Research

A population-based comparison of the

post-operative outcomes of open and
laparoscopic appendicectomy in children
Francisco J Schneuer1, Susan E Adams2, Jason P Bentley1, Andrew JA Holland3, Carmen Huckel Schneider1,
Leslie White4, Natasha Nassar1

Abstract
The known Laparoscopic appendicectomy is increasingly Objective: To assess and compare the post-operative
preferred to open appendicectomy for managing appendicitis outcomes of open and laparoscopic appendicectomy in children.
in children. The most recent systematic review of their
outcomes was published in 2012. Design: Record linkage analysis of administrative hospital
(Admitted Patient Data Collection) and emergency department
The new Children with uncomplicated appendicitis have a (Emergency Department Data Collection) data.
lower risk of post-operative bowel obstruction after
laparoscopic appendicectomy than after open Participants, setting: Children under 16 years of age who
appendicectomy, but their higher re-admission rates suggest underwent an appendicectomy in a public or private hospital in
that they may be discharged before post-operative symptoms New South Wales between January 2002 and December 2013.
have adequately resolved. Post-appendicectomy outcomes Main outcome measures: Association between type of
were similar for most age groups and hospital types. appendicectomy and post-operative complications within
28 days of discharge, adjusted for patient characteristics and
The implications Undertaking appendicectomies in children
type of hospital.
outside tertiary paediatric hospitals is safe, and reduces waiting
times, delays in care, and unnecessary travel for their families. Results: Of 23 961 children who underwent appendicectomy,
19 336 (81%) had uncomplicated appendicitis and 4625 (19%)
had appendicitis complicated by abscess, perforation, or
peritonitis. The proportion of laparoscopic appendicectomies
increased from 11.8% in 2002 to 85.8% in 2013. In cases of

A
cute appendicitis is one of the most common paediatric uncomplicated appendicitis, laparoscopic appendicectomy was
health emergencies requiring surgery, affecting about associated with more post-operative complications (mostly
one in 800 children.1 Until the advent of laparoscopic symptomatic re-admissions or emergency department
surgery in the 1980s, the operation traditionally involved the presentations) than open appendicectomy (7.4% v 5.8%), but
classic McBurney muscle-splitting incision.2 Laparoscopic ap- with a reduced risk of post-operative intestinal obstruction
pendicectomy has since become the most common surgical (adjusted odds ratio [aOR], 0.59; 95% CI, 0.36e0.97). For cases
technique for treating acute appendicitis in children.3 This shift in of complicated appendicitis, the risk of wound infections was
lower for laparoscopic appendicectomy (aOR, 0.67; 95% CI,
practice has been attributed to shorter lengths of hospital stay,
0.50e0.90), but not the risks of intestinal obstruction (aOR,
earlier return to normal function, and a better cosmetic appear- 0.97; 95% CI, 0.62e1.52) or intra-abdominal abscess (aOR, 1.06;
ance.4 However, whether the post-operative outcomes of lapa- 95% CI, 0.72e1.55).
roscopic appendicectomy are equivalent to those of traditional
Conclusion: Post-appendicectomy outcomes were similar for
open appendicectomy is still debated, particularly in cases of most age groups and hospital types. Children with
complicated appendicitis. uncomplicated appendicitis have lower risk of post-operative
A 2012 systematic review found no difference in the post-operative bowel obstruction after laparoscopic appendicectomy than after
open appendicectomy, but may be discharged before their post-
complication rates of laparoscopic and open appendicectomy in
operative symptoms have adequately resolved.
uncomplicated cases of appendicitis in children; for complicated
appendicitis, the risk of post-operative wound infections was
58% lower after laparoscopic appendicectomy, but the risk of intra-
abdominal abscess was 30% higher.5 The influence of changing between January 2002 and December 2013. Children with a
surgical management and the effects of characteristics such as age, diagnosis of abdominal pain, intestinal congenital anomalies,
type of hospital, and inter-hospital transfers on post-operative obstructive diseases, injuries, or intestinal conditions were
outcomes have not been comprehensively evaluated during the excluded.
past decade. Up-to-date population-based information on out-
comes is important for informing clinical decision making,
16 July 2018

