Laparoscopic vs open appendectomy in specific patient groups

Introduction: Laparoscopic appendectomy, once considered a novelty and now established as the standard procedure for most patients, stands as a dilemma when it comes to certain specific patient groups: pregnant women, the elderly (≥ 65 years), children, patients with severe comorbidities, or those with a history of previous abdominal surgeries.
Methods: This article aims to conduct a systematic review of the global medical literature published between 2005 and 2025 to address the ongoing debate over whether open or laparoscopic appendectomy should be the preferred approach in these specific groups. All major medical databases were searched, and the identified relevant studies were analyzed. Systematic reviews, meta-analyses, and large cohorts were prioritized. Additionally, the article incorporates our institutional experience at Burgasmed Hospital over a six-year period (2019-2025), encompassing 321 patients of varying ages.
Results: Studies on pregnant patients with acute appendicitis report heterogeneous findings regarding fetal loss and safety. Some demonstrate a higher rate of miscarriages following a laparoscopic intervention, but also show a shorter hospital stay and fewer wound complications. Recent studies published after 2010 highlight the acceptability of laparoscopic appendectomy in pregnant patients, provided that the procedure is performed by an experienced surgical team, in coordination with an obstetrician-gynecologist, with appropriate equipment available, and with careful consideration of the patient’s condition (including proper positioning and maintenance of low insufflation pressure) up to the end of the second trimester. For pregnant women in the third trimester, open appendectomy remains the preferred method of choice.
For pediatric patients, meta-analyses indicate that laparoscopic appendectomy is associated with fewer wound complications and a shorter hospital stay, with no significant difference in operative time.
Among elderly and polymorbid patients, existing studies support the advantages of laparoscopic appendectomy if the patient's condition allows for its safe and feasible conduct. However, in cases of complicated acute appendicitis, conventional appendectomy is recommended. Prior abdominal surgery is not an absolute contraindication for laparoscopy, but it is associated with an increased risk of conversion.
Conclusion: There is no universal or single correct approach. The choice whether to perform a laparoscopic or open appendectomy must be made based on a patient`s individual case, specific clinical circumstances, and the surgical team’s expertise.