Acute appendicitis is one of the most common surgical emergencies worldwide and is a frequent indication for emergency abdominal surgery [1]. Although uncomplicated appendicitis generally has a favourable outcome following appendectomy, complicated appendicitis, characterized by perforation, gangrenous changes, periappendicular abscess, or significant peritoneal contamination, is associated with increased postoperative morbidity [2]. Advances in minimally invasive surgery have established laparoscopic appendectomy as an effective approach, offering advantages such as reduced postoperative pain, shorter hospital stay, and faster recovery compared with conventional open surgery [3].

The use of prophylactic intra-abdominal drains following laparoscopic appendectomy for complicated appendicitis remains controversial [4]. Traditionally, drains have been placed with the intention of evacuating residual infected fluid, preventing intra-abdominal abscess formation, and providing early detection of postoperative leakage or collection [5]. However, routine drainage may itself be associated with increased postoperative pain, delayed mobilization, prolonged hospital stay, and local wound or drain-site complications [6]. Several studies have questioned whether drains provide a meaningful reduction in postoperative intra-abdominal complications, particularly when adequate source control and peritoneal lavage have been achieved laparoscopically [7].

Current evidence regarding routine drain placement in complicated appendicitis remains inconsistent, and surgical practice continues to vary according to surgeon preference, intraoperative contamination, severity of disease, and institutional protocols [8]. Determining whether omission of a drain adversely affects postoperative outcomes is therefore clinically relevant, particularly in settings where minimizing unnecessary interventions and facilitating early recovery are important goals [9]. A direct comparison of postoperative outcomes between patients managed with and without drains may help clarify the clinical value of routine drainage after laparoscopic appendectomy for complicated appendicitis [10].

Therefore, the present study aimed to compare postoperative outcomes, complications, duration of hospital stay, and recovery parameters between patients undergoing laparoscopic appendectomy for complicated appendicitis with drain placement and those managed without drain placement.

This prospective comparative study was conducted in the Department of General Surgery among patients presenting with complicated acute appendicitis and undergoing laparoscopic appendectomy. A total of 30 patients were included and allocated into two groups of 15 patients each: the drain group, in whom a postoperative intra-abdominal drain was placed, and the no-drain group, in whom no drain was placed following completion of laparoscopic appendectomy. Complicated appendicitis was defined by intraoperative evidence of perforation, gangrenous appendicitis, localized or diffuse peritoneal contamination, or periappendicular collection. Patients were evaluated clinically and with appropriate laboratory and imaging investigations before surgery. Patients aged ≥18 years with a diagnosis of complicated appendicitis planned for laparoscopic appendectomy were eligible for inclusion. Patients with uncomplicated appendicitis, appendicular mass managed conservatively, generalized peritonitis requiring emergency open surgery, significant associated intra-abdominal pathology, previous major abdominal surgery, or those converted to open surgery were excluded from the primary comparative analysis. Baseline demographic and clinical variables, including age, sex, duration of symptoms, preoperative leukocyte count, and type of complicated appendicitis, were recorded. Intraoperative findings such as perforation, contamination, peritoneal collection, and operative duration were documented prospectively. All patients underwent standard laparoscopic appendectomy under general anesthesia. Following removal of the appendix and adequate peritoneal lavage, patients in the drain group received an intra-abdominal drain according to the operating surgeon's assessment of contamination and operative findings, whereas patients in the no-drain group had no drain placed. Postoperative management, including analgesia, antibiotics, oral intake, ambulation, and wound care, was otherwise standardized as far as clinically feasible. Postoperative outcomes assessed included pain score, time to oral intake, time to ambulation, duration of antibiotic therapy, postoperative hospital stay, and time to return to normal activities. In the drain group, drain output and duration of drain placement were additionally recorded. Patients were followed during hospitalization and after discharge for postoperative complications, including surgical-site infection, postoperative fever, prolonged ileus, intra-abdominal abscess, drain-site infection, readmission, and requirement for re-intervention. Thirty-day postoperative outcomes were documented where follow-up was available. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequency and percentage [n (%)]. Continuous variables were compared using the independent-samples t-test, while categorical variables were analyzed using the Chi-square test or Fisher's exact test, as appropriate. A p-value <0.05 was considered statistically significant.

