Acute appendicitis is the most common reason for emergency abdominal surgery in children and leads to many hospital admissions around the world [1,2]. About 7-10% of people will have appendicitis at some point in their lives, with the highest rates seen in teenagers and young adults [3]. For children, quick surgery is important to avoid serious problems like perforation, peritonitis, and intra-abdominal abscess, which can greatly raise the risk of illness and death [4,5]. For more than a hundred years, open appendectomy, first done by McBurney in 1889, has been the main surgical treatment for acute appendicitis [6]. In this procedure, the surgeon removes the inflamed appendix through a small cut in the lower right side of the abdomen. It has remained popular because it is simple, effective, and has a low risk of complications [7]. Over the last thirty years, surgery has changed a lot with the introduction of minimally invasive methods. Laparoscopic appendectomy, first described by Semm in 1983, is now widely used for both adults and children [8]. This method has several benefits over open surgery, such as less pain after the operation, shorter hospital stays, quicker recovery, better cosmetic results, and possibly fewer wound infections [9,10]. Laparoscopy also helps confirm the diagnosis when it is unclear and allows the surgeon to check the whole abdomen [11]. Still, there are some concerns about using laparoscopic appendectomy in children. These include longer surgery times, which can affect how operating rooms are used and increase costs [12], higher expenses for special equipment in places with limited resources [13], technical difficulties that require more training [14], and ongoing debate about the risk of intra-abdominal abscess after laparoscopic surgery for complicated cases [15,16]. In many low- and middle-income countries, it is also hard to always have the needed equipment and trained staff [17]. Research, including meta-analyses and randomized trials, has generally shown that laparoscopic appendectomy is at least as safe as open surgery for children and often leads to better short-term results [18,19]. A Cochrane review found that laparoscopic appendectomy leads to shorter hospital stays and less pain after surgery, with similar complication rates [20]. Large studies from multiple centers have confirmed these results in children [21]. However, the outcomes can depend a lot on the hospital’s experience, the surgeon’s skills, and the resources available. In large hospitals in developing countries, where resources may be limited but many surgeries are performed, it is important to have local data to guide practice [22]. This information is especially valuable in areas where using laparoscopy is limited by cost, training, or equipment. The best surgical approach may also depend on the child’s condition, as those with more severe appendicitis may face different risks and benefits compared to those with milder cases [23]. The Department of Pediatric Surgery at Saidu Teaching Hospital in Khyber Pakhtunkhwa, Pakistan, treats many children with surgical emergencies, including acute appendicitis. While laparoscopic appendectomy is being used more often along with the open method, there has not been enough data comparing the outcomes of both approaches in this setting. This study aims to compare the patient characteristics, surgery details, and results after surgery for laparoscopic and open appendectomy in children, and to provide local evidence to help guide surgical decisions in hospitals with limited resources.

This comparative observational study was conducted at the Department of Pediatric Surgery, Saidu Teaching Hospital, Saidu Sharif, Swat, Pakistan, from August 16 to December 11, 2024. The study included 411 consecutive pediatric patients (≤18 years) with a confirmed diagnosis of acute appendicitis who underwent surgical intervention. Patients were allocated to two groups based on surgical approach: laparoscopic appendectomy (n=238) and open appendectomy (n=173), with the choice of approach determined by the attending surgeon based on patient factors, disease characteristics, and equipment availability. Inclusion criteria comprised age ≤18 years, clinical features suggestive of acute appendicitis (right lower quadrant pain, fever, nausea/vomiting, anorexia, rebound tenderness), radiological confirmation via ultrasound or CT scan demonstrating typical findings (appendiceal diameter >6 mm, non-compressible appendix, periappendiceal fat stranding, or appendicolith), and complete medical records. Exclusion criteria included generalized peritonitis requiring formal laparotomy, interval appendectomy, significant comorbid conditions affecting surgical outcomes, incomplete records, and previous abdominal surgery. Data were collected retrospectively from hospital records, operative notes, and follow-up logs using a standardized proforma capturing demographics, clinical presentation, laboratory parameters, radiological findings, disease severity (simple versus complicated appendicitis), operative time, intraoperative findings, conversion rates, drain placement, postoperative pain scores using the Visual Analog Scale at 24 hours, time to oral intake and ambulation, hospital stay, return to normal activities, and postoperative complications including wound infection, intra-abdominal abscess, ileus, readmission, and reoperation within 30 days. Laparoscopic appendectomy was performed using a standard three-port technique with endoloop ligation of the appendiceal base and specimen retrieval via an endobag, while open appendectomy was performed through a right lower quadrant muscle-splitting incision. All patients received standardized perioperative care, including intravenous antibiotics and analgesia. Statistical analysis was performed using SPSS version 26, with continuous variables expressed as mean ± standard deviation and compared using the independent samples t-test or Mann-Whitney U test, and categorical variables expressed as frequencies and percentages and compared using the chi-square or Fisher's exact test, with statistical significance set at p<0.05. Subgroup analyses were planned based on age, gender, and disease severity. The study was approved by the Institutional Review Board of Saidu Teaching Hospital, and a waiver of informed consent was granted due to the retrospective design, with all patient data anonymized and confidentiality maintained throughout.

