although first reported in adult patients in the 1980s , modern video - assisted laparoscopic appendectomy ( la ) continues to be routinely used by only a small fraction of pediatric surgeons . united states discharge data from 2000 from 30 freestanding children 's hospitals revealed only 31% of pediatric appendectomies were performed laparoscopically . an american pediatric surgical association ( apsa ) survey published in june 2004 showed only 31% of pediatric surgeons perform la frequently or always , and 39% of them do them rarely or never . many series ( table 1 ) have failed to demonstrate any specific advantages to the newer laparoscopic technique compared with open appendectomy ( oa ) . these reports have been criticized , however , for including the surgical learning curve , wherein surgeons inexperienced with laparoscopic techniques compare their results with results for oa , with its extensive history , potentially resulting in misleading conclusions . this study was designed to investigate outcomes in a series of pediatric appendectomy patients managed by surgeons with extensive laparoscopic experience . pediatric laparoscopic versus open appendectomy comparative series oa = open appendectomy ; la = laparoscopic appendectomy ; los = length of stay . following institutional review board approval , a retrospective medical record review of 197 consecutive children from may 2002 to january 2004 at a university - affiliated private teaching hospital was performed . patients received all pre- , intra- , and postoperative care by the same emergency department staff , anesthesiologists , surgical residents , and nurses . data collected included demographics ( age , sex , insurance status ) ; preoperative data , including temperature , white blood cell count , wait until surgical treatment , preoperative imaging studies performed and results ; operating time ; and surgical technique performed ( la vs. oa ) . wait until surgical treatment was defined as time from initial evaluation by emergency department physicians to the initial operative skin incision . operating time was defined as the time from initial skin incision to final skin suture . surgical technique ( la vs. oa ) postoperative variables collected include postoperative length of stay ( los ) , time on intravenous ( iv ) antibiotics and opiates , time to resumption of full diet , placement of drains , complications , histology of appendix , and total hospital charges . any other pathology that was found upon exploration of the abdomen or pelvis during surgery was noted . complicated appendicitis was defined as either gangrenous appendicitis or the presence of perforation as noted in either the operative report or based on the histology of the pathological specimen . chi - squared p values were used for unordered discrete or dichotomous variables , and mantel - haenszel chi - squared p values were used for ordered discrete variables . from january 2002 through may 2004 , 197 appendectomies were performed in children , with a preoperative diagnosis of appendicitis ( figure 1 ) . fifty - nine percent of the operations ( n=117 ) were laparoscopic appendectomies ( la ) , and 41% ( n=80 ) were open appendectomies ( oa ) . of the 197 patients , 122 ( 62% ) presented with acute , nongangrenous , nonperforated appendicitis , with 71 las ( 58% ) performed among this group . complicated ( gangrenous or perforated ) appendicitis cases consisted of 34 las and 26 oas . two la patients required conversion to oa ( one patient with a histologically normal appendix and one with gangrenous appendicitis ) . the negative appendectomy rate was 8% ( la , n=12 ; oa , n=3 ) . the appendectomies were performed by 24 different surgeons ( 6 pediatric surgeons and 18 general surgeons ) . appendectomies per surgeon in this series ranged from 1 to 38 ( mean , 8.2 ) . each surgeon reported extensive personal experience with laparoscopic surgery , and many answered a detailed questionnaire . these surgeons , who performed 79% of the las , had an average of 9 years of laparoscopic experience after residency or fellowship , and performed , on average , 105 laparoscopic surgeries per year . preoperative demographics for the patients were similar among the 2 groups ( table 2 ) . the average age of the patients was 10.4 years ( range , 2 to 18 ) . n = 180 ; 17 patients excluded from this table : 2 patients insurance status was not known and 15 patients with normal appendices not included . preoperative variables including temperature , white blood cell count ( wbc ) , mean wait until surgical treatment , and proportion of patients with advanced imaging studies were similar among the acute appendicitis groups . a significant difference with respect to insurance status was found among the patients who underwent open appendectomy for acute appendicitis : 65% of the 23 acute appendicitis patients with no insurance underwent open appendectomy . however , of the 97 acute appendicitis patients with insurance ( private or public ) , only 37% underwent oa ( p=0.047 ) . the mean la time was 47 minutes ( range , 25 to 94 ) , compared with 48 minutes ( range , 23 to 102 ) for oa . for the 117 la patients , 3 trocars were utilized in 116 of the patients ( 99% ) and 4 trocars in 1 patient ( 1% ) . the mean combined skin incision length was 23 mm ( 0.9 inches ) , with a range of 13 mm to 32 mm . the most commonly used trocars were a 12-mm umbilical trocar and two 5-mm trocars for a total incision length of 22 mm ( 0.87 inches ) , which was used in 78 of the 117 la patients ( 67% ) . postoperative outcome measures of mean time on intravenous antibiotics , intravenous opiates , and complication rates were similar between