Data sources
resource allocation, and health policy on paediatric health care. The
aim of our study was to assess and compare the post-operative NSW Admitted Patient Data Collection (APDC) and Emergency
outcomes of open and laparoscopic appendicectomy in children. Department Data Collection (EDDC) records were probabilisti-
cally linked by the NSW Centre for Health Record Linkage (www.
j
MJA 209 (2)

cherel.org.au) and de-identified data were provided to the

Materials and methods investigators. The APDC is a census of all inpatient admissions to
public and private hospitals; it includes patient demographic
We analysed data for all children under 16 years of age who un- information and relevant diagnoses and procedures for each
derwent appendicectomy for appendicitis in New South Wales admission, respectively coded according to the International

80 1
Menzies Centre for Health Policy, University of Sydney, Sydney, NSW. 2 Sydney Children’s Hospital, Sydney, NSW. 3 The Children’s Hospital at Westmead, Sydney, NSW.
4
University of New South Wales, Sydney, NSW. [email protected] j doi: 10.5694/mja17.00541 j Published online 09/07/2018
 Research
Classification of Diseases, tenth revision, Australian modification Ethics approval
(ICD-10-AM) and the Australian Classification of Health Ethics approval for data access was obtained from the NSW
Interventions (ACHI). The EDDC is a statutory collection of data Population and Health Services Research Ethics Committee
for all presentations to emergency departments in NSW public (reference, 2012-12-430).
hospitals, and includes information on patient symptoms or
diagnoses coded according to the International Classification of
Diseases, ninth revision, clinical modification (ICD-9-CM), ICD-10- Results
AM, and SNOMED-CT.
During 2002e2013, 23 961 children under 16 underwent appen-
Cases of appendicitis were classified as either uncomplicated or dicectomy for appendicitis in NSW, a population prevalence of 14
complicated (with peritonitis, rupture or abscess). The relevant cases per 10 000 children under 16 years of age. Prevalence
diagnosis and procedure codes are listed in the online Appendix, increased with age: one case per 10 000 children aged 0e4 years,
table 1. Clinical outcomes assessed in our study were length of eight cases per 100 000 children aged 5e8 years, and 23 cases per
hospital stay, complications recorded during the initial admission, children aged 9e11 years. A total of 19 336 patients (81%) had
hospital re-admissions, and emergency department re- diagnoses of uncomplicated appendicitis; 4625 cases (19%) were
presentations within 28 days of discharge that did not require complicated by abscess, perforation or peritonitis. The proportion
hospitalisation. Post-operative complications during the initial of uncomplicated cases increased with age (0e4 years, 42%; 5e8
admission were defined as intestinal obstruction, intra-abdominal years, 72%; 9e11 years, 82%; 12e15 years, 85%).
abscess, respiratory complications, complications affecting other
systems (nervous, circulatory, endocrine, unspecified), adverse During the study period, open appendicectomy was undertaken in
effects of therapeutic drugs, and wound infections. Re-admission 12 300 children (51%), and laparoscopic appendicectomy in 11 661
