Acute appendicitis remains one of the most frequent causes of abdominal surgical emergencies in children and adolescents worldwide, with an estimated lifetime risk of 7–9%.[1,2] Approximately 70,000–80,000 pediatric appendectomies are performed annually in the United States alone, and the disease exhibits a peak incidence between 10 and 14 years of age.[1,3] However, appendicitis in younger children — particularly those under 5 years — represents a distinct clinical entity marked by atypical symptomatology, rapid disease progression, and disproportionately high rates of perforation reaching 50–90%.[3,4] The pathogenesis involves luminal obstruction of the appendix by lymphoid hyperplasia, fecaliths, or, less frequently, foreign bodies, followed by rising intraluminal pressure, mucosal ischemia, bacterial invasion, and eventual necrosis or rupture.[4] In the pediatric population, the immature omentum and the relatively thin appendiceal wall predispose to earlier perforation and generalized peritonitis rather than a localized abscess.[3,18]. Clinical diagnosis of appendicitis in children is difficult because the classic migratory pain and localized right iliac fossa tenderness are not consistently elicited, especially in preverbal children.[7,18,19] Fever, vomiting, refusal to feed, and lethargy may dominate the clinical picture, mimicking gastroenteritis, urinary tract infection, or mesenteric adenitis. Consequently, diagnostic delays are common, with pre-hospital delays exceeding 48 hours reported in up to a third of patients.[8,14] Delayed diagnosis is a principal driver of perforation and associated morbidity, including intra-abdominal abscess, prolonged ileus, wound infection, and extended hospitalization.[8,14,20] To standardize clinical assessment, scoring systems such as the Alvarado score and the Pediatric Appendicitis Score (PAS) have been developed and validated.[5,6,21] Adjunctive imaging with graded-compression ultrasonography and, less commonly in pediatric practice, computed tomography have improved diagnostic accuracy.[11,12] Ultrasound is generally preferred in children owing to its lack of ionizing radiation, though its sensitivity is operator-dependent.[11,12] Appendectomy — whether open or laparoscopic — remains the definitive treatment.[4,15,16] Laparoscopic appendectomy has gained widespread acceptance in the pediatric population and is associated with shorter hospital stay, reduced wound infection rates, and superior cosmesis, although concerns regarding intra-abdominal abscess formation in perforated cases persist.[15,16] Despite the frequency of pediatric appendicitis, published data specific to the Indian pediatric population — particularly for children below 12 years — remain limited. Variations in health-seeking behavior, availability of diagnostic imaging, and referral patterns may influence both the clinical presentation and postoperative outcomes in this age group. A comprehensive understanding of these variables is essential for optimizing perioperative management and reducing morbidity. The present study was therefore undertaken to describe the clinical profile, operative findings, and postoperative outcomes of children below 12 years undergoing surgery for acute appendicitis at a tertiary care center, and to identify factors influencing complicated disease and length of hospital stay.

Study design and setting: This was a prospective observational study conducted in the Department of Pediatric Surgery at a tertiary care teaching hospital from January 2023 to December 2024 — a total study period of 24 months. Ethical clearance was obtained from the Institutional Ethics Committee prior to initiation, and written informed consent was obtained from the parents or legal guardians of every enrolled child. Study population: All children aged below 12 years admitted with a clinical diagnosis of acute appendicitis and undergoing surgical intervention during the study period were considered eligible. Inclusion criteria: (i) age below 12 years at presentation; (ii) clinical, laboratory, and/or radiological diagnosis of acute appendicitis; and (iii) intra-operative confirmation of appendicitis with histopathological correlation. Exclusion criteria: (i) interval appendectomy or elective appendectomy performed for chronic