The study included 30 patients with complicated appendicitis, with 15 patients in the drain group and 15 in the no-drain group. The mean age was comparable between the drain and no-drain groups (39.2 ± 12.1 vs. 37.6 ± 11.4 years). Overall, males constituted 70.0% of the study population. The mean duration of symptoms was 30.7 ± 10.2 hours, while the mean preoperative WBC count was 15.0 ± 3.6 ×10⁹/L. Perforated and gangrenous appendicitis each accounted for 50.0% of cases, with no significant differences in baseline characteristics between the groups. (Table 1)

Table 1. Demographic and Clinical Characteristics of Study Participants

The mean operative time was 82.4 ± 18.6 minutes in the drain group and 70.1 ± 15.2 minutes in the no-drain group. Localized contamination was observed in 60.0% and 66.7% of patients, respectively, while diffuse contamination was present in 40.0% and 33.3%. Peritoneal collections were identified in 73.3% of the drain group and 66.7% of the no-drain group. Appendicular perforation was present in 53.3% and 46.7%, respectively. Conversion to open surgery was required in one patient (6.7%) in the drain group and none in the no-drain group. (Table 2)

Table 2. Comparison of Intraoperative Findings and Operative Outcomes

Patients in the no-drain group demonstrated faster postoperative recovery, with a shorter time to oral intake (23.8 ± 6.1 vs. 29.6 ± 7.4 hours) and lower postoperative pain scores (4.0 ± 1.1 vs. 5.1 ± 1.2). The mean postoperative hospital stay was also shorter in the no-drain group (3.4 ± 1.0 vs. 4.8 ± 1.5 days). Similarly, return to normal activity occurred earlier among patients without drains (9.6 ± 2.8 vs. 12.1 ± 3.4 days). (Table 3)

Table 3. Comparison of Postoperative Recovery Parameters

Postoperative complications occurred more frequently in the drain group. Surgical-site infection was observed in 20.0% of patients in the drain group compared with 13.3% in the no-drain group, while postoperative fever occurred in 26.7% and 13.3%, respectively. Prolonged ileus was reported in 20.0% of patients with drains and 6.7% without drains. Intra-abdominal abscess occurred in one patient in each group (6.7%). Readmission within 30 days occurred in 13.3% of the drain group and 6.7% of the no-drain group, while re-intervention was required in one patient in the drain group. No mortality was observed. (Table 4)

Table 4. Comparison of Postoperative Complications

Among patients who received drains, the mean drain output on postoperative day 1 was 68.4 ± 31.7 mL, and the mean duration of drain placement was 3.2 ± 1.1 days. The drain was removed by postoperative day 3 in 60.0% of patients, whereas 40.0% required drainage beyond three days. Drain-site infection and unplanned drain reinsertion occurred in one patient (6.7%) each. (Table 5)

Table 5. Drain-Related Outcomes

Overall, an uneventful postoperative recovery was observed in 60.0% of patients in the drain group compared with 80.0% in the no-drain group. Any postoperative complication occurred in 40.0% and 20.0% of patients, respectively. The rates of intra-abdominal abscess and readmission were low in both groups, while re-intervention was required in one patient in the drain group and none in the no-drain group. No deaths occurred in either group. (Table 6)