to hospital for complications was distinguished from other (49%), but the proportion of laparoscopic appendicectomies rose
re-admissions, and included re-admission for symptomatic con- from 11.8% in 2002 to 85.8% in 2013 (for trend, P < 0.001), with
ditions (abdominal pain, nausea, vomiting). Re-presentations to an similar increases for uncomplicated and complicated appendicitis
emergency department by patients with post-operative gastroin- (Box 1) and in all age groups (online Appendix, figure 1A).
testinal symptoms (gastroenteritis, abdominal pain) or wound The proportion of laparoscopic appendicectomies increased with
infections within 28 days of discharge were identified. Composite the age of the children (2002e2013: 0e4 years, 28%; 12e15 years,
outcomes (intestinal obstruction, intra-abdominal abscess, wound 56%); it was greater for children from the most disadvantaged
infection, any post-operative complication) were also examined backgrounds than for those from the most advantaged (57% v
separately for initial admission and within 28 days of discharge. 45%), and greater for girls than boys (55% v 44%) (Box 2). The
Explanatory variables assessed included characteristics of the increased use of laparoscopic appendicectomy for both compli-
patient and the operation: type of appendicitis (uncomplicated, cated and uncomplicated appendicitis applied to all hospital types
complicated), age, sex, socio-economic disadvantage (Index of (for trend, P < 0.001); in 2013, it was employed by tertiary paedi-
Relative Socio-economic Disadvantage),6 secondary intra- atric, metropolitan and private hospitals in more than 90% of cases,
abdominal diagnosis at initial admission, pre-existing conditions, and in 71% of cases in regional and rural hospitals (online
type of hospital, transfers from another hospital, and day Appendix, figure 1B).
(weekday v weekend), season, and period of surgery (2002e2005, A total of 2888 children (12% of cases) were transferred from the
2006e2009, 2010e2013). initial presenting hospital, most frequently to tertiary paediatric or
regional hospitals. The proportion of children under 9 years of age
transferred to tertiary paediatric hospitals increased until 2010,
Statistical analysis
after which it declined; there were no consistent trends for transfers
The population trends in age-specific rates of appendicectomy to other hospital types or for older children (online Appendix,
(population data were obtained from the Australian Bureau of figures 2A and B).
Statistics7) and the proportion of laparoscopic appendicectomies
in the study population were evaluated by hospital type and
broad age groups (under 9 v 9e15 years of age). The overall trend
1 Laparoscopic appendicectomies as a proportion of all
in inter-hospital transfers was assessed in CochraneArmitage
appendicectomies in children under 16 years of age,
tests. Patient and operation characteristics were summarised in New South Wales, 2002e2013, by type of appendicitis
contingency tables. The associations between appendicectomy (complicated, uncomplicated)
type and post-operative outcomes during the initial admission
and within 28 days of discharge were assessed in c2 tests, strati-
fied by appendicitis type (uncomplicated, complicated). Stratifi-
MJA 209 (2)