pain; (ii) children managed non-operatively; (iii) cases with an alternate final diagnosis on histopathology (e.g., Meckel’s diverticulitis, mesenteric adenitis without appendicitis); and (iv) refusal of consent. Clinical assessment: All patients underwent a structured history focusing on the duration and character of abdominal pain, migration of pain, vomiting, fever, anorexia, altered bowel habit, and urinary symptoms. Detailed physical examination emphasized abdominal signs, including tenderness at McBurney’s point, rebound tenderness, guarding, rigidity, and Rovsing’s sign. The Pediatric Appendicitis Score (PAS) as described by Samuel was calculated for each patient.[5] Laboratory workup: Total leukocyte count, differential count, C-reactive protein (CRP), urinalysis, and serum electrolytes were obtained at admission. Leukocytosis was defined as a total leukocyte count >11,000/μL and neutrophilia as >75%. CRP >10 mg/L was considered elevated. Imaging: Abdominal ultrasonography was performed by an experienced radiologist as the primary imaging modality. Sonographic diagnostic criteria included a non-compressible, blind-ending tubular structure with a maximum outer diameter >6 mm, wall thickness >3 mm, peri-appendiceal fluid or fat stranding, and/or the presence of an appendicolith.[11] Contrast-enhanced computed tomography was used selectively when ultrasonography was inconclusive.[12] Surgical management: All patients received preoperative intravenous fluids, a third-generation cephalosporin with metronidazole, and analgesia. The choice of surgical approach — open or laparoscopic — was left to the operating surgeon’s discretion, taking into account the child’s clinical status, availability of equipment, and preoperative suspicion of complicated appendicitis. Open appendectomy was performed through a right lower quadrant Lanz or grid-iron incision. Laparoscopic appendectomy used the standard three-port technique. Intra-operative findings — extent of inflammation, perforation, gangrene, peri-appendiceal collection, and generalized peritonitis — were recorded. Perforation was defined as a visible hole in the appendix or a fecalith free in the abdomen.[22] The resected appendix was sent for histopathological examination in all cases. Postoperative follow-up: Patients were monitored for pain, fever, wound status, resumption of oral intake, passage of stools, and complications. Antibiotics were continued for 3–7 days depending on operative findings. Postoperative complications — including surgical site infection (SSI), intra-abdominal collection, prolonged ileus, wound dehiscence, and re-admission within 30 days — were documented. Length of hospital stay was recorded from the date of surgery to discharge. Statistical analysis: Data were entered in Microsoft Excel and analyzed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequencies and percentages. Comparisons between groups were performed using the chi-square test or Fisher’s exact test for categorical variables, and the Student’s t-test or Mann–Whitney U test for continuous variables, as appropriate. A p-value <0.05 was considered statistically significant.

During the 24-month study period, 128 children below 12 years of age underwent surgery for acute appendicitis and were included in the final analysis. Demographic profile: The mean age of the cohort was 8.4 ± 2.6 years (range 3–11 years). Eighty-one children (63.3%) were male and 47 (36.7%) were female, giving a male-to-female ratio of 1.72:1. The age distribution demonstrated a peak incidence in the 9–11 year group (Table 1, Figure 1). Table 1. Age and sex distribution of study population (n = 128) Age group Males, n Females, n Total, n Percentage (%) ≤5 years 14 7 21 16.4 6–8 years 27 15 42 32.8 9–11 years 40 25 65 50.8 Total 81 47 128 100.0 Presenting symptoms and signs: Abdominal pain was universal (100%). Migration of pain from the periumbilical region to the right iliac fossa was elicited in 71 children (55.5%). Vomiting was present in 101 (78.9%), fever in 84 (65.6%), anorexia in 75 (58.6%), and loose stools in 22 (17.2%). The duration of symptoms at presentation ranged from 8 to 96 hours, with a mean of 38.2 ± 20.4 hours. Right iliac fossa (RIF) tenderness was the most consistent physical sign (96.1%). Table 2 summarizes the