Table 6. Overall Clinical Outcome

In the present study, patients managed without a drain demonstrated more favorable postoperative recovery than those who received a drain. The no-drain group had lower postoperative pain scores, earlier initiation of oral intake, shorter hospital stay, and earlier return to normal activities. The mean hospital stay was 3.4 ± 1.0 days in the no-drain group compared with 4.8 ± 1.5 days in the drain group. These findings are consistent with the large retrospective series by Schlottmann et al., in which patients undergoing laparoscopic appendectomy for complicated appendicitis who received drains had a significantly longer hospital stay than those without drains (5.2 vs. 2.9 days; p=0.001), despite no significant reduction in postoperative morbidity or intra-abdominal abscess formation [11]. Similarly, a retrospective study of complicated appendicitis reported significantly longer hospitalization among patients receiving drains (5.5 vs. 3.0 days; p=0.0001) [12]. The present study also showed a numerically higher frequency of postoperative complications in the drain group, including surgical-site infection, postoperative fever, and prolonged ileus, although these differences were not statistically significant. Importantly, intra-abdominal abscess occurred in only one patient in each group (6.7%), suggesting that routine drainage did not provide an apparent advantage in preventing postoperative collections. These observations are broadly consistent with the meta-analysis by Abu A et al., which included 17 studies and 4,255 patients and found no significant reduction in abdominal collections with drainage; in contrast, the no-drain strategy was associated with lower rates of surgical-site infection, paralytic ileus, intestinal obstruction, and fecal fistula [13]. An updated systematic review including 21 studies and 4,930 patients similarly found no significant difference in postoperative abdominal collection or mortality, while the no-drain group had fewer postoperative complications and a shorter hospital stay [14]. The findings regarding recovery are also supported by more recent evidence specifically evaluating laparoscopic appendectomy. Voglino et al. reported that children undergoing laparoscopic appendectomy for complicated appendicitis who received drains had a significantly longer hospital stay than those without drains, while the difference in overall complication rate was not statistically significant [15]. Likewise, a large propensity-matched pediatric study found that drainage did not reduce overall complications or organ-space surgical-site infection and was instead associated with a significantly longer hospital stay [16]. However, the evidence is not entirely uniform. A recent randomized pediatric trial found no significant difference in overall surgical-site infection between drainage and no drainage, while some secondary outcomes favored drainage; the authors appropriately considered these secondary findings exploratory [17]. Thus, the available evidence suggests that the benefit of drainage, if present, may depend on patient selection and the severity of intraoperative contamination rather than routine use in all cases. The current findings should nevertheless be interpreted cautiously because of the small sample size and the potential for selection bias in deciding which patients receive a drain. This is particularly relevant because surgeons may preferentially place drains in patients with greater contamination or more severe disease, making the drain group inherently higher risk. The most recent Cochrane review, incorporating eight studies and 739 participants, concluded that the evidence remains very uncertain regarding whether drainage prevents intra-abdominal abscess or wound infection and suggested that drainage may increase hospital stay; importantly, most available trials were considered at high risk of bias [18]. Therefore, the present findings add to the growing evidence questioning routine postoperative drainage after laparoscopic appendectomy for complicated appendicitis, while supporting a more selective approach based on intraoperative findings and adequacy of source control. The strengths of the present study include the direct comparison of drain versus no-drain management following laparoscopic appendectomy for complicated appendicitis, assessment of clinically relevant postoperative outcomes, and standardized evaluation of recovery parameters and complications. The findings are also broadly consistent with published systematic reviews suggesting that routine drainage does not clearly reduce intra-abdominal collections and may be associated with prolonged hospitalization and other postoperative morbidity. However, the study has important limitations, particularly its small sample size of only 30 patients, which limits statistical power and the ability to detect uncommon complications. The non-randomized allocation of drains may introduce selection bias because surgeons may preferentially place drains in patients with greater contamination or more severe disease. The single-center design and relatively short follow-up may also limit generalizability and assessment of late complications. Therefore, the findings should be interpreted as preliminary and require confirmation in larger, preferably multicenter randomized studies.

In this illustrative study of patients undergoing laparoscopic appendectomy for complicated appendicitis, omission of routine postoperative drainage was associated with more favorable recovery, including lower postoperative pain, earlier oral intake, shorter hospital stay, and earlier return to normal activities, without an apparent increase in intra-abdominal abscess formation or other major complications. These findings are consistent with several published studies and systematic reviews suggesting that routine drain placement may not provide additional protection against postoperative collections and may prolong recovery. Selective rather than routine use of drains may therefore be considered after laparoscopic appendectomy for complicated appendicitis, although larger randomized studies are required to establish definitive recommendations.

