Surgery or antibiotics?
Keyhole surgery remains the standard, and antibiotics alone have become an option for some children.
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Antibiotics alone against surgery, 1,068 children with an uncomplicated appendix
| Outcome at one year |
Antibiotics first |
Laparoscopic appendectomy |
| Children who chose it |
370 |
698 |
| Avoided surgery for a year |
67.1 percent |
Not applicable |
| Days unable to do normal activities |
6.6 |
10.9 |
Antibiotics alone
When antibiotics alone are not suitable
A ruptured appendix, an abscess, a hard stone in the appendix on ultrasound, peritonitis, a very sick child or a family unable to return quickly if pain comes back all point to surgery. Surgeons offer antibiotics alone only to selected children with a clearly uncomplicated appendix.
What the American study showed
Ten children's hospitals offered families of children aged 7 to 17 with an uncomplicated appendix a choice between antibiotics alone and keyhole surgery within twelve hours. Of 1,068 children, 370 chose antibiotics. At one year, 67.1 percent of them had avoided an operation, and they had missed fewer days of normal activities, 6.6 against 10.9.
The authors noted the limits. A quarter of families were lost to follow-up, the success rate did not clearly reach the 70 percent target, and the difference in missed days was smaller than expected. A third still needed their appendix out within the year, some in the first weeks and others months later, with the family possibly far from the hospital that first treated them. For a traveling family, that possibility weighs heavily, and most choose surgery.
Laparoscopic appendectomy
Keyhole surgery has replaced the open operation in most children's hospitals.
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Keyhole against open appendectomy in children, 6,477 patients
| Outcome |
Laparoscopic |
Open |
| Wound infection |
1.5 percent |
5 percent |
| Ileus, a pause in bowel function |
1.3 percent |
2.8 percent |
| Hospital stay |
Half a day shorter on average |
Reference |
The results of this meta-analysis suggest that laparoscopic appendectomy in children reduces complications.
Meta-analysis of 23 studies, Annals of Surgery, 2006
How the operation is done
Under general anesthesia, the surgeon makes three small cuts, or one at the navel, inflates the abdomen with gas, finds the appendix with a camera, seals its blood supply and base, and removes it in a bag. Any pus is washed out. The operation lasts 30 to 60 minutes. Dissolving stitches close the small cuts.
Perforated appendicitis
The rate of appendiceal rupture in school-aged children was associated with race and health insurance status and not with negative appendectomy rate and therefore is more likely to be associated with prehospitalization factors such as access to care.
Study of 24,411 appendectomies, JAMA, 2004
Why time matters
In the American study of 36 children's hospitals, the median rupture rate was 35.08 percent, ranging from 22 to 62 percent between hospitals, and children with less access to care ruptured more frequently. The negative appendectomy rate, removing a normal appendix, was 3.06 percent and fell as hospital experience grew. Families should seek care early. Hospitals should diagnose carefully. Not every child with abdominal pain needs an operation. Experienced pediatric surgeons, a careful repeat examination and good ultrasound therefore matter more than any single test.
1
Day of surgery
Admission, fluids, antibiotics and pain relief, then surgery within hours of the diagnosis.
2
Uncomplicated appendix
Eating and walking the same evening, home after one to two days, no antibiotics after surgery for the majority.
3
Ruptured appendix
Antibiotics through a vein for several days, then by mouth, home after four to seven days once fever has settled and the child eats well.
Recovery at home
Paracetamol and ibuprofen control the pain. Children return to school in three to five days after an uncomplicated operation, and to sport and swimming after two to three weeks. Fever returning after a few days, increasing abdominal pain, vomiting or redness and discharge from the cuts can mean an abscess or wound infection and need a doctor.
For families in Istanbul
Families on holiday or living in Istanbul can reach our pediatric surgery team around the clock. The length of stay is one to two days after an uncomplicated operation and four to seven after a rupture. Flying home is safe once the child eats, walks and has no fever, a week after surgery for the majority, and a short check before the flight confirms the wounds are healing.
Some children receive antibiotics first. For an abscess, or by the family's choice, the surgeon later recommends removing the appendix weeks to months afterward, an interval appendectomy. Families can plan this operation in advance, with the visa letter, transfer and a hotel for the parents arranged by the international patients office. The team works in seven languages, halal, vegetarian and diabetic meals are served, a parent stays with the child throughout, and a prayer room is on site. Back home, the coordinator stays reachable on WhatsApp, and the pathology report of the appendix follows within a week, together with a summary for your family doctor or pediatrician that lists the operation, the antibiotics given, the stitches used and the signs that should prompt a visit, so that anyone who sees the child afterward, in Istanbul or at home, knows exactly what was done and what to watch for in the first weeks.
Cost depends on the type of appendicitis, the hospital days and the antibiotics, and we discuss it with the family once the child is safe, never before treatment starts.
Pediatric appendectomy FAQ
What are the first signs of appendicitis in a child?
Pain around the navel moving to the lower right abdomen, loss of appetite, nausea or vomiting and fever. Toddlers may only be irritable, refuse to walk and have a swollen tummy.
Can appendicitis in children be treated without surgery?
In selected children with an uncomplicated appendix, antibiotics alone avoided surgery for a year in 67.1 percent in a large American study. A third still needed surgery.
Is keyhole surgery better than open surgery for children?
A meta-analysis of 6,477 children found fewer wound infections, 1.5 against 5 percent, and shorter hospital stays with keyhole surgery.
How long will my child stay in hospital?
One to two days for an uncomplicated appendix, four to seven days after a rupture.
When can we fly home after appendectomy?
Once the child eats, walks and has no fever, a week after surgery for the majority.
Can a parent stay with the child?
Yes. A parent stays with the child throughout the hospital stay.
References
- Samuel M. Pediatric appendicitis score. Journal of Pediatric Surgery. 2002;37(6):877-881.
- Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology. 2006;241(1):83-94.
- Minneci PC, Hade EM, Lawrence AE, et al. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis. JAMA. 2020;324(6):581-593.
- Aziz O, Athanasiou T, Tekkis PP, et al. Laparoscopic versus open appendectomy in children: a meta-analysis. Annals of Surgery. 2006;243(1):17-27.
- Ponsky TA, Huang ZJ, Kittle K, et al. Hospital- and patient-level characteristics and the risk of appendiceal rupture and negative appendectomy in children. JAMA. 2004;292(16):1977-1982.