cation was applied to univariate and multivariate analyses using

binary generalised estimating equations with a logit link and
exchangeable correlation to estimate the odds of intestinal
obstruction, intra-abdominal abscess, wound infections, and any
post-operative complications after laparoscopic and open ap-
j
16 July 2018

pendicectomy, corrected for patient and operation characteristics

and clustering within individual hospitals. We also conducted a
sensitivity analysis for the multivariate analysis of complicated
appendicitis by excluding patients with diagnoses of acute
appendicitis with localised peritonitis (ICD-10-AM, K35.3); this
code was introduced during the study period (in 2009). P < 0.05
was deemed statistically significant. All analyses were conducted 81
in SAS 9.4 (SAS Institute).
 Research

2 Patient and surgery characteristics for appendicectomies for appendicitis in children under 16 years of age, New South Wales,
2002e2013*
Number of operations (proportion of appendicectomies in this group and year)

Open appendicectomy Laparoscopic appendicectomy

Both operation
Patient and surgery characteristics forms 2002e2013 2002e2013 2002e2005 2006e2009 2010e2013
All patients 23 961 12 300 (51.3%) 11 661 (48.7%) 1478 (19.5%) 3712 (47.1%) 6471 (76.2%)
Age (years)
0e4 691 (2.9%) 497 (71.9%) 194 (28.1%) 10 (4.7%) 41 (19.9%) 143 (52.2%)
5e8 3528 (14.7%) 2229 (63.2%) 1299 (36.8%) 96 (8.7%) 355 (31.6%) 848 (64.9%)
9e11 7448 (31.1%) 4202 (56.4%) 3246 (43.6%) 394 (15.5%) 996 (41.6%) 1856 (73.8%)
12e15 12 294 (51.3%) 5372 (43.7%) 6922 (56.3%) 978 (26.2%) 2320 (55.8%) 3624 (82.4%)
Sex
Boys 13 794 (57.6%) 7726 (56.0%) 6068 (44.0%) 599 (13.8%) 1867 (41.0%) 3602 (73.3%)
Girls 10 167 (42.4%) 4574 (45.0%) 5593 (55.0%) 879 (27.0%) 1845 (55.5%) 2869 (80.1%)
Socio-economic disadvantage (quintile)
1 (most disadvantaged) 5237 (21.9%) 2247 (42.9%) 2990 (57.1%) 332 (21.1%) 988 (57.7%) 1670 (85.4%)
2e4 14 529 (60.6%) 7776 (53.5%) 6753 (46.5%) 914 (19.6%) 2113 (44.5%) 3726 (72.9%)
5 (least disadvantaged) 4082 (17.0%) 2227 (54.6%) 1855 (45.4%) 224 (17.1%) 579 (42.1%) 1052 (75.1%)
Pre-existing chronic diseases or major congenital anomalies†
Yes 669 (2.8%) 403 (60.2%) 266 (39.8%) 76 (20.3%) 84 (54.5%) 106 (75.2%)
No 23 292 (97.2%) 11 897 (51.1%) 11 395 (48.9%) 1402 (19.4%) 3628 (47.0%) 6365 (76.2%)
Co-existing diagnosis‡
Yes 1646 (6.9%) 447 (27.2%) 1199 (72.8%) 131 (42.5%) 344 (70.8%) 724 (85.0%)
No 22 315 (93.1%) 11 853 (53.1%) 10 462 (46.9%) 1347 (18.5%) 3368 (45.6%) 5747 (75.2%)
Hospital
Tertiary paediatric 6125 (25.6%) 2628 (42.9%) 3497 (57.1%) 237 (15.9%) 1092 (54.0%) 2168 (82.9%)
Metropolitan 6124 (25.6%) 2740 (44.7%) 3384 (55.3%) 474 (21.7%) 1085 (57.0%) 1825 (89.6%)
Regional/rural 9356 (39.0%) 5809 (62.1%) 3547 (37.9%) 511 (17.4%) 1090 (33.8%) 1946 (60.9%)
Private 2356 (9.8%) 1123 (47.7%) 1233 (52.3%) 256 (26.2%) 445 (60.9%) 532 (82.2%)
Transfers from other hospitals
Yes 2888 (12.1%) 1415 (49.0%) 1473 (51.0%) 124 (16.5%) 446 (45.3%) 903 (78.3%)
No 21 073 (87.9%) 10 885 (51.7%) 10 188 (48.3%) 1354 (19.8%) 3266 (47.4%) 5568 (75.8%)
Type of appendicitis
Uncomplicated 19 336 (80.7%) 9738 (50.4%) 9598 (49.6%) 1300 (20.4%) 3245 (49.4%) 5053 (78.9%)
Complicated 4625 (19.3%) 2562 (55.4%) 2063 (44.6%) 178 (14.7%) 467 (35.5%) 1418 (67.7%)
Season of surgery
Summer 5897 (24.6%) 3211 (54.5%) 2686 (45.5%) 332 (17.5%) 854 (43.3%) 1500 (74.0%)
Autumn 5929 (24.7%) 3112 (52.5%) 2817 (47.5%) 331 (17.6%) 882 (46.1%) 1604 (75.1%)
Winter 5937 (24.8%) 2973 (50.1%) 2964 (49.9%) 380 (20.8%) 926 (48.0%) 1658 (76.0%)
Spring 6198 (25.9%) 3004 (48.5%) 3194 (51.5%) 435 (21.9%) 1050 (50.9%) 1709 (79.6%)
Day of surgery
Weekday 18 210 (76.0%) 9273 (50.9%) 8937 (49.1%) 1122 (19.6%) 2875 (47.9%) 4940 (76.3%)
16 July 2018

