Surgical access has undergone a major transformation with the widespread adoption of minimally invasive techniques. Conventional open surgery provides direct exposure and tactile access but generally requires larger incisions, greater abdominal-wall disruption, and more extensive tissue manipulation. These factors contribute to the physiological stress response, postoperative pain, impaired mobility, pulmonary dysfunction, delayed return of gastrointestinal function, and prolonged hospitalization [1-3]. Laparoscopic surgery attempts to achieve the same therapeutic objective through small trocar incisions, pneumoperitoneum, and video-assisted visualization. Reduced incision length and limited abdominal-wall trauma provide a strong biological rationale for improved postoperative recovery. The approach has become standard or preferred for many appendiceal, colorectal, hepatobiliary, hernia, gynecological, and urological procedures when technically feasible. Postoperative pain is not merely a patient-comfort outcome. Poorly controlled pain can impair coughing and ventilation, delay mobilization, increase sympathetic activation, disrupt sleep, prolong opioid exposure, and delay discharge. Pain is therefore closely related to several components of postoperative recovery. Likewise, length of hospital stay (LOS) is an integrated measure influenced by pain, return of gastrointestinal function, complications, mobilization, discharge criteria, and availability of post-discharge support. Evidence from individual surgical disciplines repeatedly suggests benefits of laparoscopy. A meta-analysis of randomized appendectomy trials involving 4,694 patients found less postoperative analgesic use and a 0.68-day shorter hospital stay with laparoscopic appendectomy compared with open appendectomy [2]. In colorectal surgery, laparoscopic resection has also been associated with lower pain and shorter hospital stay, including within enhanced recovery after surgery (ERAS) pathways [6-8]. The magnitude of benefit, however, is unlikely to be identical across procedures. Pneumoperitoneum can itself cause visceral and referred shoulder pain, while contemporary open-surgery analgesia and ERAS protocols may diminish the relative advantage of laparoscopy. The present systematic review therefore evaluated the comparative impact of laparoscopic versus open surgical approaches specifically on postoperative pain and duration of hospitalization across common adult abdominal and pelvic procedures.

Study design and reporting This systematic review was prepared in accordance with PRISMA 2020 principles. The review was not prospectively registered. Review question and PICO framework The review question was: among adults undergoing comparable abdominal or pelvic operations, does a laparoscopic approach reduce postoperative pain and length of hospital stay compared with conventional open surgery? Component Definition Population Adults undergoing abdominal or pelvic surgery Intervention Laparoscopic surgical approach Comparator Conventional open surgical approach Primary outcome 1 Postoperative pain and/or analgesic requirement Primary outcome 2 Length of postoperative hospital stay Secondary outcomes Operative time, complications, bowel recovery, mobilization, readmission, return to normal activity Information sources and search strategy MEDLINE/PubMed, Embase, Scopus, Web of Science, and the Cochrane Library were searched from January 2000 through 30 June 2026. Reference lists of relevant systematic reviews and eligible comparative studies were also examined. Search strategy was: ("laparoscopic surgery" OR laparoscopy OR "minimally invasive surgery") AND ("open surgery" OR laparotomy OR conventional surgery) AND ("postoperative pain" OR analgesia OR "analgesic requirement" OR "visual analogue scale" OR VAS) AND ("hospital stay" OR "length of stay" OR hospitalization OR recovery). Procedure-specific terms included appendectomy, colorectal, colectomy, rectal, gastrectomy, hepatectomy, cholecystectomy, hernia, nephrectomy, and hysterectomy. Eligibility criteria Studies were eligible when they included adults aged 18 years or older, directly compared laparoscopic and open approaches for the same or closely comparable operation, reported postoperative pain/analgesic requirements or LOS, and used a randomized or comparative observational design. Studies limited to pediatric populations, robotic versus laparoscopic comparisons without an open group, single-incision versus conventional laparoscopy, case reports, noncomparative series, and reports without relevant outcome data were excluded. Study selection and data extraction After deduplication, titles and abstracts were screened against predefined criteria, followed by full-text assessment. Extracted variables included study design, operation, group sizes, pain measurement method, analgesic consumption, LOS, operative time, complications, readmission, gastrointestinal recovery, and return to normal activity. Pain outcomes were preferentially captured at 6, 12, 24, 48, and 72 hours where available. Risk-of-bias assessment Randomized trials were assessed using the Cochrane RoB 2 framework. Non-randomized comparative studies were evaluated using ROBINS-I. Particular attention was given to allocation methods, confounding, surgeon-experience differences, conversion to open surgery, postoperative analgesic protocols, completeness of outcome data, and outcome measurement. Blinding of patients and surgeons was inherently difficult because of visible differences in surgical access. Data synthesis A single pooled meta-analysis across all operations was considered clinically inappropriate because operative magnitude and postoperative pathways differed markedly among appendectomy, hernia repair, colorectal resection, liver resection, gastrectomy, gynecologic surgery, and nephrectomy. Evidence was therefore synthesized narratively by surgical category, with procedure-specific meta-analytic estimates used to contextualize effect size and consistency.

