Obesity and perioperative outcomes in pediatric laparoscopic appendectomy: a retrospective, propensity score-matched cohort study

Introduction

Acute appendicitis represents the most common indication for emergency abdominal surgery in pediatric patients, and appendectomy is widely accepted as the standard treatment (1). However, the global prevalence of childhood obesity has emerged as a significant comorbidity, introducing new complexities and postoperative risks to surgical management (2-4). This clinical intersection demands urgent attention, given that obesity has been clearly demonstrated in adult populations to correlate with adverse surgical outcomes—including prolonged operative time, increased technical difficulty, and elevated risks of complications such as surgical site infections (SSIs) and intra-abdominal abscesses (5). Nevertheless, the applicability of these findings to pediatric populations remains uncertain. Due to children’s distinct physiological characteristics and the importance of long-term outcomes, the impact of obesity on pediatric surgical patients may entail more pronounced implications; however, relevant studies remain relatively limited to date.

Current evidence regarding the impact of childhood obesity on outcomes following appendectomy remains both limited and conflicting (6-8). Previous studies have been predominantly restricted to single-center designs with small sample sizes, resulting in insufficient statistical power and, more critically, a failure to adequately control for selection bias and confounding variables (7). Obesity in clinical practice rarely occurs in isolation; it is frequently associated with delayed presentation, more severe disease manifestations, and various social determinants of health (9). Conventional regression-based approaches exhibit considerable limitations in mitigating these baseline imbalances, thereby failing to accurately isolate the independent effect of obesity on postoperative recovery (10).

To address these methodological challenges, the present study employs a propensity score matching (PSM) retrospective analysis. By constructing a well-balanced cohort matched for key clinical covariates—including age, sex, perforation status, American Society of Anesthesiologists (ASA) Physical Status Classification, and surgical approach, among others—this study aims to provide a more robust evaluation of the association between obesity and perioperative outcomes in children undergoing laparoscopic appendectomy. The findings are expected to yield higher-quality evidence for clinical decision-making in this population. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0023/rc).

Methods

Study design and population

This retrospective cohort study employed a propensity score-matched design to evaluate the impact of obesity on perioperative outcomes in pediatric patients undergoing appendectomy for acute appendicitis. Data were sourced from electronic medical records of pediatric appendectomy patients at Jiaxing University Affiliated Women and Children Hospital between January 2021 and late November 2025. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board (IRB) of Jiaxing University Affiliated Women and Children Hospital (IRB No. 2025-Y-108). The requirement for individual informed consent was waived for this retrospective analysis.

Patients were included if they met the following criteria: (I) aged 0–18 years; (II) underwent laparoscopic appendectomy with histopathological confirmation of acute appendicitis; and (III) had complete documentation of body mass index (BMI) and key perioperative outcomes. The key perioperative outcomes predefined in this study included operative time, estimated blood loss, SSI, length of hospital stay (LOS), and overall complication rates. Exclusion criteria comprised cases of chronic appendicitis, incidental appendectomies, allergy to the antibiotics administered, patients with missing BMI or key perioperative outcomes data, and those with comorbidities potentially confounding surgical outcomes (e.g., immunodeficiencies, malignancies, or concurrent infections/surgical trauma within 3 months prior to surgery).

Both patients with non-perforated and perforated appendicitis were included. The diagnosis of perforated appendicitis was primarily based on the intraoperative surgical findings, defined by the presence of a visible hole in the appendix or the presence of a fecalith or abscess in the peritoneal cavity. This was corroborated by the final histopathological report when available.

Chronic appendicitis, defined by pathological evidence of chronic inflammation or a clinical history of prolonged right lower quadrant pain (>4 weeks), was excluded to maintain a homogeneous acute appendicitis cohort.

Patients were stratified by weight status using World Health Organization (WHO) pediatric BMI percentile criteria referenced to Centers for Disease Control and Prevention (CDC) 2000 growth charts. Patients with underweight (BMI <5th percentile) were excluded from the analysis to ensure a clear comparison between normal weight (NW) and overweight/obesity (OW/OB) groups (11). The NW group was defined as BMI <85th percentile for age and sex, while the OW/OB group included those with BMI ≥85th percentile (overweight: 85th–94th percentile; obese: ≥95th percentile). This classification aligns with international standards for pediatric obesity research and ensures consistent risk stratification across the cohort.