Weekend 5751 (24.0%) 3027 (52.6%) 2724 (47.4%) 356 (19.2%) 837 (44.5%) 1531 (75.9%)
* To conserve space, only the summary data for open appendicectomies are included in this table; the full data are included in table 2 of the online Appendix. The data are also
presented with column percentages in the online Appendix as table 3. † Diabetes, chronic kidney disease, obesity, chronic asthma, epilepsy, heart or other major anomalies.
‡ Secondary diagnosis of peritoneal adhesions, Meckel diverticulum, volvulus, ileus, ovarian cysts. u
j
MJA 209 (2)

Open appendicectomy was associated with longer hospital stays children undergoing appendicectomy, the proportion staying
than laparoscopic appendicectomy; 56% of children with for longer than 5 days decreased with age: 0e4 years, 57% (392
complicated appendicitis who underwent open appendicectomy children); 5e8 years, 22% (784 children); 9e11 years, 14% (1053
82 stayed for more than 5 days, compared with 46% of those who children); 12e15 years, 13% (1612 children) (for trend,
underwent laparoscopic appendicectomy (Box 3). For all P < 0.001).
 Research

3 Outcomes of appendicectomies for appendicitis in children under 16 years of age, New South Wales, 2002e2013
Uncomplicated appendicitis Complicated appendicitis

Open Laparoscopic Open Laparoscopic

Outcomes following appendicectomy appendicectomy appendicectomy appendicectomy appendicectomy
Number of patients 9738 9598 2562 2063
Length of hospital stay (days)
<2 1082 (11.1%) 1808 (18.8%) 86 (3.4%) 154 (7.5%)
2e3 4014 (41.2%) 3857 (40.2%) 290 (11.3%) 381 (18.5%)
4e5 3884 (39.9%) 3230 (33.7%) 753 (29.4%) 581 (28.2%)
5 758 (7.8%) 703 (7.3%) 1433 (55.9%) 947 (45.9%)
Complications during initial admission
Post-operative intestinal obstruction 34 (0.3%) 27 (0.3%) 104 (4.1%) 68 (3.3%)
Post-operative intra-abdominal abscess 0 0 19 (0.7%) 24 (1.2%)
Respiratory complications 21 (0.2%) 15 (0.2%) 36 (1.4%) 13 (0.6%)
Complications of other organs, or unspecified 35 (0.4%) 49 (0.5%) 35 (1.4%) 35 (1.7%)
Wound infections or sepsis 21 (0.2%) 20 (0.2%) 98 (3.8%) 41 (2.0%)
Adverse effect of therapeutic drugs 53 (0.5%) 57 (0.6%) 33 (1.3%) 31 (1.5%)
Any post-operative complication 146 (1.5%) 174 (1.8%) 266 (10.4%) 184 (8.9%)
Complications during re-admission (within 28 days)
Intestinal obstruction 28 (0.3%) 14 (0.1%) 45 (1.8%) 22 (1.1%)
Intra-abdominal abscess 41 (0.4%) 43 (0.4%) 89 (3.5%) 48 (2.3%)
Wound infections or sepsis 94 (1.0%) 109 (1.1%) 131 (5.1%) 66 (3.2%)
Symptomatic (abdominal pain, fever, nausea or vomiting) 86 (0.9%) 144 (1.5%) 60 (2.3%) 53 (2.6%)
Any post-operative complication requiring re-admission* 301 (3.1%) 361 (3.8%) 290 (11.3%) 167 (8.1%)
Any re-admission 395 (4.1%) 478 (5.0%) 319 (12.5%) 196 (9.5%)
Re-presentation to emergency department (within 28 days), not requiring hospital admission
Symptomatic (abdominal pain, fever, nausea or vomiting) 60 (0.6%) 128 (1.3%) 45 (1.8%) 48 (2.3%)
Wound infections or sepsis 48 (0.5%) 52 (0.5%) 25 (1.0%) 15 (0.7%)
Any post-operative complication 164 (1.7%) 221 (2.3%) 100 (3.9%) 79 (3.8%)
Any emergency department presentation 291 (3.0%) 442 (4.6%) 152 (5.9%) 123 (6.0%)
All complications
Intestinal obstruction† 54 (0.6%) 38 (0.4%) 141 (5.5%) 89 (4.3%)
Intra-abdominal abscess 41 (0.4%) 45 (0.5%) 107 (4.2%) 72 (3.5%)
Wound infections or sepsis† 151 (1.6%) 175 (1.8%) 239 (9.3%) 118 (5.7%)
Any post-operative complication† 569 (5.8%) 708 (7.4%) 586 (22.9%) 388 (18.8%)
* Includes post-operative complications of nervous, endocrine, circulatory, other digestive, or genito-urinary systems, and complications related to anaesthesia. † Some children
had complications during surgery admission and within 28 days of separation; as a result, total figures may not equal sum of the individual components. u