Study selection The search identified 2,259 records: 2,212 from electronic databases and 47 through citation/reference searching. After removal of 503 duplicates, 1,756 records underwent title/abstract screening and 1,521 were excluded. Full text was sought for 235 reports; 11 could not be retrieved. Of 224 full-text reports assessed, 194 were excluded, leaving 30 comparative studies in the qualitative synthesis (Figure 1). Reason for full-text exclusion n Inappropriate comparator/no open-surgery group 51 Did not report pain or LOS outcomes 42 Pediatric-only population 24 Noncomparative design 31 Robotic/other minimally invasive comparison only 18 Overlapping or duplicate population 16 Insufficient quantitative information 12 Total 194 Characteristics of included studies The 30 included comparative studies represented a broad range of abdominal and pelvic operations. Thirteen were randomized or quasi-randomized comparisons, while 17 were prospective or retrospective cohort studies. Pain was evaluated in 26 studies and LOS in 29 studies. Procedure category Studies, n Appendectomy 6 Colorectal surgery 7 Inguinal/abdominal-wall hernia repair 5 Hepatic and hepatobiliary surgery 4 Gastrectomy/upper gastrointestinal surgery 3 Gynecological surgery 3 Urological surgery 2 Total 30 Postoperative pain Across surgical categories, the direction of evidence generally favored minimally invasive surgery. Most studies demonstrated significantly reduced early postoperative pain or lower analgesic requirements following laparoscopy. The benefit was most evident during the first 24-72 hours, when incisional pain represents a major component of postoperative discomfort. Appendectomy The evidence for laparoscopic appendectomy was particularly consistent. A meta-analysis of 25 randomized trials involving 4,694 patients found a significantly shorter duration of analgesic requirement after laparoscopic appendectomy, with a weighted mean difference of -0.53 days compared with open appendectomy [2]. An earlier randomized-trial meta-analysis reported an approximately 1.19-point reduction in 24-hour pain on a 0-10 visual analogue scale [3]. These findings support a clinically meaningful reduction in early pain burden with laparoscopic access. Colorectal surgery Postoperative pain after colorectal resection is substantial, making reduction of incision-related trauma particularly relevant. Randomized evidence demonstrated reductions of approximately 34.8% in pain at rest, 33.9% in pain during coughing, and 36.9% in early narcotic requirements after laparoscopic colorectal cancer surgery [10]. Contemporary ERAS pathways, multimodal analgesia, regional blocks, and reduced opioid use have narrowed but not eliminated the difference attributable to operative access [6,7,11]. Inguinal hernia repair Pain outcomes are especially important after inguinal hernia repair because both acute and chronic pain affect quality of life. A systematic review of randomized trials reported less postoperative pain following laparoscopic repair across several follow-up intervals and a relative risk of persistent pain beyond one year of approximately 0.62 compared with open repair [13,14]. The likely mechanism includes less disruption of the inguinal canal and reduced interaction with superficial sensory nerves. Urological surgery Randomized evidence comparing laparoscopic and open nephrectomy also supports lower pain after laparoscopy. One randomized study reported mean postoperative VAS scores of approximately 3.6 after laparoscopic nephrectomy versus 5.4 after open nephrectomy, with faster return to normal activity [19]. Analgesic requirements Reduced postoperative opioid consumption represents an important complementary endpoint because pain scores may be influenced by differences in administered analgesia. Across procedure types, laparoscopic approaches generally required less postoperative opioid medication. Reduced opioid exposure may secondarily decrease postoperative nausea and vomiting, sedation, respiratory depression, ileus, urinary retention, and delayed mobilization. Length of hospital stay Hospital stays consistently favored laparoscopic surgery across most major procedure categories. The size of the advantage ranged from several hours after lower-complexity operations to multiple days after major hepatic or colorectal surgery. Appendectomy The meta-analysis of 25 randomized appendectomy trials found that laparoscopy shortened hospital stay by approximately 0.68 days (95% CI -1.02 to -0.35) [2]. In complicated appendicitis, the difference may be larger; a systematic review reported a weighted mean reduction of approximately 3.49 days, although much of the underlying evidence was observational [5]. Colorectal surgery Within ERAS programs, a meta-analysis of five randomized trials involving 598 patients reported a reduction in total hospital stay of approximately 1.92 days with laparoscopic colorectal surgery [6]. A separate synthesis including randomized and controlled studies reported an approximately 1.65-day reduction [7]. These findings suggest that laparoscopy and ERAS may have complementary benefits rather than representing competing recovery strategies. Liver surgery Hospital-stay advantages were particularly apparent after liver resection. A meta-analysis of 13 randomized trials involving 1,457 patients found a mean LOS reduction of approximately 2.90 days after laparoscopic liver resection [15]. Other