All appendectomies were performed by a dedicated pediatric surgery team. Per institutional protocol, attending surgeons directly supervised or performed critical steps, with documented experience in minimally invasive techniques.

A standardized, institution-specific protocol guided postoperative care. All patients received intravenous antibiotics until meeting objective cessation criteria: afebrile for >24 hours, improved abdominal signs, and declining inflammatory markers. Discharge required meeting all predefined criteria: afebrile status, oral diet tolerance, adequate oral analgesia, a clean dry wound, and surgeon approval. This protocol ensured consistent endpoint measurement.

To mitigate baseline confounding, propensity scores were derived from a non-parsimonious logistic regression model incorporating clinically relevant covariates: demographic factors (age, sex), disease severity features (appendiceal perforation status classified intraoperatively and confirmed pathologically), surgical technique (single-port vs. multiport laparoscopy), anesthetic risk (ASA physical status classification​) and preoperative white blood cell count (WBC).

A 3:1 matching ratio without replacement was implemented using nearest-neighbor methodology, with a caliper width constrained to 0.2 standard deviations of the logit propensity score. Post-matching equilibrium was rigorously evaluated via standardized mean differences (SMDs), where SMD <0.2 for all covariates indicated successful balance achievement—validating comparability between matched cohorts for outcome analysis.

Follow-up

Postoperative follow-up data were obtained by reviewing electronic medical records for all patients. The follow-up interval was defined as the period from the date of surgery until 30 days postoperatively. For cases with incomplete documentation, additional telephone follow-ups were conducted to retrieve missing endpoint information. Those still lacking verification after outreach were classified as lost to follow-up.

Data acquisition and outcomes

Data were independently collected and adjudicated by two investigators who were blinded to the patient groups. Any discrepancies were resolved through discussion or by a third senior investigator. The primary outcomes of this study were operative time (OT), LOS, estimated blood loss, SSI, and complication rates. Secondary analyses assessed a composite of duration of intravenous antibiotics, methicillin-resistant staphylococcus aureus (MRSA) infection, positive blood culture, total hospitalization expense, readmissions within 30 days, emergency department (ED) visits within 30 days, conversion to open surgery, and mortality. Pain intensity was assessed using the Numeric Rating Scale, ranging from 0 (no pain) to 10 (worst imaginable pain). Short-term postoperative complications occurring within the 30-day follow-up period were identified and graded according to the Clavien-Dindo classification system (12). Complications graded as I or II were defined as minor complications, while those graded III and above were defined as major complications.

Statistical analysis

Continuous variables were expressed as mean ± standard deviation for normally distributed data and median [interquartile range (IQR)] for non-normally distributed data, while categorical variables were reported as frequencies and percentages.

Pre-matching comparisons utilized independent samples t-tests for normally distributed continuous variables and Mann-Whitney U tests for non-normally distributed continuous variables, with categorical variables analyzed using chi-squared tests or Fisher’s exact tests as appropriate. Normality was assessed via Shapiro-Wilk tests.

Post-matching analyses employed paired t-tests for matched continuous outcomes with normal distributions and Wilcoxon signed-rank tests for non-normally distributed data, while categorical outcomes were evaluated using McNemar’s tests. For complication endpoints (e.g., SSIs), conditional logistic regression adjusted for residual confounders such as age and perforation status. Statistical significance was uniformly defined as P<0.05. Statistical analyses were performed using R version 4.3.1 (CRAN project, Lucent Technologies, New Jersey, USA. www.r-project.org).

Results

Patient characteristics

Between January 2021 and December 2025, a total of 738 pediatric patients with histopathologically confirmed acute appendicitis undergoing laparoscopic appendectomy were screened for eligibility at Jiaxing University Affiliated Women and Children Hospital (Figure 1). After excluding 108 underweight cases (BMI <5th percentile), 25 with missing BMI or key perioperative outcomes, 2 with incidental appendectomies, 27 with allergy to the antibiotics administered, 12 with prior abdominal surgery within 3 months, 4 with immunodeficiencies or malignancies, and 11 with lost to follow-up the final cohort comprised 549 patients.

