Acute appendicitis is the most common intra-abdominal condition requiring emergency surgery [
25]. The possibility of appendicitis must be considered in any patient presenting with an acute abdomen, and a certain preoperative diagnosis is still a challenge [
28,
29]. Although more than 20 years have elapsed since the introduction of laparoscopic appendectomy (performed in 1983 by Semm, a gynaecologist), open appendectomy is still the conventional technique. Some authors consider emergency laparoscopy as a promising tool for the treatment of abdominal emergencies able to decrease costs and invasiveness and maximize outcomes and patients’ comfort [
30,
31]. Several studies [
4,
10,
13,
16,
18,
32‐
34] have shown that laparoscopic appendectomy is safe and results in a faster return to normal activities with fewer wound complications. These findings have been challenged by other authors who observed no significant difference in the outcome between the two procedures, and moreover noted higher costs with laparoscopic appendectomy [
3,
19,
20,
33,
35]. Anyway, a recent systematic review of meta-analyses of randomised controlled trials comparing laparoscopic versus open appendectomy concluded that both procedures are safe and effective for the treatment of acute appendicitis [
36]. Total operative time in our series was significantly longer in the laparoscopic group than in open group (
P <0.0001). Generally, the lack of experience of surgeons in the laparoscopic approach may contribute to a longer duration of the operation. By contrast, in the present study the learning curve effect was minimal as the surgeons performing the procedures were highly experienced in laparoscopic procedures, including laparoscopic bariatric surgery and colectomy surgery. So, in our series the longer operation time in laparoscopic appendectomy may be due to additional steps like setup of instruments, insufflation, making ports under vision and a phase of diagnostic laparoscopy. Length of hospital stay represents a critical factor that directly influences the economy and the well-being of the patient. We found that hospital stay was significantly shorter in laparoscopic group (
P = 0.015) with a concomitant earlier bowel movements in patient managed laparoscopically, leading to earlier feeding and discharge from hospital. Our findings are in agreement with several studies that demonstrated a significantly short hospital stay for the laparoscopic approach [
8,
22,
32,
33,
37]. In our Surgery Department, post-operative pain is assessed both subjectively
via a visual analogue scale and objectively by the tabulation of analgesic use. In the present study, to prevent that the perception of pain may have been influenced by the patient’s enthusiasm for a novel technique, we used only the number of analgesics doses (oral and parenteral) required by individual patient to compare the 2 groups. In this series, parenteral and oral analgesic requirements were less in the laparoscopic group [parenteral 1 (mean); oral 1.86 (mean)] than in the open group [parenteral 1.5 (mean); oral 2 (mean)] and we found a statistically significant difference (
P <0.001) in agreement with many other studies [
15,
38,
39] that reported less pain in the laparoscopic group. Several studies showed no difference between open and laparoscopic appendectomy with respect to early return to activity and performance of daily activities. However, this issue is still debated because of the different definitions and classifications of “activity” in such studies [
20,
40‐
43]. In this study we used the return to work as an endpoint with a mean time of 11.5 ± 3.1 days in the laparoscopic group and 16.1 ± 3.3 in the open group (
P <0.001). Our results are in agreement with a study by Hellberg et al. [
44] and other randomized clinical trials and meta-analysis.[
4,
39] The mortality rate was nil in our study. The low mortality rates reported in previous research (0.05 % and 0.3 % rate in laparoscopic and open groups [
4]) indicated that appendectomy, especially in absence of complicated disease, is a safe procedure regardless of the technique used [
33]. In the present study, the overall complication rates were 24.5 % and 6.7 % for open and laparoscopic appendectomy respectively, with a rate of wound infection and dehiscence significantly higher in the open group (
P <0.001). Wound infection is more common in complicated appendicitis and may not represent a serious complication
per se but has a strong impact for convalescence time and quality of life of patients. In our study no statistically difference was observed in the intraoperative findings between the two groups (Table
2), so the lower rate of wound infection in laparoscopic group may be due to placement of the detached appendix into an endobag before its removal from the abdominal cavity, reducing contact with the fascial surfaces and minimizing contamination. Conversely, intra-abdominal abscess is a serious and life-threatening complication. We observed intra-abdominal abscess formation in 4 patients in laparoscopic group (4.1 %) and in 1 patient in the open group (0.32 %). These findings are consistent with other studies that showed an increased risk of intra-abdominal abscess after laparoscopic appendectomy compared with open surgery [
32,
33]. Several hypotheses have been suggested to find possible explanations: mechanical spread of bacteria in the peritoneal cavity promoted by carbon dioxide insufflation, especially in case of ruptured appendix [
25,
44‐
47], inadequate learning curve [
32], the meticulous irrigation, instead of simple suctioning, of the infected area in severe peritonitis, that leads to contamination of the entire abdominal cavity, which is difficult to aspirate latter [
35]. However, in our study this finding was not statistically significant (
P = 0.147). The management of intrabdominal abscesses included percutaneous drainage as first-line therapy, and surgical procedures. Antibiotics were given before and after percutaneous drainage or surgery. Other observed postoperative complications included vomiting, paralytic ileus and hemoperitoneum (Table
4). The higher cost of laparoscopic instruments (1245 € in our Department) compared to the conventional technique (50 € in our Department) represents an obstacle to its greater use. However, because of the shorter hospital stay, the total cost for laparoscopic appendectomy (operating room + ward costs) was only 155 € higher than open appendectomy. In addition, Moore and al. demonstrated an economic benefit of laparoscopic appendectomy from a social perspective, since earlier return to daily activities is crucial, especially for patients who are young and lead a productive life [
38]. Limitations of our study included the lack of evaluation of laparoscopic surgery in obese patients, as we did not collect data on body mass index (BMI). Moreover the follow up period was only limited to two weeks after hospital discharge.