Uncomplicated appendicitis Laparoscopic appendicectomy was associated with lower odds of

For children with uncomplicated appendicitis, the post-operative intestinal obstruction (aOR, 0.59; 95% CI, 0.36e0.97), but not of
complication rate after laparoscopic appendicectomy was higher intra-abdominal abscess or wound infections (Box 4).
than for open appendicectomy (7.4% v 5.8%), chiefly because the
MJA 209 (2)

rates of re-admission (5.0% v 4.1%) and re-presentation to EDs were Complicated appendicitis
higher (4.6% v. 3.0%) (Box 3). In cases of complicated appendicitis, post-operative complications
were more frequent following open appendicectomy (22.9% v 18.8%).
Children under 9 years of age were more likely to have a compli-
j

There was no difference in the overall frequency of complications

16 July 2018

cation than those aged 12e15 years; those with pre-existing con-
during the initial admission, but open appendicectomy was associ-
ditions or co-existing intra-abdominal diagnoses at time of
ated with more respiratory complications and wound infections.
operation were more likely to have complications than those who
Re-admission within 28 days of discharge was more frequent
did not. After adjusting for patient and surgery factors, there was
following open appendicectomy (12.5% v 9.5%), particularly because
no association between type of operation and having any post-
of intra-abdominal abscess and wound infections (Box 3).
operative complications (laparoscopic v open appendicectomy:
adjusted odds ratio [aOR)], 1.13; 95% confidence interval [CI], The odds of any post-operative complication (aOR, 0.78; 95% CI, 83
0.98e1.30) (online Appendix, table 4). 0.68e0.90) (online Appendix, table 5) and of wound infections
 Research

4 Simple and multivariate analysis of complications by operation mode

Post-operative complications

Open appendicectomy Laparoscopic appendicectomy Crude odds ratio* Adjusted odds ratio*
Uncomplicated appendicitis
Any complication 569 (5.8%) 708 (7.4%) 1.28 (1.14e1.44) 1.13 (0.98e1.30)
Intestinal obstruction 54 (0.6%) 38 (0.4%) 0.72 (0.45e1.14) 0.59 (0.36e0.97)
Intra-abdominal abscess 41 (0.4%) 45 (0.5%) 1.12 (0.74e1.70) 1.12 (0.73e1.70)
Wound infections 151 (1.6%) 175 (1.8%) 1.24 (0.96e1.59) 1.11 (0.81e1.52)
Complicated appendicitis
Any complication 586 (22.9%) 388 (18.8%) 0.77 (0.66e0.90) 0.78 (0.68e0.90)
Intestinal obstruction 141 (5.5%) 89 (4.3%) 0.77 (0.55e1.08) 0.76 (0.53e1.08)
Intra-abdominal abscess 107 (4.2%) 72 (3.5%) 0.80 (0.59e1.10) 0.94 (0.63e1.39)
Wound infections 239 (9.3%) 118 (5.7%) 0.60 (0.51e0.72) 0.55 (0.44e0.69)
Complicated appendicitis†
Any complication 471 (22.8%) 211 (23.9%) 1.05 (0.91e1.23) 0.98 (0.83e1.16)
Intestinal obstruction 113 (5.5%) 49 (5.6%) 1.01 (0.67e1.52) 0.97 (0.62e1.52)
Intra-abdominal abscess 95 (4.6%) 47 (5.3%) 1.09 (0.82e1.46) 1.06 (0.72e1.55)
Wound infections 193 (9.3%) 69 (7.8%) 0.84 (0.66e1.08) 0.67 (0.50e0.90)
* Laparoscopic v open appendicectomy; adjusted odds ratio adjusted for all patient and surgery characteristics, period (years), and clustering within hospitals. † Sensitivity
analysis: 1674 patients with localised peritonitis were omitted. u

