RESULTS OF MINIMALLY INVASIVE VERSUS OPEN APPROACHES IN PEDIATRIC APPENDICITIS: A SYSTEMATIC REVIEW
DOI:
https://doi.org/10.56238/levv17n58-005Keywords:
Appendicitis, Laparoscopy, Pediatric Surgery, Minimally Invasive Surgical ProceduresAbstract
Introduction: Acute appendicitis is the most common surgical emergency in children and remains a major cause of hospital admission and perioperative morbidity worldwide. Over recent decades, laparoscopic appendectomy has increasingly replaced open appendectomy in pediatric practice, yet uncertainty persists regarding comparative outcomes in uncomplicated and complicated disease.
Objective: The primary objective of this systematic review was to compare clinical outcomes of minimally invasive appendectomy versus open appendectomy in pediatric patients with acute appendicitis. Secondary objectives were to evaluate differences in postoperative complication rates, length of hospital stay, operative time, readmission, cost-related outcomes, and patient-centered recovery metrics.
Methods: A systematic search was conducted in PubMed, Scopus, Web of Science, Cochrane Library, LILACS, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. Comparative studies published within the last five years involving pediatric populations were included. Risk of bias was assessed using RoB 2 and ROBINS-I tools, and certainty of evidence was evaluated using the GRADE framework.
Results and Discussion: Twenty comparative studies were included in the final synthesis. Minimally invasive appendectomy was consistently associated with reduced wound infection rates, shorter hospital stay, and improved postoperative recovery metrics compared with open appendectomy. Intra-abdominal abscess rates were generally comparable between approaches, including in complicated appendicitis. Operative time was frequently longer with laparoscopy, but this did not translate into increased morbidity or readmission. Certainty of evidence was moderate for reductions in length of stay and surgical site infection, and low-to-moderate for organ-space infection due to heterogeneity across studies.
Conclusion: Contemporary evidence supports laparoscopic appendectomy as the preferred approach in most pediatric appendicitis cases when appropriate expertise is available. Benefits in recovery and wound morbidity appear robust across disease severities, while serious complication rates remain comparable to open surgery. Surgical decision-making should remain individualized, integrating disease severity, institutional capability, and multidisciplinary care pathways.
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References
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3 Botchway, A., et al. (2021). Laparoscopic appendectomy in children: Impact of surgeon experience on outcomes. Pediatric Surgery International, 37(9), 1207–1214. https://doi.org/10.1007/s00383-021-04902-1
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10 Fourie, C., Theron, A., Millar, A. J. W., et al. (2022). Complicated appendicitis in children: Outcomes of laparoscopic versus open appendectomy. Pediatric Surgery International, 38(5), 657–665. https://doi.org/10.1007/s00383-022-05089-9
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14 Kumar, S. S., et al. (2024). SAGES guideline for the diagnosis and treatment of appendicitis. Surgical Endoscopy, 38(3), 1501–1520. https://doi.org/10.1007/s00464-023-10342-7
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17 Neogi, S., Choudhury, S. R., Mondal, S., et al. (2022). Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis. Journal of Pediatric Surgery, 57(3), 394–405. https://doi.org/10.1016/j.jpedsurg.2021.07.005
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22 Rolle, U., et al. (2021). Postoperative adverse events after pediatric appendectomy: Analysis of risk factors. European Journal of Pediatric Surgery, 31(6), 514–520. https://doi.org/10.1055/s-0041-1727284
23 Sermonesi, G., Coccolini, F., Catena, F., et al. (2023). WSES consensus on laparoscopic-first approach in emergency surgery. World Journal of Emergency Surgery, 18, 26. https://doi.org/10.1186/s13017-023-00480-6
24 Tanaka, Y., Uchida, H., Kawashima, H., et al. (2020). Laparoscopic versus open appendectomy in children with perforated appendicitis: Multicenter analysis. Pediatric Surgery International, 36(8), 913–920. https://doi.org/10.1007/s00383-020-04682-9
25 Zitouni, H., et al. (2024). Sex differences in pediatric appendicitis: Analysis of surgical outcomes. Frontiers in Pediatrics, 12, 1278453. https://doi.org/10.3389/fped.2024.1278453Alganabi, M., et al. (2021). Surgical site infection after open and laparoscopic appendectomy in children: A systematic review and meta-analysis. Journal of Pediatric Surgery, 56(6), 1122–1130. https://doi.org/10.1016/j.jpedsurg.2020.10.014
26 Almaramhy, H. H. (2021). Acute appendicitis in young children less than 5 years: Review article. Italian Journal of Pediatrics, 47(1), 15. https://doi.org/10.1186/s13052-021-00964-3
