laparoscopic appendectomy , first performed by semm in 1983 , has become increasingly popular . the surgical management of complicated pediatric appendicitis ( gangrenous or perforated ) has been more controversial , and the role of laparoscopy in its treatment has not yet been established . intraabdominal abscess ( iaa ) can form after laparoscopic appendectomy ( la ) , especially in complicated cases and is associated with significant morbidity . the aim of our study was to establish the incidence of iaa formation in complicated pediatric appendicitis ( cpa ) treated with laparoscopy . pediatric patients presenting with acute appendicitis were identified from our prospectively collected database . between march 1996 and october 2001 , a standard 3-trocar technique is used with two 5-mm trocars and one 12-mm trocar for the introduction of the stapling device ( endogia , united states surgical corporation , norwalk , ct ) . the appendix is freed , and the mesoappendix is divided between applied clips or staples . the appendiceal base is divided with the stapling device ; the freed appendix is placed in an endoretrieval bag and removed . when present , a special effort is made to debride the fibrin peel from the peritoneum . patients with cpa have a jackson - pratt drain placed in the pelvis and right lower quadrant after completion of the appendectomy ; the drain exits through the suprapubic port site . after removal of the trocars , the fascia and the skin edges are approximated with absorbable sutures . postoperative analgesia and perioperative intravenous antibiotics are administered in the same fashion as in open appendectomy . noncomplicated cases received antibiotics only perioperatively , but patients with cpa received antibiotics during their entire hospital stay . an oral diet was resumed usually within 24 hours after admission . the diagnosis of acute appendicitis in all patients was based on clinical and computed tomography ( ct ) scan findings . patients with a positive ct scan underwent laparoscopy , and all of them had appendicitis . patients with vague symptoms and negative ct imaging were observed and did not undergo laparoscopy . thirty - five ( 67% ) male and 17 ( 33% ) female patients underwent surgery . five of the 52 patients ( 10% ) had cpa . among the patients with cpa were 2 female ( 40% ) and 3 ( 60% ) male patients ( table 1 ) . one of the 5 ( 20% ) patients with cpa developed postoperative intraabdominal abscess and underwent laparoscopic drainage during the same admission . the single postoperative abscess occurred early during our initial experience with laparoscopic appendectomy , and it was the first case of cpa performed laparoscopically . the average operative time for laparoscopic appendectomy has been 60 minutes ( range , 30 to 120 minutes ) and recently 40 minutes . in cases of cpa , the average operative time was 130 minutes ( range , 120 to 200 minutes ) . at the same time , the average length of stay after laparoscopy in noncomplicated acute appendicitis was one day . the cost of the laparoscopic surgery was difficult to calculate because of the retrospective nature of our study . in recent cases , the specifics of the equipment used were not always available except for the standard stapling device . all these patients underwent laparoscopic appendectomy plus drainage if the appendix was gangrenous or perforated . all patients with noncomplicated appendicitis were effectively and definitively treated with laparoscopy , and almost all of them were discharged home within 24 hours . our findings corroborate previously established knowledge that appendicitis can be safely and effectively treated in children through laparoscopy . up to 21% of patients presenting with acute appendicitis can have a perforated appendix . in our series , 5 ( 10% ) of the 52 patients presenting with acute appendicitis all of these 5 patients with cpa were treated with laparoscopy without conversion to open technique . although the patient underwent an extra laparoscopic procedure , it was well tolerated , and he was discharged home without other complications . this single complication occurred during the initial learning curve of laparoscopic appendectomy , was the first case of laparoscopic appendectomy performed for cpa at our institution , and was associated with a long operative time . since then , as experience has accumulated , no more complications have occurred after laparoscopic appendectomy for cpa . . a high degree of suspicion and liberal use of imaging helps in the diagnosis and early treatment of postoperative iaa . in a recent study , it was suggested that the placement of drains in the right lower quadrant might be beneficial in patients with perforated appendicitis and localized abscess cavities . in that study , it has been suggested in the past that laparoscopic appendectomy for cpa in children is not a safe procedure and should be avoided . our recent findings suggest that laparoscopy can be a reasonable therapeutic alternative to open appendicitis in these complicated cases . the incidence of postoperative iaa formation after laparoscopy in children with cpa varies anywhere between 5.8% and 41% . some of these abscesses are treated with antibiotics , but most of them require drainage . in another recent study , comparing laparoscopy to open appendectomy for cpa , no iaa occurred after la . it has been suggested that visualization of the abdominal cavity seems to be improved with laparoscopy . the pelvis and the abdominal cavity can be thoroughly irrigated , debrided , and drained . the surgery is less traumatic , and most patients return to their regular activities sooner . on the other hand , in cases of perforated appendicitis , anatomy can be obscure , and the operative time can be significantly prolonged . laparoscopy in complicated cases of acute appendicitis can be a challenging and technically demanding procedure that requires more than basic laparoscopic skills . there is limited tactile sensation , manipulation of inflamed tissues is difficult , and inadvertent injury to adjacent organs is possible . one should attempt laparoscopy in these complicated cases only after performance of many routine laparoscopic appendectomies . it can not be overemphasized that one should be prepared to convert early to an open appendectomy should a difficult case of cpa be encountered . that is especially true when the surgeon is on the initial part of the learning curve . our data were retrospectively collected , and the numbers are too small to draw safe conclusions . our findings and those of others suggest that laparoscopy might be a safe alternative even for cpa , but properly randomized , prospective studies will answer this question . complicated appendicitis in children can be effectively treated with laparoscopy by experienced laparoscopic pediatric surgeons . complicated appendicitis should not be considered a contraindication for laparoscopy , but more solid evidence is necessary before it becomes the standard treatment . close postoperative follow - up and a high index of suspicion for development of complications is essential . prospective randomized trials will be necessary to establish the role of laparoscopy in complicated appendicitis in the pediatric population .