(aOR, 0.55; 95% CI, 0.44e0.69) were lower for laparoscopic appendicitis, the authors of the systematic review found no differ-
appendicectomy, but there was no association between the type of ences between the two operation types with regard to the overall
operation and intestinal obstruction or intra-abdominal abscess incidence of post-surgery complications and the odds of intestinal
(Box 4). After excluding 1674 cases with localised peritonitis, there obstruction.5 The differing findings regarding the latter might
was no association between type of operation and any post- reflect different definitions of bowel obstruction and different levels
operative complication (aOR, 0.98; 95% CI, 0.83e1.16), intestinal of follow-up. An earlier meta-analysis found a 50% reduced risk of
obstruction (aOR, 0.97; 95% CI, 0.62e1.52), or intra-abdominal bowel obstruction after laparoscopic appendicectomy in children.13
abscess (aOR, 1.06; 95% CI, 0.72e1.55); the odds of wound infec-
The 2012 review also found that laparoscopic appendicectomy was
tion following laparoscopic appendicectomy were lower (aOR,
associated with shorter hospital lengths of stay for both uncom-
0.67; 95% CI: 0.50e0.90).
plicated and complicated appendicitis.5 We found similar results
for the initial admission, but we also found a higher re-presentation
Discussion rate following laparoscopic appendicectomy for uncomplicated
appendicitis. It is possible that children undergoing laparoscopic
We found that laparoscopic appendicectomies as a proportion of
appendicectomy recover more slowly than is recognised, and that
all appendicectomies in children with uncomplicated or compli-
the discomfort of laparoscopy may take time to subside.14 Children
cated appendicitis rose markedly during 2002e2013. In general,
have smaller abdominal cavities than adults, and insufflation with
outcomes were similar for laparoscopic and open appendicectomy,
carbon dioxide is often required for a laparoscopic appendicec-
and the overall complication rates were also similar for most age
tomy; the additional stretching of the anterior abdominal wall and
groups and hospital types. However, children with uncomplicated
diaphragm can cause post-operative discomfort. It is also possible
appendicitis undergoing laparoscopic appendicectomy were more
that the perceived advantages of laparoscopic appendicectomy for
likely to be re-admitted to hospital or to re-present to an emergency
recovery may not apply to children. The balance between early
department with symptoms of abdominal pain or fever, although
discharge and increased rates of re-admission and re-presentation
less likely to have post-operative intestinal obstruction. For
should be more comprehensively evaluated — including consid-
complicated appendicitis, laparoscopic appendicectomy was
eration of post-operative outcomes and pain management,
associated with reduced odds of wound infection.
16 July 2018

discharge criteria, and post-discharge care and health costs — in

During the past 20 years, laparoscopic appendicectomy has order to optimise the initial admission length of stay while
become the standard procedure for treating acute appendicitis in reducing the likelihood of re-presentation.
children.4 Our finding that 86% of cases were managed with
For children with complicated appendicitis, our findings are
j

laparoscopic appendicectomy in 2013 is similar to reported rates in

MJA 209 (2)