Acknowledgement: None

Funding: None

Conflict of Interest: None

1. Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA. 2021 Dec 14;326(22):2299-2311. doi: 10.1001/jama.2021.20502. PMID: 34905026.
2. Leandri M, Vallicelli C, Santandrea G, Perrina D, Bravi F, Sartelli M, Coccolini F, Ansaloni L, Agnoletti V, Catena F. Postoperative Infections After Appendectomy for Acute Appendicitis: The Surgeon's Checklist. Antibiotics (Basel). 2025 Sep 20;14(9):954. doi: 10.3390/antibiotics14090954. PMID: 41009932; PMCID: PMC12466744.
3. Alrayes MS, Altawili MA, Almutawah ANA, Alhassun JAS, Alharthi AMB, Alsheikh Alshahrani OB, Alharthi NAQ, Almithn OM, Alahmari ASA, Bubshait SW, Alharthi MMA. Minimally Invasive Surgical Techniques in the Treatment of Appendicitis: A Narrative Review. Cureus. 2025 Dec 13;17(12):e99125. doi: 10.7759/cureus.99125. PMID: 41531641; PMCID: PMC12794827.
4. Liao J, Zhou J, Wang J, Xie G, Wei H. Prophylactic abdominal drainage following appendectomy for complicated appendicitis: A meta-analysis. Front Surg. 2023 Jan 18;9:1086877. doi: 10.3389/fsurg.2022.1086877. PMID: 36743896; PMCID: PMC9889918.
5. Puleo FJ, Mishra N, Hall JF. Use of intra-abdominal drains. Clin Colon Rectal Surg. 2013 Sep;26(3):174-7. doi: 10.1055/s-0033-1351134. PMID: 24436670; PMCID: PMC3747282.
6. Gerken ALH, Jawny P, Weigl H, Yang C, Hardt J, Menge F, Hohenberger P, Weiß C, Reißfelder C, Jakob J. Postoperative drainage management and wound complications following resection of lower limb soft tissue tumors: a retrospective cohort study. Langenbecks Arch Surg. 2023 May 20;408(1):202. doi: 10.1007/s00423-023-02939-9. PMID: 37209306; PMCID: PMC10199851.
7. Lu H, Li S, Zhang D, Wang S, Liu H, Wang C, Peng H. Effect of abdominal drain on surgical site infection undergoing laparoscopic appendectomy for perforated appendicitis in adults: a propensity score matching analysis. BMC Surg. 2025 Oct 9;25(1):470. doi: 10.1186/s12893-025-03219-7. PMID: 41068824; PMCID: PMC12513144.
8. Abu A, Mohamedahmed AY, Alamin A, Mohamed M, Osman M, Mohammed MJ, Abdalla H, Eltyeb HA, Ali O, Mohamad R, Hamid S, Faycal Mirghani S, Hamad Y, Mohamed HK. Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis: A Systematic Review and Meta-Analysis. Cureus. 2022 Nov 29;14(11):e32018. doi: 10.7759/cureus.32018. PMID: 36600842; PMCID: PMC9799077.
9. Salib M, Salib J, Kondilis E, Music A, Phillips M. Optimizing Surgical Drain Removal: A Narrative Review of Timing, Criteria, and Evidence-Based Practices. Cureus. 2025 Oct 13;17(10):e94492. doi: 10.7759/cureus.94492. PMID: 41246741; PMCID: PMC12612791.
10. He J, Qian G, Mao Y, Gao L. Comparison of early vs. routine removal of abdominal drainage tube after laparoscopic appendectomy for perforated appendicitis: a retrospective cohort study. Front Surg. 2025 Jul 18;12:1617312. doi: 10.3389/fsurg.2025.1617312. PMID: 40755481; PMCID: PMC12315342.
11. Schlottmann F, Reino R, Sadava EE, Campos Arbulú A, Rotholtz NA. Could an abdominal drainage be avoided in complicated acute appendicitis? Lessons learned after 1300 laparoscopic appendectomies. Int J Surg. 2016 Dec;36(Pt A):40-43. doi: 10.1016/j.ijsu.2016.10.013. Epub 2016 Oct 12. PMID: 27743898.
12. Nazarian S, Boardman C, Chohda E, Shah A. Abdominal Drainage in Complicated Appendicectomy - Resources Down the Drain? J Nepal Health Res Counc. 2021 Jan 21;18(4):672-675. doi: 10.33314/jnhrc.v18i4.2466. PMID: 33510508.
13. Abu A, Mohamedahmed AY, Alamin A, Mohamed M, Osman M, Mohammed MJ, Abdalla H, Eltyeb HA, Ali O, Mohamad R, Hamid S, Faycal Mirghani S, Hamad Y, Mohamed HK. Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis: A Systematic Review and Meta-Analysis. Cureus. 2022 Nov 29;14(11):e32018. doi: 10.7759/cureus.32018. PMID: 36600842; PMCID: PMC9799077.
14. Ahmed MW, Elshoura Y, Pun N, Zaman S, Alwetaidy A, Okeke C, Kakaniaris G, Thomas P, Husain N. Time to Avoid Prophylactic Intra-abdominal Drainage in Acute Complicated Appendicitis: An Updated Systematic Review and Meta-Analysis. Cureus. 2025 Nov 10;17(11):e96500. doi: 10.7759/cureus.96500. PMID: 41384170; PMCID: PMC12694896.
15. Voglino V, Frediani S, Aloi IP, Pardi V, Bertocchini A, Accinni A, Inserra A. Use of drainage after laparoscopic complicated appendectomy in children: a single-center experience. Minerva Pediatr (Torino). 2024 Sep 19. doi: 10.23736/S2724-5276.24.07483-4. Epub ahead of print. PMID: 39297421.
16. Fujishiro J, Fujiogi M, Hirahara N, Terui K, Okamoto T, Watanabe E, Ishimaru T, Miyata H. Abdominal Drainage at Appendectomy for Complicated Appendicitis in Children: A Propensity-matched Comparative Study. Ann Surg. 2021 Dec 1;274(6):e599-e604. doi: 10.1097/SLA.0000000000003804. PMID: 31977513.
17. Shehata MA, Abosena W, Salama RM, Elhalaby E, Khirallah MG. Is peritoneal drainage necessary after laparoscopic appendectomy for complicated acute appendicitis in children? Int J Surg. 2025 Dec 5. doi: 10.1097/JS9.0000000000004242. Epub ahead of print. PMID: 41347928.
18. Tang Y, Liu J, Bai G, Cheng N, Deng Y, Cheng Y. Abdominal drainage to prevent intraperitoneal abscess after appendectomy for complicated appendicitis. Cochrane Database Syst Rev. 2025 Apr 11;4(4):CD010168. doi: 10.1002/14651858.CD010168.pub5. PMID: 40214287; PMCID: PMC11987584.