA vs. CO. From 2001 to 2007, 8 LA were compared with
116 OA and 8 CO. From 2008 to 2010, 67 LA were compared
with 6 OA and 16 CO. Additionally, for every surgical
procedure statistical differences between the time frames
2001–2007 and 2008–2010 were excluded for every compli-
cation parameter (Table 2).

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Laparoscopic appendectomy for perforated appendicitis 559

Fig. 3 Impact of the follow-up period on complications and on frequency of adhesiolysis. The postoperative duration in days until re-
admission for observation, abscess treatment, wound revision, or adhesiolysis was plotted for the entire observation period (A) and for the first
50 postoperative days (B inlay). The vertical line in panel B marks the first 30 postoperative days.

The incidence of re-admissions (Fig. 4) was lower for LA
(1.3%, 1/75) than for OA (12.3%, 15/122, P=.006). The re-
admission rate for CO (41.7%, 10/24) was higher than those
of both LA (P=.000) and OA (P=.002).
The incidence of re-operations (Fig. 4) was lower for LA
(4%, 3/75) than for OA (17.2%, 21/122, P=.006). The re-
operation rate for CO (37.5%, 9/24) was higher than for both
LA (P =.000) and OA (P=.049).
The incidence of intra-abdominal abscesses (Fig. 4) was
not significantly lower for LA (4%, 3/75) than for either OA
(11.5%, 14/122, P=.114) or CO (12.5%, 3/24, P=.151), but
demonstrated a trend toward fewer abscesses. OA and CO
did not differ (P=1.000).
The incidence of wound infections (Fig. 4) was lower for
LA (0%, 0/75) than for both OA (11.5%, 14/122, P=.001)
and CO (29.2%, 7/24, Pb.001). OA also had a significantly
lower rate of wound infections compared to CO (P=.049).
3. Discussion
A number of investigators have described the advantages
of LA, including reduced abdominal scarring, less postop-
erative pain, and earlier recovery [1,6–9]. Despite the
multitude of relevant publications—including prospective
randomized studies, meta-analyses, and systematic critical
reviews—the optimal surgical choice between LA and OA
for children with perforated appendicitis has still not been
fully clarified [4,10]. Furthermore limited information is
available concerning the impact of conversion from LA to
OA with regard to complications in children. The present
clinical study was designed to retrospectively compare LA
with OA and CO in children with perforated appendicitis in
our pediatric surgery department.
In contrast to previous reports showing a longer operative
time for LA compared with OA in perforated appendicitis
[4,9–13], we did not observe any difference in the duration
of operation in our cohort. This result validates the
observations of Vernon et al. [14], who reported no
difference between LA and OA, neither in operative time
nor in total patient time in the operating room. Increased
experience of the surgeon with LA could explain the lack of a
significant difference in operative time for perforated
appendicitis, as reported by prior studies [6,15].
An advantage of LA over open procedures is the
reduced frequency of adhesiolysis. Re-operations for
adhesiolysis due to bowel obstruction occurred predomi-
nantly beyond 30 postoperative days. This complication

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560 M.R. Vahdad et al.

Fig. 4 Impact of surgical procedure on re-admission, re-operation, abscess formation, and wound infection. Patients underwent laparoscopic
appendectomy (LA), open appendectomy (OA), or conversion from laparoscopic to open appendectomy (CO). Patients were evaluated to
determine whether they fulfilled the conditions for re-admission, re-operation, abscess formation, and wound infection. The clustered bars
represent the percentage of patients having the same complication among all patients who underwent the same surgical procedure. *Pb.05,
**Pb.01, ***Pb.001.