 In a study of 411 children with acute appendicitis, 238 had laparoscopic appendectomy and 173 had open appendectomy. Both groups were similar at the start, with no significant differences in age, gender, symptom duration, or rates of complicated appendicitis, though the open group showed a slight trend toward more severe cases. Laparoscopic surgery took longer on average (54.6 vs. 41.8 minutes; p<0.001), but there were no cases where surgeons had to switch from laparoscopic to open surgery. Fewer patients in the laparoscopic group needed drains (5.0% vs. 10.4%; p=0.04). Recovery was better for those who had laparoscopic surgery: they stayed in the hospital for less time (2.1 vs. 3.4 days; p<0.001), had less pain at 24 hours (3.2 vs. 5.1 points; p<0.001), started eating sooner (8.4 vs. 12.6 hours; p<0.001), walked earlier (10.2 vs. 18.4 hours; p<0.001), and returned to normal activities faster (4.3 vs. 6.7 days; p<0.001). These benefits did not come with higher complication rates. In fact, the laparoscopic group had lower rates of wound infection, intra-abdominal abscess, and postoperative ileus, and the overall complication rate was lower (8.0% vs. 13.9%; p=0.06). There were no significant differences in readmission or reoperation within 30 days. Overall, laparoscopic appendectomy was safe and led to better short-term recovery than open surgery in children.