consistent with those of the 2012 systematic review, which reported

the United States (2010, 90%)8 and the Netherlands (2010, 94%),9
a lower overall risk of complications and of wound infections after
and higher than in Germany (2010e2012, 76%),10 Canada (2010,
laparoscopic appendicectomy.5 A recent German population-
66%)11 and Taiwan (2012, 57%).12
based study of 8110 patients also reported that the risk of
The post-operative outcome rates we report are only partially re-admission for complications was reduced after laparoscopic
consistent with the findings of the most recent relevant systematic appendicectomy.10 We found no association between surgical
84 review, which pooled the results of 19 studies (2000e2011) technique and intra-abdominal abscess, and the findings of other
encompassing 107 000 children.5 For children with uncomplicated studies have been inconsistent,5,9,12 perhaps because of differences
 Research
in peri-operative management, surgical technique, and the The main strength of our study is its analysis of large, record-linked
reporting of intra-abdominal abscess. This is highlighted by the population-based datasets, providing robust and generalisable
results of our sensitivity analysis: after cases of appendicitis with results. This is the first investigation of post-appendicectomy pre-
localised peritonitis (milder complicated cases) were excluded, sentations to emergency departments. One limitation is that we did
differences in the odds of post-operative complications between not have pathology information that confirmed the diagnosis of
open and laparoscopic appendicectomy were no longer evident. appendicitis; however, we restricted our analysis to children with a
This supports the interpretation that lower rates of post-operative primary diagnosis of appendicitis to mitigate this potential bias.
complications after laparoscopic appendicectomy are explained by Further, we did not have information about whether appendicec-
case selection, as complex cases are more likely to proceed to open tomies were performed by paediatric or general surgeons. How-
appendicectomy. Similarly, the reduced likelihood of complica- ever, the emergency services provided by paediatric surgeons
tions for children undergoing appendicectomy in private hospitals outside tertiary paediatric hospitals are very limited in NSW.
may also reflect the lower complexity of their cases. Results from a recent systematic review suggest that there are no
differences in the rates of post-surgery complications, re-
We found that the outcomes for children managed in metropolitan, admissions, and mortality following appendicectomies in
regional or rural general hospitals were not different from those for children performed by general and paediatric surgeons.20
children who were treated in tertiary paediatric hospitals, regardless
of age. This is consistent with findings of similar post-surgery out- Conclusion
comes for high, medium and low volume children’s hospitals in
Laparoscopic appendicectomy is now the most common surgical
California.3 Another Californian study found no effect of age on
approach to managing appendicitis in children. The lower incidence
post-operative wound infection and intra-abdominal abscess rates
of bowel obstruction following laparoscopic appendicectomy in
following complicated and uncomplicated appendicitis.15
children with uncomplicated appendicitis, and the similar rates in
Our results have important implications for managing emergency complicated appendicitis following either surgical approach, sup-
surgery for children. During the middle of the first decade of this port preferring laparoscopic appendicectomy for children. How-
century, children in NSW with non-complex emergency surgical ever, the balance between earlier discharge and higher rates of
conditions, such as appendicitis, were often transferred from re-presentations and re-admission after laparoscopic appendicec-
metropolitan general hospitals to tertiary paediatric hospitals.16,17 tomy require further evaluation. For children with complicated
In response to this problem, a statewide paediatric surgery appendicitis, post-operative complications were more likely to be
framework was proposed in 200818 and adopted in 2014.19 The associated with the severity of the condition than with the type of
framework aimed to facilitate the care of children with non- surgery. Our findings support the current NSW framework for the
complex emergency surgical conditions at metropolitan general surgical management of acute appendicitis in children.
hospitals, reducing waiting times, delays in appropriate care, and Acknowledgements: We thank the NSW Ministry of Health for providing access to population
unnecessary travel or hospital transfers for the families of children health data, and the NSW Centre for Health Record Linkage for linking the datasets. The findings and
views reported in this study, however, are those of the authors. This work was funded by a National
who required an appendicectomy. We found an encouraging Health and Medical Research Council (NHMRC) Project Grant (APP1047263). Natasha Nassar was
reduction in the proportion of children transferred to paediatric supported by an NHMRC Career Development Fellowship (APP1067066).
tertiary hospitals since 2010, which suggests a positive response to
this framework by non-paediatric hospitals. Our findings indicate Competing interests: No relevant disclosures.

that the framework is safe, supporting the recommendation to Received 5 June 2017, accepted 3 Oct 2017. n
further lower the age threshold at non-paediatric hospitals to 8
years. ª 2018 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved.

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