Figure 1 Flow diagram. BMI, body mass index; NW, normal weight; OW/OB, overweight/obesity.

These patients were stratified into NW (n=428) and OW/OB (n=121) groups based on WHO pediatric BMI criteria (Table 1). As illustrated, significant baseline imbalances existed in age (NW: 7.97±2.76 years vs. OW/OB: 8.87±2.87 years; P=0.002, SMD =0.320). SMD analysis revealed clinically meaningful imbalances (SMD ≥0.1) in residential district (SMD =0.115), fever presence (SMD =0.139), ASA classification (SMD =0.108), and perforated appendicitis (SMD =0.113). PSM (3:1 ratio, caliper=0.2) balanced covariates (age, ASA classification, perforation status, etc.), yielding a matched cohort of 448 patients (327 NW; 121 OW/OB). Post-matching analysis confirmed covariate equilibrium with standardized mean differences (SMD) <0.2 for all variables (P>0.05, Table 2), establishing robust comparability for outcome analyses.

Perioperative outcomes

Following PSM, comparative analysis of perioperative outcomes demonstrated that OW/OB group experienced significantly prolonged operative time [median: 45 (IQR, 35–63) vs. 41 (IQR, 31–55) min; P=0.02] and increased absolute estimated blood loss [median: 5 mL (IQR, 2–6) vs. 3 (IQR, 1–4) mL; P=0.001] compared to the NW group (Table 3). However, when normalized for body weight, estimated blood loss per kilogram showed no significant difference between groups [OW/OB: 0.045 (IQR: 0.032–0.074) mL/kg vs. NW: 0.044 (IQR, 0.031–0.097) mL/kg; P=0.64]. Additionally, no significant disparities were observed in conversion to open surgery (0.8% vs. 0.6%; P>0.99), or postoperative recovery metrics, including duration of intravenous antibiotics (median 4 days both groups; P=0.23) and length of hospitalization (median 5.5 days; P=0.93).

Postoperative infection events showed no significant differences, with comparable rates of bloodstream infections (positive blood cultures: 2.5% vs. 2.1%; P=0.73) and MRSA infections (1.7% vs. 2.5%; P=0.75). Total hospitalization costs trended higher in the OW/OB group (CNY 8,830.6 vs. 8,505.8; P=0.055).

During the 30-day follow-up period, complication rates were comparable between the NW and OW/OB groups (15.6% vs. 14.1%; P=0.89), with no significant differences in minor (Clavien I–II: 12.2% vs. 11.6%; P=0.87) or major complications (Clavien III–V: 2.4% vs. 2.5%; P>0.99). Specifically, the major complications comprised: Grade IIIa complications (requiring percutaneous drainage) occurred in 4 non-obese and 1 obese patient. Grade IIIb complications (requiring re-operation) were recorded in 2 non-obese patients (one for intra-abdominal abscess and one for small bowel obstruction) and 1 obese patient (for small bowel obstruction). Grade IVa complications [respiratory failure requiring Intensive Care Unit (ICU) care] affected 2 non-obese and 1 obese patient.

However, SSI were significantly higher in the OW/OB group (6.6% vs. 2.7%; P=0.04), primarily driven by a near-significant increase in superficial/deep incisional infections (5.8% vs. 2.1%; P=0.056). Intra-abdominal infections remained rare and comparable (0.8% vs. 0.6%; P>0.99). Rates of ileus (7.4% vs. 6.7%; P=0.77), unplanned Hospital Revisits (19.8% vs. 17.0%; P=0.49), and readmissions (0.8% vs. 0.9%; P>0.99) showed no statistical differences. No in-hospital mortality occurred in either group.

Discussion

The escalating global prevalence of obesity constitutes a critical public health challenge, with projections indicating 360 million children and adolescents affected by 2050—a 120% surge from 2021 levels (2). In China, overweight and obesity prevalence among children aged 6–17 years reached 19.0% (overweight 11.1%, obesity 7.9%) during 2015–2019, reflecting a 233% increase since 1985 (3). According to the latest Global Burden of Disease (GBD) 2021 data, metabolic risks—particularly high BMI—have emerged as the fastest-growing contributor to the global disease burden, driving significant increases in disability-adjusted life years (DALYs) and surgical complications worldwide (4). However, the impact of childhood obesity on laparoscopic appendectomy outcomes remains contentious.