frequency of presenting features. Table 2. Frequency of presenting clinical features Symptom / Sign Frequency, n Percentage (%) Abdominal pain 128 100.0 Vomiting 101 78.9 Fever 84 65.6 Anorexia 75 58.6 Migration of pain 71 55.5 Loose stools 22 17.2 RIF tenderness 123 96.1 Rebound tenderness 78 60.9 Guarding 54 42.2 Rovsing’s sign 41 32.0 Palpable RIF mass 9 7.0 Laboratory and imaging findings: Leukocytosis (>11,000/μL) was seen in 104 children (81.2%), with neutrophilia (>75%) in 96 (75.0%). Elevated CRP was documented in 89 (69.5%). Ultrasonography was performed in all patients and was suggestive of acute appendicitis in 106 (82.8%). Ultrasonographic findings included an appendicular diameter >6 mm in 104 (81.2%), peri-appendiceal fluid in 62 (48.4%), an appendicolith in 24 (18.7%), and a localized collection in 19 (14.8%). Contrast-enhanced computed tomography was used in 12 patients (9.4%) with inconclusive ultrasound and confirmed the diagnosis in all. The mean Pediatric Appendicitis Score was 7.2 ± 1.6; a PAS of ≥7 (high probability) was recorded in 98 children (76.6%), 4–6 (equivocal) in 26 (20.3%), and ≤3 in 4 (3.1%). Operative details and intra-operative findings: Laparoscopic appendectomy was performed in 80 children (62.5%) and open appendectomy in 48 (37.5%). Mean operative time was 52.3 ± 17.8 minutes for laparoscopic and 46.5 ± 15.4 minutes for open procedures (p = 0.06). Uncomplicated (simple/suppurative) appendicitis was seen in 74 children (57.8%), gangrenous appendicitis without perforation in 20 (15.6%), and perforated appendicitis in 34 (26.6%). The rate of perforation was strongly age-related, being 47.6% in children ≤5 years, 26.2% in the 6–8-year group, and 20.0% in the 9–11-year group (p = 0.03) (Table 3, Figure 2). Table 3. Intra-operative findings stratified by age group Age group Uncomplicated Gangrenous Perforated Total ≤5 years 8 (38.1%) 3 (14.3%) 10 (47.6%) 21 6–8 years 24 (57.1%) 7 (16.7%) 11 (26.2%) 42 9–11 years 42 (64.6%) 10 (15.4%) 13 (20.0%) 65 Total 74 (57.8%) 20 (15.6%) 34 (26.6%) 128 Histopathology: Histopathology confirmed acute appendicitis in 122 of 128 specimens (95.3%). Six specimens (4.7%) demonstrated lymphoid hyperplasia without transmural inflammation, giving a negative appendectomy rate of 4.7%. Fecaliths were reported in 29 (22.7%). No appendiceal malignancy was identified. Postoperative complications: Postoperative complications occurred in 20 children (15.6%). Surgical site infection was the most frequent (9 patients, 7.0%), followed by intra-abdominal collection (5, 3.9%), prolonged ileus (3, 2.3%), and wound dehiscence (2, 1.6%). One child (0.8%) required re-exploration for a missed pelvic collection. There were no mortalities in the study. Table 4 summarizes the complication profile. Complications were significantly more frequent in perforated cases (35.3%) than in non-perforated cases (8.5%) (p < 0.001). Table 4. Postoperative complications (n = 128) Complication Frequency, n Percentage (%) Surgical site infection 9 7.0 Intra-abdominal collection 5 3.9 Prolonged ileus 3 2.3 Wound dehiscence 2 1.6 Re-exploration 1 0.8 Mortality 0 0.0 Total 20 15.6 Comparison of open versus laparoscopic appendectomy: When compared with the open group, the laparoscopic group demonstrated a significantly lower rate of surgical site infection (2.5% vs 14.6%, p = 0.008), earlier resumption of oral intake (1.1 ± 0.5 vs 1.8 ± 0.9 days, p < 0.001), and a shorter mean hospital stay (4.0 ± 1.7 vs 5.6 ± 2.4 days, p < 0.001). The rate of intra-abdominal collection did not differ significantly between the two approaches (Table 5, Figure 3). Table 5. Comparison of postoperative outcomes: open versus laparoscopic appendectomy Parameter Open (n = 48) Laparoscopic (n = 80) p-value Operative time (min), mean ± SD 46.5 ± 15.4 52.3 ± 17.8 0.06 Surgical site infection, n (%) 7 (14.6) 2 (2.5) 0.008 Intra-abdominal collection, n (%) 3 (6.3) 2 (2.5) 0.36 Time to oral intake (days), mean ± SD 1.8 ± 0.9 1.1 ± 0.5 <0.001 Length of hospital stay (days), mean ± SD 5.6 ± 2.4 4.0 ± 1.7 <0.001 Length of hospital stay: The overall mean hospital stay was 4.6 ± 2.1 days (range 2–14 days). Children with perforated appendicitis had a significantly longer stay compared with those with non-perforated disease (7.2 ± 2.8 vs 3.8 ± 1.2 days, p < 0.001).

