Discussion about the superiority of LA versus OA is as old as the laparoscopic procedure itself. In the meantime the advantages of the laparoscopic procedure in adults seem to be accepted . In children the relevance of LA is still on debate . Previous studies showed several disadvantages of LA in children: longer operative time, increased risk for intraabdominal abscess etc. [1, 14, 15]. However, meta-analysis and large database analyses were unable to confirm these findings . Beside this, large cohort studies showed a rapid increase of the proportion of laparoscopically performed appendectomies in children over the last 10 years: the frequency of LA increased up to 50% [15, 17]. This correlates with the data presented here showing an increase of the laparoscopic proportion from 5% at the beginning of the evaluation to 75% at the end.
The proportion of perforated appendicitis in the study presented here is with 14 vs. 12% lower than in large cohort studies  but is comparable with other published studies . Furthermore, the conversion rate of 6.6% in our study is similar to other retrospective and randomised studies in children . The same holds true for early postoperative complications. Our rate of complications is being also comparable with large database analyses and multicentre analyses for children [15, 18].
An often applied argument against LA is the longer operative time . Compared to published studies focussing on children the operative time in our study has to be considered as quite short. The median operative time for LA is with 30 min significantly shorter than the operative time for OA (38 min). The clinical relevance of this difference however, is only of minor importance .
The early postoperative results of this study are not the primary endpoint of this study and were only described to show that this is a representative study population which is comparable to published studies regarding the primary complication rate [15, 17].
Instead, our primary endpoint is the long term quality of life. The question investigated here is how operated children would apprehend possible constrictions following OA or LA and judge those in a different manner. It is interesting that, while for other laparoscopic procedures quality of life comparisons exist, for comparison of LA vs. OA in general only two studies could be retrieved evaluating this fact. Unfortunately, these studies included only patients older than 14 or 16 years [7, 8]. Furthermore, these studies evaluated only the first half year after operation. This is a short period of time compared to our seven years re-evaluation period. We applied the SF-36 questionnaire an established tool for evaluation of quality of life [9, 21, 22]. This tool is applicable for children up to 14 years [23, 24]. Even younger children are able to provide valid answers in such as questionnaires . The differences between the laparoscopic and open operative procedure for appendectomy are not significant in this study as both operations are comparable with respect to all eight investigated scores of the SF-36 which is in accordance with other studies comparing laparoscopic and open procedure. In general measurable early postoperative advantages of the laparoscopic procedure appear to decrease over time [26, 27].
Evaluation of questions concerning the operation directly shows a significantly higher satisfaction of the patients in the laparoscopic group concerning size and appearance of scars. The disposition to recommend the laparoscopic procedure to family members or friends may be based on this higher level of satisfaction with the scar.
The number of long term complications after seven years are equal in both operation groups since two patients in the open group and three patients in the laparoscopic group reported complications. Therefore, it may be considered interesting that intestinal adhesions were the main reason in the laparoscopic group. This matches with other findings which report that laparoscopic procedures do not reduce clinical relevant adhesions connected with pain or bowel obstruction .
Regarding the results of this study it should be taken into account that this is a retrospective study. No randomization was applied and the choice of operation method depended on the preferences of the surgeon. Nevertheless, randomized trials seldom report long term clinical outcomes such as quality of life. So, retrospective analyses can also give valuable information on postoperative quality of life . In general retrospective analyses are included in meta-analyses in children given the limited availability of data .
The limited recovery rate of 59% may be seen as a further limitation of this study. Evaluating this recovery rate one has to keep in mind that even large data base analyses for appendectomy in children do not achieve higher follow-up rates [15, 17]. Even though our sample size of approximately 80 patients per group may appear small it is still sufficient to show statistical significances for large to medium effect sizes. In this context it has to be pointed out that large sample size analyses have to be interpreted carefully since those are able to show statistical significances for small effect sizes with marginal differences which may be clinically unimportant [20, 29]. Same holds true for the question if girls in the long term judge the cosmetic benefit higher than boys. Given the sample size a possible clinical significance should be seen with care. Unfortunately this holds true for the question if patients who were children or adolescents at the time of surgery would state their current quality of life differently as well. This is the reason for not showing a detail analysis regarding these two interesting facts as part of this manuscript.
It may be seen as a problem of the presented study that the patients are not blinded and a bias in the provided answers cannot be fully excluded. There is the possibility that the perception of LA as a more modern procedure may have influenced the patients’ recommendation to family members and friends.
The long term results of this study correlate with other studies in adults regarding the quality of life for open vs. laparoscopic procedures. During the years after surgery the early postoperative advantages of the laparoscopic procedure minimize in comparison to the open procedure [26, 27, 30–32]. Only the cosmetic advantages experienced by the patient seem to remain, which would be an argument for the application of mini laparoscopic instruments (2.5 mm ports) or the use of single port techniques.