This study employed PSM analysis to isolate the independent impact of pediatric obesity on perioperative outcomes in laparoscopic appendectomy, addressing critical methodological gaps in controlling for confounding factors such as perforation status and surgical approach. Our key findings indicate that obesity amplifies technical challenges during surgery, manifested through prolonged operative time, increased intraoperative blood loss, and elevated SSI risk. Set against that, no significant association was observed with overall complication rates or recovery metrics.

Notably, the prevalence of OW/OB in our cohort (22.0%) exceeded China’s national average (19.0%), a discrepancy attributable to regional disparities and methodological factors (3). As a tertiary center in Jiaxing (East China)—a region with documented higher childhood obesity rates (12.4% vs. national 7.9%) due to elevated urbanization and socioeconomic status—our sample reflects localized epidemiological trends. Additionally, the exclusion of underweight children may have proportionally amplified the OW/OB group.

Our findings regarding prolonged operative time in OW/OB pediatric patients align with the majority of existing literature (6,13). For instance, Delgado-Miguel et al. reported significantly longer operative durations in OW/OB children (57.6 vs. 44.6 minutes; P<0.001), a trend corroborated by propensity-matched analyses in our cohort (median: 45 vs. 41 min; P=0.02) (6). This consistency underscores obesity’s role in amplifying technical challenges—thickened abdominal walls and mesenteric adiposity impede anatomical exposure and instrument maneuverability, necessitating extended dissection time. Moreover, OW/OB status independently increases the risk of complicated appendicitis, with studies reporting higher perforation rates in OW/OB children (45% vs. 30%; P=0.03) (5,14). The resultant inflammatory adhesions and friable tissues further exacerbate technical difficulties, compounding operative time prolongation. This time prolongation may contribute to higher costs (e.g., anesthetic fees) and could potentially elevate SSI risk due to prolonged wound exposure.

Nevertheless, the impact of obesity on operative time remains contentious in specific contexts. Notably, Litz et al. reported that in their study utilizing single-incision laparoscopic appendectomy (SILA), there was no significant difference in operative duration across BMI categories (NW: 27.0±9.1 min; OW/OB: 28.4±9.4 min; P=0.51) (15). This divergence may be attributed to standardized SILA techniques and surgeon expertise: high-volume centers mitigate OW/OB-related anatomical constraints through fixed umbilical port placement (reducing fascial trauma in thickened abdominal walls), articulating instrumentation (counteracting triangulation loss from mesenteric adiposity), and operator proficiency (optimizing navigation in adipose-rich fields) (16).

While hospitalization costs trended higher in the OW/OB group (CNY 8,830.6 vs. 8,505.8; P=0.055), this finding aligns with economic analyses by Delgado-Miguel et al. (6), though our study advances prior work by integrating cost data with matched clinical outcomes.

For 30-day outcomes, readmission rates (0.8% vs. 0.9%; P>0.99) aligned with Litz et al. but diverged from registry studies (e.g., NSQIP) (15,17). This divergence underscores the advantage of our PSM approach, which rigorously controlled for perforation status and surgical technique—confounders often unaddressed in large-scale databases.

Existing literature reports conflicting relationships between OW/OB status and postoperative complications, exemplified by studies reporting both elevated (e.g., Witt et al.) and comparable (e.g., Papillon et al.) complication rates in obese children (7,18). This inconsistency is primarily attributable to heterogeneity in complication definitions across studies—ranging from minor wound disruptions to life-threatening events—as highlighted in prior systematic reviews (10). While our aggregate complication rates showed no significant difference (14.6% vs. 14.1%; P=0.89), this metric may obscure severity-based disparities when minor and major complications are conflated. To resolve this, we implemented the Clavien-Dindo classification, which stratifies complications by therapeutic consequence (e.g., Grade II: pharmacological intervention; Grade IIIb: reoperation) (19). This granular approach eliminates definitional bias, reconciling prior contradictions by isolating the true effect of OW/OB status on severe complications (Grade ≥III). Consequently, our Clavien-graded dataset establishes a structured data infrastructure for future meta-analyses and risk stratification models.

