Is peritoneal drainage necessary after laparoscopic appendectomy for complicated acute appendicitis in children?

Purpose: This study aimed to evaluate the efficacy of peritoneal drainage following laparoscopic appendectomy for complicated acute appendicitis in pediatric patients. Methods: This prospective randomized, parallel-group superiority trial with 1:1 allocation at a single tertiary pediatric center included 210 children (≤18 years) with complicated appendicitis (appendicular mass, abscess, gangrene, perforation, or free peritoneal pus) who underwent laparoscopic appendectomy. Patients were randomly assigned to 2 groups (105 each): Group A (drainage) and Group B (no drainage). Standardized operative and postoperative protocols were applied. The primary outcome was overall surgical-site infection (SSI). Pre-specified secondary outcomes included intra-abdominal infection (IAI, a subtype of SSI), wound infection, postoperative ileus, time to return of bowel function, duration of antibiotic therapy, length of hospital stay, and 30-day hospital cost. Robust regression methods including penalized likelihood and quantile regression were used for adjusted analyses. Results: Baseline characteristics were comparable. Overall surgical-site infection (primary endpoint) did not differ significantly between the drainage and no-drainage groups (20.0% vs. 27.6%; p = 0.312). In exploratory secondary analyses, drainage was associated with a lower rate of intra-abdominal infection (6.67% vs. 15.24%; p = 0.046), similar wound infection rates (13.33% vs. 12.38%; p = 0.836), fewer postoperative ileus events (4.76% vs. 13.33%; p = 0.050), earlier return of bowel function (median 13.9 h [IQR 11.0–16.5] vs. 17.3 h [14.0–20.8]; p < 0.001), shorter antibiotic duration, reduced length of stay, and lower 30-day hospital costs. These secondary findings were not α-adjusted and are interpreted as hypothesis-generating. Conclusion: Peritoneal drainage did not significantly reduce the primary endpoint of overall surgical-site infection. However, secondary analyses suggested potential benefits (including fewer intra-abdominal infections, faster recovery, and lower short-term costs) that should be considered exploratory. Selective drainage may be beneficial in this setting, but confirmation in larger multicenter pediatric trials is needed before routine adoption.