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Comparing the Outcomes of Single-port and Three-port Laparoscopic Appendectomies in Pediatric Patients
Elyssa Harris*1, Max D. Hazeltine1, Robert McLoughlin1, Julie Flahive2, Yurima Guilarte-Walker3, Jeremy Aidlen1, Michael Hirsh1, Kaitlyn Wong1, Muriel Cleary1
1Pediatric Surgery, UMass Memorial Medical Center, Worcester, MA; 2Surgery, UMass Chan Medical School, Worcester, MA; 3Health Informatics and Implementation Science, UMass Chan Medical School, Worcester, MA

Objectives: This study aims to provide a thorough comparison of outcomes of single-port, transumbilical, laparoscopic appendectomy (TULA) with the traditional three-port laparoscopic appendectomy (LA) in acute and interval appendectomies performed for perforated and non-perforated pediatric appendicitis.
Design: Retrospective cohort study.
Setting: The setting of this study was UMass Memorial Health"ôs Children"ôs Medical Center, a tertiary care, academic center.
Patients: 443 appendectomies were performed between 10/2017 and 2/2020 on children ages 0 to 18. 2 were excluded for incomplete data and 1 for an open appendectomy. The 399 acute appendectomies were analyzed separately from the 41 interval appendectomies.
Interventions: The two interventions being studied were the TULA, which uses a single trocar and zero-degree operative telescope to exteriorize the appendix to facilitate an extracorporeal appendectomy, and the LA wherein one umbilical and two suprapubic ports are used to excise the appendix intraabdominally before removing it.
Main outcome measures: The main outcome examined was the safety and feasibility of TULA as measured by operative times, postoperative lengths of stay, and incidence of postoperative complications. The estimated cost of each procedure was also examined.
Results: Of the 440 patients included, 399 underwent acute appendectomies with 371 TULA and 28 LA. Of the 28, 25% were converted intraoperatively from TULA to LA, 4 of those due to appendiceal perforation. 19% of TULA versus 43% of LA were performed for perforated appendicitis (p=0.003). There was a statistically significant difference in mean operative time with the TULA and LA averaging 46 minutes (CI: 43,49) and 83 minutes (CI: 66,100) respectively (p<.0001). The TULA group also showed significantly shorter lengths of stay with a median stay of 19 hours (CI: 19,20) compared to 67 (CI: 26,115; p<.0001). There were no significant differences found in frequency of additional clinic or ED visits within 6 weeks or readmissions within 30 days of initial presentation. Neither age nor weight were found to have a significant association with the type of surgery performed and neither variable accounted for the difference in the surgical times. The remaining 41 patients underwent interval appendectomies, 36 TULA and 5 LA. When comparing acute and interval TULA there were no statistically significant differences found in procedure time or postoperative complications and the median length of stay after interval TULA was 6 hours (CI: 6,7).
Conclusions: TULA is a safe and feasible approach in children of all sizes, for both acute and interval appendectomies, that results in both shorter procedure and hospitalization times when compared to the standard LA. As these times are the two largest factors in determining cost and, given the smaller amount of equipment necessary for the TULA, the TULA is also more cost effective. However, it may have limitations in the most complicated cases.

Comparison of demographics and outcomes of acute single- (TULA) and three-port (LA) appendectomies
 TULA (n=371)LA (n=28*) 
  95% CI 95% CIp-value
Age, mean (SD)11 (3.7)(11, 12)11 (4.5)(9.2, 13)0.76
Weight in kg, mean (SD)46 (19)(44, 48)49 (27)(38, 59)0.57
Surgery minutes in OR, mean (SD)90 (44)(86, 95)140 (57)(117, 162)0.0001
Procedure time in minutes, mean (SD)46 (33)(43, 49)83 (45)(66, 100)<.0001
Length of stay, median (IQR)19 (13, 26)(19, 20)67 (25,120)(26, 115)<.0001
Readmission to hospital within 30-days of initial presentation, n (%)6 (1.6)(0.6, 3.5)2 (7.1)(0.88, 24)0.10
Additional ED or clinic visits within 6 weeks from initial admission, n (%)56 (15)(12, 19)3 (11)(2.3, 28)0.78
Discharged on antibiotics, n (%)72 (19)(16, 24)12 (43)(24,63)0.003

*7 were converted intraoperatively from TULA to LA (25%)

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