Notably, the absence of an overall complication difference does not preclude obesity-driven increases in specific complications, such as SSI. SSI rates were significantly elevated in the OW/OB group (6.6% vs. 2.7%; P=0.04), corroborating Witt et al. (18), yet conflicting with Michailidou et al. (17), who reported no significant BMI-SSI association in predominantly laparoscopic cohorts. SSI cases were predominantly Clavien Grade II (managed with antibiotics), explaining their limited impact on aggregate complication rates.

Our data showed no significant differences in length of hospitalization (5.5 vs. 5.5 days, P=0.93) or duration of intravenous antibiotics (4 vs. 4 days, P=0.23) between the OW/OB and NW groups. Although prolonged operative time and higher SSI risk were observed in the OW/OB group, standardized perioperative protocols (e.g., uniform antibiotic regimens) may have mitigated the negative impact of obesity on hospitalization duration. This aligns with literature emphasizing the value of standardized care. For instance, Javanmard-Emamghissi et al. demonstrated that propensity score-matched patients under standardized antibiotic management had significantly shorter median hospital stays (2.5 vs. 3 days) and reduced complications (OR 0.36) (20).

There are several limitations in this study that should be considered when interpreting the findings. First, its single-center, retrospective design, despite the use of PSM and multivariate adjustments to mitigate known confounds, carries an inherent risk of residual confounding (e.g., from unmeasured surgeon preferences or socioeconomic factors) and potential selection bias. Second, the postoperative management protocol applied in our cohort differs from contemporary enhanced recovery after surgery (ERAS) pathways that advocate for same-day discharge and minimal postoperative antibiotics. While this reflects real-world practice within our specific healthcare context and provided a consistent baseline for assessing obesity-related risk, it may affect the direct generalizability of our findings to centers employing aggressive ERAS protocols (21). Future studies comparing outcomes across different management intensities are warranted. Third, outcome ascertainment relied on our institution’s records and a regional healthcare information platform. Although this platform captures cross-institutional inpatient and emergency visits, we estimated a 7.6% loss to follow-up for any acute care encounter within 30 days. More importantly, isolated outpatient visits for minor concerns at non-networked facilities would not be captured, which may lead to an underestimation of the total incidence of minor complications. However, given that our primary outcomes were serious events (e.g., SSI, reoperation) likely to result in acute care contact, and that any under-ascertainment is unlikely to be differentially related to obesity status, we believe the impact on the identified association between obesity and major morbidity is minimal.

Finally, to ensure cohort homogeneity and clearly isolate the effect of obesity from the distinct pathophysiology associated with undernutrition, we excluded underweight children. Consequently, our results are most applicable to children across the normal to obese BMI spectrum and may not be generalizable to the full pediatric population, including those who are underweight.

Future studies should prioritize a multicenter, prospective design and adopt standardized data collection instruments (e.g., objectively quantified nursing workload scales) to validate our conclusions. Mechanisms should also be established to track patient outcomes beyond the initial healthcare system to ensure complete capture of postoperative complications. In addition, further research specifically examining the impact of underweight and nutritional status on appendectomy outcomes would be of considerable clinical value.

Based on the distinct technical and anatomical challenges posed by obesity, coupled with its established physiological complexities, we advocate for a tailored perioperative strategy to optimize outcomes in these patients. Accordingly, this structured approach begins with comprehensive preoperative planning to address anticipated technical needs. Intraoperatively, we emphasize meticulous technique and senior surgeon involvement for complex cases. Postoperative care should prioritize vigilant wound monitoring and early complication detection. Ultimately, implementing a standardized yet adaptable protocol for these patients will help mitigate risks and maintain high-quality surgical care.

