We included patients (children <18 years of age), who were diagnosed with acute appendicitis, and in whom we performed appendectomy in Linyi People’s Hospital, China from 1st September 2008 to 1st September 2014. The study was approved by our hospital Ethics Committee. Informed consent was obtained from patients’ guardians. Patients with incidental appen-dectomy were excluded. We analyzed the clinical data of patients, including sociodemographic characteristics, postoperative complications, duration of the surgery, blood loss, postoperative length of hospital stay, and postoperative quality of life within 1 month. In addition, the cost of hospitalization was also estimated.

Postoperative pain was assessed by a score based on severity of pain: 0=no pain; 1=mild pain; 2=moderate pain; 3=severe pain. The score of pain activities scale was assessed by severity of pain in three activities (rest, daily activities and strenuous exercise): 0=no pain; 1=mild pain; 2=moderate pain; 3=severe pain. The clinical pain scores were measured at day 1, and 1 month after operation.

Major complications, including perforation, abscesses, recurrence of appendicitis and wound infection were recorded. Minor complications, including antibiotic-related rash, fever, diarrhea, vomiting and paralytic ileus were also recorded. Duration of the surgery was the time period from incising the skin to the last suture insertion. Postoperative length of stay was calculated from the end of surgery to the date of discharge. The discharge criteria included no fever, no abdominal pain, healed operative wound, and stable vital signs.

Postoperative quality of life was evaluated by the SF-36 at one month after surgery. The SF-36 [5] includes 8 items: physical functioning (PF), role limitations due to physical health (RP), bodily pain (BP), general health perceptions (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH). All items were standardized from 0 to 100 with ameliorated status. The data related to pain and quality of life are routinely collected at our unit.

Statistical analysis: Statistical analysis was performed by Fisher’s exact test or t-test using SPSS version 17.0 to compare parameters of open appendectomy and laparoscopic　appendectomy in children with acute appendicitis. P<0.05 was considered statistically significant.

389 children (age <18 years) (216 boys) were included in the study. There were 190 patients with laparoscopic appendectomy. Patient demographics and baseline characteristics were similar in both groups (Table I ).

TABLE I	Patient Demographics and Baseline Characteristics

Postoperative pain scores between the two groups are summarized in Table II. Preoperative severity of pain and its influence on activities showed no significant difference in the two groups (P=0.17). The pain severity score was substantially lower in the laparoscopic group than in the open appendectomy group from the 2nd to the 26th day after the procedure (P=0.04). The impact of patient’s pain on daily activities was also lower in laparoscopic group from the 8th to the 22th day after operation (P=0.01). The patients in both groups had no pain at 1 month postoperatively.

TABLE II	Change in Pain Scores from Pre-Treatment to 1 Month After Surgery 

The incidence of major complications in laparoscopic group was significantly lower than in open appendectomy group (P=0.01), although it was comparable for minor complications (Table III). The median operative time of the laparoscopic group was significantly longer than that of the open appendectomy group (P=0.01). There was also a significant difference in the length of hospital stay between two groups (P=0.02).

TABLE III  Complications in Open and Laparoscopic Appendectomy Groups in Children with Acute Appendicitis 

Quality of life scores were comparable in the two groups preoperatively and 1 month postoperatively, but a significantly higher score of vitality and mental health were found in laparoscopic group at 1 month postoperatively (P =0.01) (Web Fig.1).

In this retrospective comparative analysis, we observed that laparoscopic appendectomy in children is a safe surgical procedure with minimal access and lesser frequency of major complications and post-operative incisional pain.

Several earlier studies in adults have also documented the advantages of laparoscopic appendectomy over open appendectomy in terms of rapid postoperative recovery and lower degree of surgical stress [6,7], less postoperative complication [8-11], shorter hospitalization period [12,13]. The benefits of laparoscopic appendectomy are controversial in children with perforated appendicitis and acute appendicitis [14]. An earlier study [15] also documented the benefits of laparoscopic appendectomy in terms of reduction of major complications. We documented laparoscopic appendectomy to result in shorter duration of hospitalization. This result is in agreement with most earlier studies, [7,10,13].

Our study had a major limitation of being a retrospective comparison rather than a controlled assessment of differences between these two procedures. Non-standardized evaluation is also a serious limitation of such retrospective studies. Long-term follow-up was also not done.

We conclude that Laparoscopic appendectomy seems to have considerable advantages over open appendectomy in cases of acute appendicitis in children for relieving postoperative pain and reducing major postoperative complication rates.

Contributors: YL: conceptualization of study and data collection; RZ: data collection; ZC: data analysis and drafting of the manuscript. All authors approved the final version of manuscript.

Funding: None; Competing interest: None stated.