ppendicitis is a common cause of acute abdominal pain in children. Surgical removal of the appendix by laparoscopic appendectomy (LA) or open appendectomy (OA) approaches is the standard treatment in acute appendicitis(AA).Surgical intervention has a lower rate of post-appendectomy complications than that seen with antibiotic therapy alone (1). LA has shown advantages over OA in many aspects, such as shorter hospital stay, decreased recovery time with a faster return to normal daily activities, less postoperative pain, shorter postoperative ileus, better cosmetic results, lower time for wound healing, and less wound infection (2)(3)(4)(5)(6)(7)(8). However, other studies have shownthat LA is associated with longer operative time, increased incidence of an intraabdominal abscess, and higher cost (7)(8)(9). Also, a previous study showed that LA has a shorter operative time in complicated appendicitis (10). One trend analysis demonstrated that LA showed a higher risk for complication compared with OA in uncomplicated appendicitis (11). In contrast, other studies havereported that OA has a shorter hospital stay and lower cost (12,13).LA is not the standard approach to AA management in children (11). This subject remains debatable, especially in pediatric patients in which there is a lack of published studies. The aim of the present study was to assess the advantages of LA compared withOA in children, regarding outcomes, operative time, length of hospital stay, antibiotic use, and other available variables.

The present study was a retrospective chart reviewconducted at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia.

A total of 1883 pediatric patients (? 14 years old) who were diagnosed with acute appendicitis and underwent LA or OA between January

Excel was used for data entry. SPSS version 24 software (IBM Corp., Armonk, New York, USA)was used for data management and analysis. Descriptive statistics were used to describe demographic variables. The chisquare test was used to assess the relationship between each surgical approach and categorical variables by percentages and frequencies (e.g., surgical approach and gender). T-tests were used to assess the difference between the type of surgery and quantitative values by measuring the mean and standard deviation (e.g., surgical approach and age). A p-value of <0.05 was considered statistically significant.

A total of 1883 pediatric patients (mean age of 10 years old) that underwent appendectomy were included in the present study. Males accounted for 64.9% of the patients (male: female ratio was 2:1). OA surgical approach was performed in 1673 (88.8%) patients with a mean age of 10 ± 2.4. LA was performed in 210 (11.2%) with a mean age of 10.28 ± 2.5. Conversion of LA to OA was needed for one patient and was included in OA numbers. Additional variables were compared between the two approaches, including gender, WBC count, neutrophil percentage, imagining, operative surgeons, histopathology reports, and rate of complication (Table 1). A statistically significant difference was seen between LA and OA neutrophil percentages, operative surgeons, and histopathology reports (p-value =0.003, <0.001 and <0.001, respectively) (Table 1). The rates of complication were 3.2% for OA and 5.7% for LA, with no statistically significant difference observed between the two surgical approaches (p-value =0.057). The length of hospital stay was significantly longerfor LA (3.81 ± 2.4 days) compared with OA(3.19 ± 2.3 days) (p-value <0.001; Table 2). However, there were no statistically significant differences between the two groups regarding antibiotic consumption during admission (p-value = 0.077). LA demonstrated asignificantly longer operative time (73.2 ±25.3 min)compared with OA (53.1 ± 24 min)(p-value <0.001; Table 2). A significantly higher percentage (30%) of patients that underwent LA used antibioticsupon discharge fora longer period (2.43 ± 2.4 days)compared with OA (p-value s<0.001; Table 2). The LA approach has significantly increased over the study time from 0% use in 1998 to 42% use in 2014 (Figure 1).

Since the first use of the laparoscopic appendectomy approach for the management of acute appendicitis by Semm in 1983(14), it has failed to show superiority over the OA approach in adults and children (11,15). In contrast, in acute cholecystitis, the laparoscopic approach has been shownto have wellestablished superiority over the open approach (16). However, the LA approach is widely preferred by most surgeons and acceptable as the standard of treatment for AA. A technique is preferred over another due to its safety and few complications. In the present study, the overall complication rate was 3.5% and included IAA, wound infection, and bowel obstruction. The complication rate for both LA and OA approaches in children failed to show statistically significant differences, similar to the majority of recent studies (17)(18)(19). However, another report claimed that LA showed less complication rate in pediatric appendectomy (20). In the present study, the LA approach did not reduce the need for imagining (abdominal US and CT) for the diagnosis of appendicitis, which is similar to results from another study (17).However,a new trend is to use imagining for the diagnosis of appendicitis to reduce the incidence of a normal appendix (21). Senior surgeons (consultants and associate consultants) prefer the LA approach; instead, junior surgeons (fellows and residents) prefer the OA approach,which might be due to educational reasons. Similar to many previous studies that included meta-analysis, randomized trial, and cohort studies, the LA approach has been shown to have longer operation times (7)(8)(9)12). However, a report byAxel Elofsson 18 and his colleagues found no difference between the two techniques (LA and OA) regarding operative time in children. In the present study, approximately half of LA surgeries were performed by junior surgeons,which may contribute to the longer operative times that we observed. The LA technique can have shorter operative times, but this might depend on the surgeon'sexperience (21).

Interestingly, our study and others found that the histopathology reports showed that non-perforated appendix and normal appendix were statistically significant between the two methods (LA and OA), with no statistical difference observed in perforated appendix cases (18). Upon seeing more normal or healthy appendicesduring LA, raises the concern that the LA approach may participate in misdiagnosis of AA. Furthermore, in the present study, the hospital stay was longer after LA in pediatric patients; however,additional pediatric studies have shown that LA resulted in a shorter hospital stay (17,18,20). The overall hospital stay in our study was longer than most previous studies. One of the main goals of LA is to reduce the use of antibiotics in AA patients, however we did not find an advantage regarding this issue. The present study found a low rate of LA for the management of AA;however, this is no longer the case becausethe medical community is shifting toward minimally invasive techniques and considers the LA approach the standard treatment of AA (see Figure 1).

LA and OA demonstratesimilar risk for postappendectomy complicationsin the pediatric population. LA is associated with longer operation times, which might lead to higher cost. Both LA and OAshow asimilar need for antibiotics post-surgery. LA is not superior to OA in children, although further studies, including a randomized controlled trial and meta-analysis, are required.

Our single-center study was a retrospective chart review that was associated with the limited patient information. The large variation between LA and OA cases might affect the results. However most our resultswere constant with most recent studies.