Conclusions

In conclusion, this propensity score-matched analysis demonstrates that obesity is a significant independent risk factor for adverse perioperative outcomes in pediatric laparoscopic appendectomy, associated with longer operative duration, extended hospitalization, and a higher rate of postoperative complications. These findings underscore the need to recognize obese children as a higher-risk surgical subgroup. This warrants consideration in preoperative counseling, surgical planning, and the development of tailored postoperative care pathways to potentially mitigate risks and improve outcomes in this population.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0023/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0023/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0023/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0023/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board (IRB) of Jiaxing University Affiliated Women and Children Hospital (IRB No. 2025-Y-108). The requirement for individual informed consent was waived for this retrospective analysis.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bhangu A, Søreide K, Di Saverio S, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015;386:1278-87. [Crossref] [PubMed]
2. The global, regional, and national burden of cancer, 1990-2023, with forecasts to 2050: a systematic analysis for the Global Burden of Disease Study 2023. Lancet 2025;406:1565-86. [Crossref] [PubMed]
3. Pan XF, Wang L, Pan A. Epidemiology and determinants of obesity in China. Lancet Diabetes Endocrinol 2021;9:373-92. [Crossref] [PubMed]
4. Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2024;403:2162-203. [Crossref] [PubMed]
5. Al Sabr A, Aljohani A, Althoubi S, et al. Surgical Complications Following Appendectomy in Obese Patients: A Single Tertiary Care Center Study. Cureus 2024;16:e74033. [Crossref] [PubMed]
6. Delgado-Miguel C, Muñoz-Serrano AJ, Barrena Delfa S, et al. Influence of overweight and obesity on acute appendicitis in children. A cohort study. Cir Pediatr 2020;33:20-4.
7. Papillon S, Candelaria PG, Arthur LG, et al. Obesity is not associated with increased resource utilization or morbidity in patients undergoing appendectomy. J Pediatr Surg 2023;58:648-50. [Crossref] [PubMed]
8. Kutasy B, Puri P. Appendicitis in obese children. Pediatr Surg Int 2013;29:537-44. [Crossref] [PubMed]
9. Jalava K, Sallinen V, Lampela H, et al. Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial. Lancet 2023;402:1552-61. [Crossref] [PubMed]
10. Zavras N, Vaou N, Zouganeli S, et al. The Impact of Obesity on Perioperative Outcomes for Children Undergoing Appendectomy for Acute Appendicitis: A Systematic Review. J Clin Med 2023;12:4811. [Crossref] [PubMed]
11. Cole TJ, Bellizzi MC, Flegal KM, et al. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320:1240-3. [Crossref] [PubMed]
12. Hidalgo CM, Martin EJ, Eyassu DG, et al. Modified Clavien-Dindo Classification for Adverse Events in Otolaryngology-Head and Neck Surgery. JAMA Netw Open 2025;8:e2539761. [Crossref] [PubMed]
13. Timmerman ME, Groen H, Heineman E, et al. The influence of underweight and obesity on the diagnosis and treatment of appendicitis in children. Int J Colorectal Dis 2016;31:1467-73. [Crossref] [PubMed]
14. Blanco FC, Sandler AD, Nadler EP. Increased incidence of perforated appendicitis in children with obesity. Clin Pediatr (Phila) 2012;51:928-32. [Crossref] [PubMed]
15. Litz CN, Farach SM, Danielson PD, et al. Obesity and single-incision laparoscopic appendectomy in children. J Surg Res 2016;203:283-6. [Crossref] [PubMed]
16. Liu Z, Long Y, Ma N, et al. Single-port gasless retroperitoneal laparoscopic adrenalectomy. Br J Surg 2024;111:znae289. [Crossref] [PubMed]
17. Michailidou M, Sacco Casamassima MG, Goldstein SD, et al. The impact of obesity on laparoscopic appendectomy: Results from the ACS National Surgical Quality Improvement Program pediatric database. J Pediatr Surg 2015;50:1880-4. [Crossref] [PubMed]
18. Witt CE, Goldin AB, Vavilala MS, et al. Effect of body mass index percentile on pediatric gastrointestinal surgery outcomes. J Pediatr Surg 2016;51:1473-9. [Crossref] [PubMed]
19. Dell-Kuster S, Gomes NV, Gawria L, et al. Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study. BMJ 2020;370:m2917. [Crossref] [PubMed]
20. Javanmard-Emamghissi H, Hollyman M, Boyd-Carson H, et al. Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study. Br J Surg 2021;108:1351-9. [Crossref] [PubMed]
21. Clasie KA, Ng SG, Adams S, et al. Same-Day Discharge for Paediatric Uncomplicated Appendicitis in Australia. ANZ J Surg 2025;95:2543-9. [Crossref] [PubMed]