27 Botchway, A., et al. (2021). Laparoscopic appendectomy in children: Impact of surgeon experience on outcomes. Pediatric Surgery International, 37(9), 1207–1214. https://doi.org/10.1007/s00383-021-04902-1
28 Brucchi, F., et al. (2023). Nonoperative management of uncomplicated appendicitis in children: Systematic review and meta-analysis. Annals of Surgery, 277(2), e286–e294. https://doi.org/10.1097/SLA.0000000000005565
29 Doshi, N., et al. (2024). Risk of adhesive bowel obstruction after pediatric appendicitis: Systematic review. Journal of Pediatric Surgery, 59(3), 531–538. https://doi.org/10.1016/j.jpedsurg.2023.11.004
30 Duan, D., et al. (2024). Outcomes of pediatric laparoscopic appendectomy across training environments. Journal of Surgical Education, 81(1), e13–e20. https://doi.org/10.1016/j.jsurg.2023.08.012
31 Emil, S. (2022). Surgical management of pediatric appendicitis in the era of minimally invasive surgery. Seminars in Pediatric Surgery, 31(2), 151175. https://doi.org/10.1016/j.sempedsurg.2022.151175
32 Fadgyas, B., Monostori, G., Ori, D., & Vajda, P. (2024). Appendicitis in children: Correlation between surgical and histological diagnosis. Pediatric Surgery International, 40(1), 262. https://doi.org/10.1007/s00383-024-05846-2
33 Ferguson, D. M., Beaton, A. Z., Kelleher, D. C., et al. (2021). Clinical practice guideline adherence and outcomes in pediatric perforated appendicitis. Journal of Pediatric Surgery, 56(1), 123–129. https://doi.org/10.1016/j.jpedsurg.2020.06.008
34 Fourie, C., Theron, A., Millar, A. J. W., et al. (2022). Complicated appendicitis in children: Outcomes of laparoscopic versus open appendectomy. Pediatric Surgery International, 38(5), 657–665. https://doi.org/10.1007/s00383-022-05089-9
35 Fujishiro, J., Watanabe, E., Hirahara, N., et al. (2021). Laparoscopic versus open appendectomy for complicated appendicitis in children: A propensity score-matched analysis. Surgical Endoscopy, 35(7), 3619–3627. https://doi.org/10.1007/s00464-020-07878-0
36 Huerta, C. T., Oyetunji, T. A., Sirinek, K. R., et al. (2023). Nationwide management of perforated pediatric appendicitis: Interval versus same-admission appendectomy. Journal of Pediatric Surgery, 58(2), 294–301. https://doi.org/10.1016/j.jpedsurg.2022.09.021
37 Kiblawi, R., et al. (2022). Laparoscopic versus open pediatric appendectomy: Contemporary outcomes. European Journal of Pediatric Surgery, 32(1), 9–25. https://doi.org/10.1055/s-0041-1739418
38 Kumar, S. S., et al. (2024). SAGES guideline for the diagnosis and treatment of appendicitis. Surgical Endoscopy, 38(3), 1501–1520. https://doi.org/10.1007/s00464-023-10342-7
39 Lam, J. Y., Loewen, S., Atkinson, P., et al. (2021). Implementation of a fast-track protocol in pediatric appendicitis. Journal of Pediatric Surgery, 56(12), 2267–2274. https://doi.org/10.1016/j.jpedsurg.2021.06.025
40 Lee, S. L. (2020). Complicated appendicitis in children: Laparoscopic versus open approach. Journal of Pediatric Surgery, 55(5), 893–897. https://doi.org/10.1016/j.jpedsurg.2020.01.019
41 Neogi, S., Choudhury, S. R., Mondal, S., et al. (2022). Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis. Journal of Pediatric Surgery, 57(3), 394–405. https://doi.org/10.1016/j.jpedsurg.2021.07.005
42 Nehra, D., & Goldstein, S. D. (2021). Pediatric appendicitis: Current management and controversies. Surgical Clinics of North America, 101(1), 75–87. https://doi.org/10.1016/j.suc.2020.09.006
43 Omling, E., Salö, M., Saluja, S., et al. (2021). Nationwide cohort study of outcome after pediatric appendicitis. European Journal of Pediatric Surgery, 31(1), 9–16. https://doi.org/10.1055/s-0040-1710555
44 Pawelczyk, T., Dudek-Warchol, T., Kowalczyk, M., et al. (2021). Impact of the COVID-19 pandemic on appendicitis in children. Children, 8(6), 458. https://doi.org/10.3390/children8060458
45 Podda, M., Gerardi, C., Cillara, N., et al. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery, 15, 27. https://doi.org/10.1186/s13017-020-00306-3
46 Rolle, U., et al. (2021). Postoperative adverse events after pediatric appendectomy: Analysis of risk factors. European Journal of Pediatric Surgery, 31(6), 514–520. https://doi.org/10.1055/s-0041-1727284
47 Sermonesi, G., Coccolini, F., Catena, F., et al. (2023). WSES consensus on laparoscopic-first approach in emergency surgery. World Journal of Emergency Surgery, 18, 26. https://doi.org/10.1186/s13017-023-00480-6
48 Tanaka, Y., Uchida, H., Kawashima, H., et al. (2020). Laparoscopic versus open appendectomy in children with perforated appendicitis: Multicenter analysis. Pediatric Surgery International, 36(8), 913–920. https://doi.org/10.1007/s00383-020-04682-9
49 Zitouni, H., et al. (2024). Sex differences in pediatric appendicitis: Analysis of surgical outcomes. Frontiers in Pediatrics, 12, 1278453. https://doi.org/10.3389/fped.2024.1278453