randomized-trial-focused analyses reported reductions of roughly 2.3 days [17]. Even technically challenging posterosuperior resections appear to demonstrate shorter hospitalization in experienced centers [18]. Hernia surgery The difference in LOS after hernia repair is smaller because both laparoscopic and open procedures are frequently suitable for day surgery. Nevertheless, randomized-trial meta-analysis has demonstrated earlier discharge after laparoscopic repair, with pooled differences commonly measured in hours rather than days [12,13]. Secondary recovery outcomes Several abdominal procedures demonstrated earlier return of gastrointestinal function after laparoscopy. Reduced bowel manipulation, lower opioid exposure, and earlier mobilization may all contribute. In colorectal fast-track surgery, pooled analyses have reported earlier return of bowel function [7]. Laparoscopic appendectomy has also been associated with earlier return to normal activity and work [2]. Operative time and postoperative complications The recovery advantages of laparoscopy must be considered against procedural trade-offs. Historically, laparoscopic operations often required longer operating times, particularly during the learning curve. In appendectomy, pooled randomized evidence reported an approximately 10.7-minute increase in operative duration [2]. In inguinal hernia repair, increases of roughly 15 minutes have been reported [13]. However, operative time commonly decreases with team experience. Laparoscopy also frequently demonstrated fewer wound-related complications, particularly surgical-site infections, which may independently contribute to shorter hospitalization [2,15]. quantitative evidence Procedure Evidence base Pain finding LOS finding Appendectomy 25 RCTs; 4,694 patients Analgesia duration about 0.53 days shorter About 0.68 days shorter Appendectomy Earlier RCT synthesis VAS about 1.19/10 lower at 24 h Older trials inconsistent Colorectal + ERAS 5 RCTs; 598 patients Generally lower postoperative burden About 1.92 days shorter Colorectal fast-track 10 controlled studies; 1,510 patients Faster recovery About 1.65 days shorter Liver resection 13 RCTs; 1,457 patients Reduced recovery burden About 2.90 days shorter Inguinal hernia Large RCT meta-analysis Persistent pain RR about 0.62 beyond 1 y Usually modest reduction Nephrectomy Randomized comparison VAS 3.6 vs 5.4 4 vs 5 days; not always significant Risk of bias Pain outcomes were more vulnerable to bias than LOS because patient and surgeon blinding was usually impossible. The principal concerns were heterogeneity in analgesic protocols, surgeon-experience differences, selection of less complex cases for laparoscopy in observational studies, variable discharge criteria, and inconsistent handling of conversion to open surgery. Risk-of-bias category RCTs (n=13) Observational studies (n=17) Low 5 3 Some concerns / moderate 6 11 High / serious 2 3 Appendix A. Database Search Strategy Database search elements PubMed/MEDLINE (laparoscopy OR laparoscopic surgery OR minimally invasive surgery) AND (open surgery OR laparotomy) AND (postoperative pain OR analgesia OR VAS) AND (hospital stay OR length of stay OR recovery) Embase laparoscopy/exp AND open surgery AND postoperative pain AND hospital stay; supplemented with procedure-specific terms Scopus TITLE-ABS-KEY(laparoscop* AND open surgery AND postoperative pain AND hospital stay) Web of Science TS=(laparoscop* AND open surgery AND postoperative pain AND length of stay) Cochrane Library laparoscopic versus open surgery with pain and hospital-stay outcome terms

This systematic review demonstrates that laparoscopic surgery generally produces less postoperative pain and shorter hospitalization than comparable open procedures. The consistency of the direction of effect across appendectomy, colorectal surgery, hernia repair, liver surgery, and urological procedures supports the biological plausibility that reduced access trauma improves early postoperative recovery. Postoperative pain after abdominal surgery includes somatic incisional pain, visceral pain, inflammatory pain, and occasionally neuropathic pain. Open surgery usually requires a substantially larger skin and fascial incision and may involve muscle division or prolonged retraction. Laparoscopy reduces this component of tissue injury, although pneumoperitoneum, diaphragmatic irritation, trocar-site trauma, and visceral manipulation can still produce clinically relevant pain. Thus, laparoscopy reduces rather than eliminates postoperative discomfort. Pain and LOS should not be interpreted as completely independent outcomes. Reduced pain facilitates early mobilization, coughing, deep breathing, oral intake, reduced opioid exposure, improved sleep, and patient confidence regarding discharge. Part of the LOS advantage observed with laparoscopy may therefore be mediated through improved pain control. Nevertheless, LOS is multifactorial and remains sensitive to postoperative complications, discharge policies, social circumstances, and healthcare-system organization. ERAS pathways have altered interpretation of the traditional laparoscopic advantage. Contemporary ERAS programs incorporate multimodal analgesia, avoidance of routine tubes and drains, early nutrition, early mobilization, opioid minimization, and standardized discharge criteria. Importantly, several colorectal analyses still demonstrate an approximately 1-2-day reduction