was encountered in our series exclusively after initial open
procedures. We elected to divide the complications into re-
admissions, re-operations, intra-abdominal abscess forma-
tion, and wound infections.
We chose 2007 as the cut-off point between the time
frames 2001–2007 and 2008–2010, because in 2007 the
policy in our department changed, with COs performed
routinely until 2007 if suppuration was visualized intra-
abdominally but more recently was indicated only upon
inability to continue with LA. Accordingly, the evaluation of
our surgical procedures per year revealed a change in the
frequencies of LA and OA from 2007 onward. From 2001 to
2007 most appendectomies were OA, while LA was
predominantly performed thereafter.
For each parameter, we excluded differences between time
frames. To avoid a statistical bias arising from the different
sample sizes, we chose to pool both time frames to achieve a
more robust statistical analysis for re-admissions, re-opera-
tions, intra-abdominal abscesses, and wound infections.
The re-admission rate was reduced after LA compared
with OA, confirming the results of prior studies [13,16].
The role of LA has been somewhat more controversial
regarding the occurrence of intra-abdominal abscesses. A
number of reports in the recent literature have emphasized
the increased occurrence of postoperative intra-abdominal
abscess formation after LA [17–21]. While a Cochrane
review from 2010 reported a nearly threefold increase in
intra-abdominal abscess formation after LA compared with
OA [2] for suspected appendicitis, a meta-analysis from
2010 [10] observed a trend toward higher abscess rate after
LA, which failed to achieve statistical significance. In
contrast, several recent studies have suggested that LA is
safer [4] or equivalent [6,9,10,22] to OA in cases of
appendicitis with regard to intra-abdominal abscess forma-
tion. One of the reasons for the discrepancy in the rate of
intra-abdominal abscess formation may be that most
reported studies lack a clear definition for the term
“perforated appendicitis” [5]. This deficiency makes a
uniform analysis of the impact of the surgical procedure on
complication rates difficult.
As proposed previously [5], we retrospectively included
patients with perforated appendicitis based on standardized
features such as a hole in the appendix, fecalith, or intra-
abdominal abscess observed during the operation and
histological confirmation of the perforation. We observed a
trend toward a lower rate of intra-abdominal abscesses after
LA compared to OA, although it did not reach statistical
significance. There is no clear explanation for this result;
however, our general perioperative scheme of antibiotic
therapy may assist in reducing the rate of intra-abdominal
abscesses after LA. Our abscess rate of 4% was lower than
the rates of 19% and, 20%, respectively, after either
intravenous ceftriaxone and metronidazole once daily for
5 days or oral amoxicillin/clavulanate when tolerating a
regular diet to complete 7 days, as published by Fraser et al.
[23]. We did not use interventional radiology to drain the

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Laparoscopic appendectomy for perforated appendicitis
abscess followed by delayed surgery but instead, chose to
drain the abscess during one operative procedure.
Our results clearly indicate that LA reduces the incidence
of wound infections when compared to OA. This finding
concurs with most published studies [4,10,11,13,24]. One
reason for this outcome is the minimally invasive approach
of LA, with incisions limited to trocar entry sites, and
extraction of the perforated appendix occurring without
contact with the wounds. The 0% rate of wound infection in
patients who underwent LA in our study is a strong argument
in favor of the procedure. Wound infections and their side
effects, such as secretion, appearance of pus and repeated
painful bandage change traumatize children, their parents,
and medical personnel. Additionally, wound infections have
a negative influence on cosmesis, which has gained
increasing importance, and is time-consuming for the
medical community.
Our results underscore the importance of avoiding
conversions. In this study, we observed a conversion rate
of 24%, which is slightly higher than the published range of
0–23.04% [10]. One reason for this outcome is that until
2007, CO was performed routinely if pus was visualized
intra-abdominally. Since 2007, however, the only indication
for CO has been the inability to continue with LA. Moreover,
the duration of the study was influenced by the learning
curve for the LA procedure in our department. A similar
institutional bias has been identified in other long-term
studies evaluating new surgical techniques [22]. However,
the results from our data suggest that conversions should be
avoided whenever possible, since they carry an increased
risk of re-admissions, re-operations, and occurrence of
wound infections compared to either LA or OA.
The 0% rate of wound infections and adhesiolysis also led
to a reduced rate of re-operations for LA compared to OA
and CO.
Laparoscopic appendectomy for perforated appendicitis
in children has a comparable complication rate to that of
open appendectomy. In our data, LA reduced the incidence
of re-admissions, re-operations, wound infections and
adhesiolysis in comparison to OA. Conversions from LA
to OA, however, should be avoided wherever possible, as
they lead to a higher incidence of all complications, except
for intra-abdominal abscesses, compared to LA.
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