The present prospective study evaluated the clinical profile and outcomes of 128 children below 12 years undergoing surgery for acute appendicitis. Our findings underscore both the ubiquity of acute appendicitis in the pediatric age group and the distinctive diagnostic and therapeutic challenges it poses, particularly in children under 5 years. The observed male-to-female ratio of 1.72:1 is consistent with previously published series that have consistently reported male preponderance ranging from 1.3:1 to 2:1.[1,9,13] The physiological basis of this gender difference remains uncertain but has been attributed to anatomic, hormonal, and immunological factors.[9] Age distribution in our cohort followed the well-recognized pattern of increasing frequency with age, peaking in the 9–11-year group.[1,2,3] Only 16.4% of our patients were below 5 years, mirroring reports that appendicitis in this age group represents less than one-fifth of pediatric cases yet contributes disproportionately to morbidity.[3,4,18] Abdominal pain was universal in our series, consistent with all major published series.[4,7] However, the classical migration of pain from periumbilical to right iliac fossa was elicited in only 55.5% of children. Bundy et al., in a systematic review, demonstrated that migration is one of the most useful clinical predictors but is present in only about half of pediatric patients.[7] The lower frequency in our cohort is likely attributable to the difficulty in obtaining an accurate history from younger children. Vomiting (78.9%) and fever (65.6%) were common, corroborating findings by Almaramhy and Marzuillo et al., who emphasized that non-specific symptoms often dominate the presentation in the pediatric population.[3,18] Physical examination revealed right iliac fossa tenderness in 96.1%, similar to the 95–97% reported by Rentea and St Peter.[2] Rebound tenderness (60.9%) and guarding (42.2%) were less frequently elicited, likely because of the poor cooperation of younger children and reflex withdrawal. Aneiros et al. observed that children under 5 years are significantly less likely to display classical peritoneal signs, resulting in delayed recognition.[10] Laboratory investigations demonstrated leukocytosis in 81.2% and elevated CRP in 69.5%. Combined use of these parameters improves diagnostic accuracy, as suggested by Bundy et al.[7] However, neither parameter is sufficiently sensitive or specific to be used in isolation, and clinical judgment supplemented by imaging remains the diagnostic cornerstone. The Pediatric Appendicitis Score of Samuel had a mean of 7.2 in our cohort, with 76.6% scoring ≥7. Multiple studies have validated PAS as a useful triage tool with high sensitivity (>90%) and reasonable specificity for identifying children with appendicitis.[5,21] Its integration into the initial evaluation, together with imaging, can reduce unnecessary imaging and negative appendectomies. Ultrasonography demonstrated a sensitivity of 82.8% in our cohort, consistent with reported ranges of 80–90% for graded-compression ultrasound.[11,12] The Kaiser et al. study and the Doria et al. meta-analysis established ultrasonography as the imaging modality of choice in children owing to accuracy, availability, and absence of ionizing radiation.[11,12] Selective use of computed tomography was reserved for equivocal cases in our study and yielded a diagnosis in all 12 patients in whom ultrasonography was inconclusive. The overall perforation rate of 26.6% in our study is comparable to the 20–40% range reported in the pediatric literature.[3,8,13,17] However, the striking age gradient — 47.6% in children ≤5 years compared with 20.0% in the 9–11-year group — replicates the observations of Bratton et al., Nance et al., and Almaramhy.[3,8,19] Contributing factors include atypical presentation, difficulty in verbalizing symptoms, and delayed access to specialist care in younger children. Papandria et al. specifically demonstrated that the risk of perforation rises significantly with each additional day of symptoms.[14] Our institution’s overall negative appendectomy rate of 4.7% is favorable compared with historical rates of 15–20% and reflects contemporary practice combining structured clinical scoring with routine ultrasonography.[7,21] Laparoscopic appendectomy was the more frequent surgical approach in our cohort (62.5%), and outcomes favored the laparoscopic technique with significantly lower surgical site infection (2.5% vs 14.6%, p = 0.008), earlier resumption of oral intake, and shorter hospital stay. These findings echo those of Esposito et al. and the meta-analysis by Zhang et al., which established laparoscopic appendectomy as safe and effective in children, including those with perforation.[15,16] Intra-abdominal abscess rates did not differ significantly between the two approaches in our study — a reassuring finding given historical concerns of higher abscess formation after laparoscopy in complicated cases.[15] Postoperative complications occurred in 15.6% overall but rose to 35.3% in perforated appendicitis, in agreement with Pham et al., who identified perforation as the strongest predictor of a complicated postoperative course.[20] Length of stay was similarly influenced. There was no mortality in our cohort, reflecting the low mortality of pediatric appendicitis in centers with pediatric surgical expertise. Study limitations: This was a single-center study with a modest sample size, and the choice of surgical technique was not randomized, introducing potential selection bias. Long-term follow-up beyond 30 days was not systematically undertaken. Multi-center prospective studies with longer follow-up are warranted to validate our findings and to identify further predictors of complicated appendicitis in the pediatric population.

Acute appendicitis in children below 12 years demonstrates a wide range of clinical presentations, with younger children being particularly susceptible to atypical symptoms and delayed diagnosis, culminating in high rates of perforation. In our cohort, nearly half of the children below 5 years presented with perforated appendicitis, whereas the rate declined progressively with increasing age. A structured clinical assessment supplemented by the Pediatric Appendicitis Score and graded-compression ultrasonography allows accurate diagnosis and minimizes negative appendectomy. Laparoscopic appendectomy, in the hands of an experienced pediatric surgeon, offers significantly lower wound infection, earlier recovery, and shorter hospital stay compared with the open approach, and is safe even in complicated disease. Heightened clinical vigilance for atypical presentations in younger children, expeditious imaging, and timely surgical intervention are essential to reduce morbidity and optimize outcomes in this vulnerable population. Ethical Approval and Conflict of Interest The study protocol was reviewed and approved by the Institutional Ethics Committee. Written informed consent was obtained from the parents or legal guardians of all participants. The authors declare no conflicts of interest and no external funding for the conduct of this study.

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