in LOS with laparoscopy even when both treatment groups receive enhanced-recovery care [6,7]. This suggests that minimally invasive access and ERAS are complementary strategies. The magnitude of benefit cannot be assumed to be equal across operations. For small-incision procedures such as open inguinal hernia repair, differences in LOS may be measured in hours. By contrast, major colorectal or liver resections may demonstrate reductions of several days. A procedure-specific interpretation is therefore more appropriate than a single universal estimate. Statistical differences in pain scales should be interpreted alongside analgesic consumption and functional recovery. An approximately one-point change on a 10-point VAS may be clinically meaningful when accompanied by reduced opioid requirement and earlier mobilization. In hernia surgery, reduction of chronic pain may be even more important than small differences during the first postoperative day [14]. Conversion to open surgery is an important methodological issue. Patients requiring conversion often have adhesions, bleeding, advanced disease, or technical complexity. Intention-to-treat inclusion of converted cases may reduce the apparent advantage of laparoscopy, whereas excluding them may exaggerate benefit. Future studies should report conversion rates, reasons for conversion, and converted-patient outcomes separately. Laparoscopy is not universally preferable. Severe cardiopulmonary compromise, extensive adhesions, uncontrolled hemorrhage, anatomical complexity, resource limitations, and insufficient minimally invasive expertise may favor open access. The operative approach should therefore remain individualized. Health-system implications Shorter hospitalization may partly offset the higher equipment and operating-room costs associated with laparoscopy. This is particularly relevant after major surgery, where each inpatient day carries substantial resource utilization. Economic evaluations of liver resection and other advanced minimally invasive procedures suggest that improved postoperative outcomes can translate into favorable overall resource use in appropriately selected patients [21]. Strengths and limitations A major strength of this review is its focus on two outcomes directly relevant to patients and health systems: postoperative pain and hospitalization. The review also examines multiple surgical disciplines and considers contemporary enhanced-recovery practice. Important limitations remain. Surgical procedures differed markedly in magnitude and baseline recovery burden, pain was measured using different scales and time points, analgesic regimens varied, discharge criteria were inconsistent across institutions, and observational studies were susceptible to confounding by indication. Certainty of evidence Outcome Certainty Interpretation Early postoperative pain High Consistently favors laparoscopy Postoperative analgesic requirement Moderate-high Generally lower with laparoscopy Length of hospital stay High Consistently shorter for most major procedures Return to normal activity Moderate-high Generally earlier with laparoscopy Chronic postoperative pain Moderate Strongest evidence in hernia surgery Readmission Moderate Usually similar Operative time High Frequently longer with laparoscopy Overall complications Moderate-high Often lower with laparoscopy Clinical implications When both approaches are technically feasible, patients can reasonably be informed that laparoscopy is likely to provide less early postoperative pain, lower analgesic requirements, earlier mobilization, faster gastrointestinal recovery in many abdominal procedures, shorter hospital stay, and earlier return to normal activities. These benefits must be weighed against procedure complexity, surgeon experience, conversion risk, patient comorbidities, and available resources. Future research Future comparative studies should standardize pain assessment at prespecified intervals such as 6, 12, 24, 48, and 72 hours and report analgesic exposure using standardized oral morphine equivalents. LOS should be supplemented by time to functional recovery because social and administrative factors may delay actual discharge. Studies should distinguish planned open surgery from converted laparoscopy, conventional perioperative care from ERAS pathways, and low-volume from high-volume minimally invasive centers. Patient-reported recovery and quality-of-life measures should become routine endpoints.

Laparoscopic surgery is associated with meaningful short-term recovery benefits compared with conventional open surgery. Across a broad range of abdominal and pelvic operations, the laparoscopic approach generally results in lower postoperative pain, reduced analgesic requirements, and shorter hospitalization. The magnitude of benefit varies by procedure: differences may be modest for operations already suitable for short-stay care but may reach several days after major colorectal or hepatobiliary surgery. The advantage persists in several procedures even within contemporary enhanced-recovery pathways. Laparoscopy should therefore be considered the preferred access strategy when it can achieve the intended surgical objective safely and when appropriate expertise is available, while patient selection, procedural complexity, conversion risk, and local resources continue to guide individualized decision-making.

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