the 2 acute appendicitis groups . la patients experienced a faster return to full diet ( la , 17.6 hrs ; oa , 28.6 hrs , p=0.001 ) and shorter postoperative los ( la , 1.06 days ; oa , 1.67 days , p<0.0001 ) ( figure 2 ) , while accumulating greater total hospital charges ( la , $ 9,730 ; oa , $ 8,434 , p=0.012 ) compared with the oa group . comp = complicated ( gangrenous or perforated ) appendicitis . for complicated ( gangrenous or perforated ) appendicitis cases , preoperative variables and postoperative outcomes were similar among the 2 groups . operation times were significantly longer for the la group , with la lasting on average 65 minutes , as opposed to only 51 minutes for their oa counterparts ( p=0.028 ) . ( p = ns ) . nineteen percent of complicated oa patients had drains placed as opposed to 13% of the complicated la cases ( p = ns ) . while the complication rate for complicated cases of appendicitis was twice the rate of the la group , this difference was not statistically significant ( table 3 ) . fourteen of the 117 la cases ( 12% ) had other intraabdominal or pelvic pathology identified during surgery as opposed to only 6 of the 80 ( 7.5% ) oa cases . preoperative variables including temperature , white blood cell count ( wbc ) , mean wait until surgical treatment , and proportion of patients with advanced imaging studies were similar among the acute appendicitis groups . a significant difference with respect to insurance status was found among the patients who underwent open appendectomy for acute appendicitis : 65% of the 23 acute appendicitis patients with no insurance underwent open appendectomy . however , of the 97 acute appendicitis patients with insurance ( private or public ) , only 37% underwent oa ( p=0.047 ) . the mean la time was 47 minutes ( range , 25 to 94 ) , compared with 48 minutes ( range , 23 to 102 ) for oa . for the 117 la patients , 3 trocars were utilized in 116 of the patients ( 99% ) and 4 trocars in 1 patient ( 1% ) . the mean combined skin incision length was 23 mm ( 0.9 inches ) , with a range of 13 mm to 32 mm . the most commonly used trocars were a 12-mm umbilical trocar and two 5-mm trocars for a total incision length of 22 mm ( 0.87 inches ) , which was used in 78 of the 117 la patients ( 67% ) . postoperative outcome measures of mean time on intravenous antibiotics , intravenous opiates , and complication rates were similar between the 2 acute appendicitis groups . la patients experienced a faster return to full diet ( la , 17.6 hrs ; oa , 28.6 hrs , p=0.001 ) and shorter postoperative los ( la , 1.06 days ; oa , 1.67 days , p<0.0001 ) ( figure 2 ) , while accumulating greater total hospital charges ( la , $ 9,730 ; oa , $ 8,434 , p=0.012 ) compared with the oa group for complicated ( gangrenous or perforated ) appendicitis cases , preoperative variables and postoperative outcomes were similar among the 2 groups . operation times were significantly longer for the la group , with la lasting on average 65 minutes , as opposed to only 51 minutes for their oa counterparts ( p=0.028 ) . total hospital charges were $ 14,244 for la and $ 13,451 for oa ( p = ns ) . nineteen percent of complicated oa patients had drains placed as opposed to 13% of the complicated la cases ( p = ns ) . while the complication rate for complicated cases of appendicitis was twice the rate of the la group , this difference was not statistically significant ( table 3 ) . fourteen of the 117 la cases ( 12% ) had other intraabdominal or pelvic pathology identified during surgery as opposed to only 6 of the 80 ( 7.5% ) oa cases . despite the recent publication of several large laparoscopic appendectomy series and meta - analysis studies in adults demonstrating clear advantages in outcomes , laparoscopic appendectomy has yet to become fully accepted for the treatment of pediatric appendicitis . examples include published series from horwitz et al ( 49 patients ) , lintula et al ( 61 patients ) and lavonius et al ( 43 patients ) . the few randomized controlled trials have suffered from weak design or poor patient selection criteria , or both of these . for example , little et al 's 2002 study and lintula , et al 's 2001 study have been criticized for their 18% and 30% negative appendectomy rates , respectively . another criticism of recent comparison studies is the failure to separate outcomes of acute appendicitis patients and those with complicated appendicitis despite often - dramatic differences in the morbidity of the 2 conditions . operation times for la were greater than those of oa in 8 of the 18 series listed in table 1 , not different in 9 of the series , and not reported in one . in the current series , mean operative times were similar for acute appendicitis . however , for complicated appendicitis in this series , la took 27% longer , on average , than oa . since this amounts to only 14 minutes , on average , in children with mean postoperative hospital stays over 4 days , its clinical significance may not be great . an advantage of this study is the documented laparoscopic experience of the pediatric and general surgeons before the study period . this experience resulted in a very low laparoscopic to open conversion rate ( 1% ) , comparable operative times between the 2 groups for the simple appendicitis cases , and a low negative appendectomy rate ( 8% ) . by studying patients operated on exclusively by surgeons who had extensive experience with both the laparoscopic and the open technique , this should eliminate the confounding variable of the surgical  learning curve  often seen in previous laparoscopic appendectomy reports . unfortunately , the  learning curve  for proficiency in laparoscopic