Appendicitis surgery – keyhole or open?

Photo of a mother and daughter at the hospital

When people have appendicitis, their appendix is usually removed with minimally invasive surgery, through small cuts in their skin (keyhole surgery). But open surgery is also an option here. What are the pros and cons of these approaches?

Removing the appendix prevents an infection from spreading through the abdomen (belly area) and stops appendicitis coming back again. The medical term for the removal of the appendix is "appendectomy."

In the past, the procedure was always done with a cut in the lower belly that was several centimeters long (open surgery, medical term: "laparatomy"). But over time, minimally invasive “keyhole surgery” techniques have been further developed and improved. As a result, the appendix is now usually removed with keyhole surgery.

What does keyhole surgery involve?

In the keyhole procedure known as a “laparoscopy,” three small cuts are generally made in the skin and wall of the belly. The surgeon feeds a camera and the surgical instruments into the abdominal cavity (space in the belly) through thin tubes. They can then clearly see the appendix and the nearby organs on a monitor. They separate the appendix from the cecum (the pouch at the beginning of the large intestine) and remove it from the abdominal cavity through one of the tubes. A general anesthetic is used for this procedure.

Laparoscopic surgery to remove the appendix

What does open surgery involve?

In open surgery, the surgeon makes a cut (about 5 centimeters long) in the lower right part of the abdomen so that they can clearly see the area around the appendix from outside. The appendix is then cut off and removed. After that, the belly is sewn back together. This procedure is also done under general anesthesia.

How do the pros and cons of the different approaches compare?

In keyhole surgery, only small cuts have to be made in the skin, so no bigger scars are left on the lower abdomen. This minimally invasive procedure is generally considered to be gentler. Researchers from the Cochrane Collaboration (an international research network) have looked into this. They compared keyhole surgery with open surgery. They analyzed several studies where adults or children with appendicitis were treated with these procedures. But the studies were carried out in different ways, and not all of them were of good quality.

Overall, the researchers came to the conclusion that many (but not all) aspects of keyhole surgery were better than open surgery.

What are the pros and cons in adults and teenagers?

The adults and teenagers who had keyhole surgery in the studies were free of pain sooner after the operation. The length of time people had to stay in hospital, and how long it took them to return to their usual daily activities, varied a lot in both groups. But it can be said that the people who had keyhole surgery had to stay in hospital for one day less on average and could carry out their daily activities around five days sooner than those people who had open surgery.

Wound infections were less common after keyhole surgery than after open surgery:

30 out of 1,000 adults and teenagers who had keyhole surgery had a wound infection, compared to
68 out of 1,000 people who had open surgery.

But open surgery was found to have a slight advantage regarding another complication. Abscesses (pockets of pus) in the abdominal cavity were less common after open surgery than after keyhole surgery:

12 out of 1,000 adults and teenagers who had open surgery developed an abscess in the abdominal cavity, compared to
20 out of 1,000 people who had keyhole surgery.

In other words: Keyhole surgery prevented wound infections in 38 out of 1,000 adults who had an operation. But, compared to open surgery, it also lead to 8 more people out of 1,000 developing an abscess in the abdominal cavity. Other research groups reached similar conclusions.

Do these results also apply to children?

The Cochrane group’s research found that keyhole surgery also prevented wound infections in children:

11 out of 1,000 children who had keyhole surgery had a wound infection, compared to
42 out of 1,000 children who had open surgery.

So keyhole surgery prevented wound infections in 31 out of 1,000 children who had an operation.

Unlike with adults and teenagers, abdominal cavity abscesses were also less common in children after keyhole surgery. The studies comparing the procedures in children were less reliable, though.

Di Saverio S, Podda M, De Simone B et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15(1): 27.

Gorter RR, Eker HH, Gorter-Stam MA et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc 2016; 30(11): 4668-4690.

Jaschinski T, Mosch CG, Eikermann M et al. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2018; (11): CD001546.

Low ZX, Bonney GK, So JB et al. Laparoscopic versus open appendectomy in pediatric patients with complicated appendicitis: a meta-analysis. Surg Endosc 2019; 33(12): 4066-4077.

Poprom N, Wilasrusmee C, Attia J et al. Comparison of postoperative complications between open and laparoscopic appendectomy: An umbrella review of systematic reviews and meta-analyses. J Trauma Acute Care Surg 2020; 89(4): 813-820.

Talan DA, Di Saverio S. Treatment of Acute Uncomplicated Appendicitis. N Engl J Med 2021; 385(12): 1116-1123.

Teoule P, Laffolie J, Rolle U et al. Acute Appendicitis in Childhood and Adulthood. Dtsch Arztebl Int 2020; 117(45): 764-774.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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