Introduction of minimal invasive surgery made a revolution in the surgical practice as it provides many advantages over conventional surgeries. LA has been reported as the best choice for managing uncomplicated pediatric appendicitis for many benefits such as early return to physical activity, reduced postoperative pain, and decreased postoperative complications. But, as regards complicated appendicitis, it shows controversy to take the decision of performing laparoscopy as distorted anatomy and severe inflammation are challenging [9, 16, 17].
Many studies reported the superiority of laparoscopy regarding surgical site infection, regaining of oral intake, length of hospital stay, and cosmesis. On the other hand, slight higher rates of intra-abdominal infection, increased costs, and increased operative time are also recorded, but with more experience, laparoscopic surgery could become faster than open one [18, 19].
The operative time was significantly longer with LA than OA by 23.48 min that was nearly similar to many published literature [7, 9, 20,21,22]. These results could be explained as laparoscopic approach needs more experience, skills, and training. Also dealing with complicated appendicitis needs meticulous dissection which needs furthermore skills and training.
The need for intraperitoneal drain insertion was significantly lower with LA than OA (p = 0.001). This significance was also reported by Horvath et al. [23]; we explained that the laparoscopic technique offers a good vision to the entire abdomen and that enables the surgeon to achieve a careful suction from every quadrant having collections.
Conversion from laparoscopic to OA occurred with 2 cases included in this study (6.7%); one of them, the appendix was inaccessible due to extensive adhesions, and the other was perforated closely to the cecum, and it was difficult to ligate the appendix. This rate of conversion was nearly the same with that published by Thomson et al. [24] which occurred with 5% of their cases. Other publications reported fewer rate of conversion from laparoscopic to open, such as Kassem et al. [25] who reported the conversion to open in 2.4% of cases. This rate may differ according to the severity of the individual case. Additionally, using “Ligasure®, Covidien, USA” was reported to decrease the rate of conversion to open, especially in case of gangrenous tissue [16].
The time taken to start oral intake was significantly shorter after LA than OA by 0.47 days, which was comparable to other published studies [9, 25]. This could be explained by the advantages of the laparoscopic technique which is less traumatic to the abdominal wall and peritoneal cavity, associated with lower chance for introducing foreign bodies, provides better ability for hemostasis and associated with quicker return of bowel motility.
The present study showed that the hospital stay was significantly shorter after LA than OA by (0.9 day), which was nearly similar to that reported by Xuan et al. in their meta-analysis [17] and also the recent Cochrane systemic review which was (0.8 day) in favor of LA [18]. These results could be explained as LA is associated with less surgical stress, early mobilization, early oral intake, and less postoperative pain.
Most of recent studies have reported the benefits of LA over OA regarding wound infection [7]. However, in this study, the rate of postoperative wound infection was not significantly different between the two groups (p = 0.542), but incidence rate was still lower after LA than OA (20% vs. 26% respectively), which was comparable to Lin et al. [26] and Khirallah et al. [20]. On the other hand, some studies reported a significant decrease in the incidence of wound infection with LA, such as Xuan et al. [17]. These results could be explained that they protect the extraction site of the appendix during LA by using retrieval bag, which was not used in our study.
Formation of postoperative intraperitoneal collection is one of the issues that had shown controversy. Many earlier studies mentioned a major concern about increasing rate of incidence after LA, such as Horwitz et al. [27] who reported the occurrence of postoperative intraperitoneal collection after 9% of OA cases vs. 41% of LA cases. Also Krisher et al [28] and Thomson et al [24] reported nearly similar results. With increasing the experience in using LA in pediatric complicated appendicitis, many recent studies such as Vahdad et al [29] and a meta-analysis performed by Xuan et al [17] proved that there was no significant difference between the two techniques in formation of postoperative intraperitoneal collection, which was aligning with our results. On the other hand, Khirallah et al. reported a significant increasing rate of postoperative intraperitoneal collection after OA (28.4%) and LA (7%) [20]. This controversy could not be explained only as a result of the operative technique, but there were other external factors that could influence the results, such as the level of experience of the surgeon, the severity of inflammation, the degree of intraperitoneal contamination, the time of diagnosis, and the time of intervention [17].
The incidence of postoperative ileus was higher after OA than LA (6.3% vs. 3.3% respectively); however, this difference was not statistically significant. This was comparable to other published studies [17, 30]. The reduced incidence of postoperative ileus after LA could be explained due to reduced manipulation of the bowel with hands, minor abdominal trauma, and less postoperative pain.
There were 3 cases of readmission in this study, 2 of them occurred after OA (6.3%); one was due to ileus, and the other was due to intraperitoneal collection. The third case occurred after LA (3.3%) due to intraperitoneal collection. All these cases were managed conservatively. There was no significant difference between the two groups regarding readmission (p > 0.999) and that was nearly similar to other publications [7, 12, 17].