appendectomy has not previously been defined . however , in a recent review of 3641 articles , dagash et al evaluated the published  learning curves  for several other commonly performed laparoscopic procedures . although somewhat controversial , proficiency for laparoscopic cholecystectomy appears to be present after approximately 30 such procedures , for laparoscopic fundoplication after roughly 28 such procedures , for laparoscopic colectomy after 40 , for laparoscopic herniorrhaphy after 30 to 50 , and for laparoscopic splenectomy after roughly 20 . in 2 published series of pediatric laparoscopic appendectomy patients , the authors have commented on a significant improvement in operative time or risk of conversion to open appendectomy after 5 years of laparoscopic experience . it would seem reasonable , therefore , to assume that surgeons who had performed at least 20 laparoscopic appendectomies and had been performing the operation for at least 5 years ( as had each surgeon in this series ) would likely be considered proficient in the operation . in this series , laparoscopic appendectomy for the treatment of simple , acute appendicitis in children appeared to offer a quicker return to full diet and shorter postoperative length of stay . first , the laparoscopic surgeon 's ability to minimize manipulation of the cecum and ileum may decrease the degree of postoperative adynamic ileus and allow one to resume a full diet earlier . secondly , the trocar incisions appear to cause minimal trauma to the abdominal wall and probably less pain . in this study , hospital charges for the laparoscopic appendectomy patients with acute appendicitis averaged 15% , or $ 1,296 , more than for oa . this is presumably due to increased operating room charges and was not quite offset by the cost savings from decreased length of hospital stay for the simple acute appendicitis cases . other authors have shown no significant difference in the charges for laparoscopic appendectomies . for complicated appendicitis , mean hospital charges for the la group were only $ 793 greater than charges for the oa group ( p = ns ) . this was an unexpected finding because the difference in the acute appendicitis cases was almost $ 1,300 . however , the smaller difference may be partially due to the fact that while 57% of the complicated oa patients underwent preoperative abdominal imaging studies [ computed tomography ( ct ) and ultrasound ( us ) ] only 38% of the complicated la patients did so . laparoscopic surgery has long been felt to have the benefit over open abdominal surgeries in its superior ability to explore the abdomen and pelvis . the findings of other pathology in 12% of the la cases versus 7.5% of oa further support this belief . the laparoscopic approach appears to be especially beneficial in female patients , in which a wider differential diagnosis for the acute abdomen must be considered . six of the 14 cases of other pathology identified in the la were of fallopian tube or ovarian pathology , while no oa cases observed female gonadal pathology . the finding of an increased use of open surgery in uninsured patients is of unclear significance . furthermore , factors not evaluated in this study , and most others , were the return to normal function outside the hospital ( such as ability to participate in sports and play ) , patient or parent satisfaction , or both , and cosmetic results associated with each method . these factors can only be studied prospectively and would require a follow - up visit or parent survey . laparoscopic appendectomy appears to offer significant advantages over open appendectomy for the treatment of acute appendicitis in children and offers no major disadvantages to children undergoing treatment of complicated appendicitis .
objectives : despite its increasing popularity , several recent studies comparing laparoscopic appendectomy ( la ) with open appendectomy ( oa ) in children have failed to demonstrate significant improvements in patient outcomes . 
 many series include the  learning curve ,  wherein surgeons inexperienced with laparoscopic techniques compare their results with results with oa with its extensive history . 
 this study was designed to investigate outcomes in pediatric appendectomy patients managed by surgeons with extensive laparoscopic experience.methods:we preformed a retrospective review of 197 consecutive children undergoing appendectomy for presumed acute appendicitis from january 2002 through may 2004 at a university - affiliated community hospital by pediatric and general surgeons with extensive laparoscopic surgical experience.results:the study included 117 patients who underwent la and 80 who underwent oa . 
 of 122 acute appendicitis cases , mean operating times were 47 minutes ( la ) and 48 minutes ( oa ) . 
 the la group ( n=71 ) had a faster return to full diet ( 17.6 h vs. 28.6 h , p=0.0008 ) , and shorter postoperative length of stay ( los ) ( 1.06 d vs. 1.66 d , p<0.0001 ) compared with the oa group ( n = 51 ) . 
 complication rates , time on intravenous ( iv ) antibiotics , and iv opiates were similar among the 2 groups . 
 complicated appendicitis cases ( la , n=34 ; oa , n=26 ) were similar with regard to los , return to normal bowel function , complication rate and time on iv antibiotics and opiates , but was associated with an increased operation time ( la , 65 min ; oa , 51 min , p=0.02).conclusions : following the completion of the laparoscopic surgery learning curve , la has a comparable operation time and results in a decreased postoperative los , and faster return to normal bowel function compared with oa in children with acute nongangrenous , nonperforated appendicitis .