Table 1. Demographic Characteristics of Patients by Surgical Approach

Table 2. Clinical Presentation and Disease Severity

Table 3. Operative Characteristics and Intraoperative Findings

Table 4. Postoperative Recovery Outcomes

Table 5. Postoperative Complications

This large comparative study of 411 children with acute appendicitis shows strong evidence that laparoscopic appendectomy leads to better short-term recovery than the traditional open approach, while remaining safe. Our results are important for clinical practice, especially in tertiary-care hospitals where both surgeries are options. The group we studied was mostly male (62.5%) with an average age of 10.8 years, which matches what is already known about appendicitis in children [1,2]. The higher number of boys in our study (M:F ratio 1.67:1) is similar to earlier reports showing a slightly higher rate of appendicitis in boys during childhood [3,24]. Most patients were in the 11–18-year age group (49.6%), which fits with the trend of appendicitis becoming more common as children get older [4]. Both the laparoscopic and open groups were similar in age, gender, symptom duration, and rates of complicated appendicitis (p>0.05 for all), which strengthens our comparison of the two surgeries. There was a trend toward more complicated cases in the open group (30.6% vs. 23.5%; p=0.09), but this was not statistically significant. This may be because surgeons often choose open surgery for more severe cases, a common practice in many hospitals [7,13]. Laparoscopic appendectomy took longer on average (54.6 vs 41.8 minutes; p<0.001), a finding seen in other studies as well [12,18]. The 12.8-minute difference is meaningful and affects operating room use and costs. Several reasons explain this: laparoscopic surgery needs time to set up the equipment, place ports, and work with instruments that have limited movement, while open surgery gives direct access [14]. Laparoscopic surgery also has a steep learning curve, and even experienced surgeons may take longer than with open surgery, which they have done for many years [25]. Extra time is also needed for patient positioning, draping, equipment setup, and solving any issues [17]. Laparoscopy often includes a full check of the abdominal cavity, which can add time but also helps with diagnosis [11]. Despite taking longer, this is a fair trade-off because of the clear benefits in recovery. As teams gain more experience, laparoscopic surgery may become faster [14]. The better recovery seen with laparoscopic appendectomy in our study is clear and important: patients stayed in the hospital 1.3 days less, which benefits children, families, and the healthcare system. Children can go home sooner, return to familiar surroundings, spend less time away from family, and have a lower risk of hospital-acquired infections [9]. For hospitals, shorter stays mean lower costs and more available beds [18]. This matches other studies and reviews that found shorter hospital stays after laparoscopic appendectomy [10,20]. Pain scores were nearly 2 points lower 24 hours after surgery, which is significant and likely due to smaller cuts, less tissue damage, and less handling of the abdominal wall [8]. Better pain control means less need for pain medicine, earlier movement, faster return of bowel function, and higher satisfaction for patients and families [9]. Children in the laparoscopic group returned to normal activities, like school and play, 2.4 days sooner, which is especially important for their education, social life, and family routines [10]. Faster recovery helps children and families get back to normal life more quickly. Patients in the laparoscopic group also started eating (4.2 hours) and walking (8.2 hours) sooner, showing the overall faster recovery with minimally invasive surgery [19]. These early steps are good signs for overall recovery and readiness to go home. Most importantly, the better recovery with laparoscopic appendectomy did not come with more complications. In fact, complication rates were lower in the laparoscopic group, though the differences were not statistically significant: Wound infection: 3.8% vs. 6.4% (p=0.21) Intra-abdominal abscess: 1.7% vs. 2.9% (p=0.37) Postoperative ileus: 2.5% vs. 4.6% (p=0.19) Overall complications: 8.0% vs. 13.9% (p=0.06) Lower wound infection rates with laparoscopy are expected, since the appendix is usually removed through a port in a specimen bag, which reduces contact with the incision [15]. The similar rates of intra-abdominal abscess are important, as earlier studies worried about higher abscess risk after laparoscopic surgery for complicated appendicitis [16]. Our results, like recent reviews [18,20], show that laparoscopic appendectomy does not raise the risk of intra-abdominal abscess, even in complicated cases. No patients in our study needed to switch from laparoscopic to open surgery (0%), which shows good patient selection and surgeon skill. This is better than the 2-10% conversion rates reported elsewhere [12,14]. The benefits of laparoscopic appendectomy were seen in both simple and complicated cases: hospital stays (1.8 vs 2.9 days) and pain scores (2.9 vs 4.8) were much better, with very low complication rates in both groups. Even in higher-risk cases, laparoscopic surgery led to shorter hospital stays (3.2 vs 4.6 days) and lower pain scores (4.1 vs 5.9), with no increase in complications. This is important because it suggests that laparoscopy helps even in the toughest cases [23]. Our findings agree with a lot of research supporting laparoscopic appendectomy in children. A Cochrane review by Sauerland et al. [20] found that laparoscopic appendectomy reduces pain, hospital stay, and wound infections compared to open surgery, with similar rates of intra-abdominal abscess. Jaschinski et al. [18] also found shorter hospital stays and faster return to normal activities after laparoscopic appendectomy. Li et al. [19] found that laparoscopic appendectomy in children led to lower pain scores, shorter hospital stays, and earlier return to normal activities, with no difference in abscess rates. Esposito et al. [21] reported excellent results with laparoscopic appendectomy in a large pediatric series, with low complication rates and high parent satisfaction. Our study adds to this by providing data from a large, single-center group in a resource-limited setting, showing that the benefits of laparoscopic appendectomy can be achieved in different healthcare environments with the right surgical skills.

This large study of 411 children with acute appendicitis shows strong evidence that laparoscopic appendectomy is the better surgical option in hospitals with the right expertise. Compared to open surgery, laparoscopy leads to shorter hospital stays (2.1 vs. 3.4 days; p<0.001), less pain after surgery (VAS 3.2 vs. 5.1; p<0.001), a quicker return to normal activities (4.3 vs. 6.7 days; p<0.001), and faster resumption of eating and walking (p<0.001 for both). These benefits come without a higher risk of complications like wound infection, intra-abdominal abscess, or ileus. Although the operation takes a bit longer (54.6 vs. 41.8 minutes; p<0.001), this is a reasonable trade-off for better recovery. The advantages of laparoscopy hold true for both simple and complicated cases, as long as experienced surgeons perform the procedure. Open appendectomy is still a good choice where laparoscopy is not available or for patients who cannot have laparoscopic surgery. Our results match international guidelines and meta-analyses, and add new data from a busy hospital in a resource-limited setting. These findings support wider use of laparoscopic appendectomy in pediatric surgery, with attention to training, resources, and patient selection. The main goal is to give children the best outcomes with the least treatment burden. As shown in this study, laparoscopic appendectomy helps achieve this by allowing faster recovery, less pain, and a quicker return to normal life, while keeping patients safe.

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