Xiao et al. BMC Pediatrics(2024) 24:593
https://doi.org/10.1186/s12887-024-05076-4

BMC Pediatrics

RESEARCH

Open Access

Application of transumbilical single-incision
laparoscopy in the treatment of complicatedappendicitis in overweight/obese adolescents
Zhixiang Xiao1,2†, Lijing Wu3,4†, Jun Li1,2†, Shaohua He1,2, Jingyi Chen1,2, Lizhi Li1,2, Di Xu1,2 and Yingquan Kang1,2*
Abstract
Objective To investigate the clinical efficacy of transumbilical single-incision laparoscopic surgery in the treatment ofcomplicated appendicitis in overweight/obese adolescents.
Methods A retrospective analysis was conducted on the clinical data of 226 adolescent patients with complicatedappendicitis who were admitted to our hospital from January 2014 to June 2022. Among them, 102 cases
underwent transumbilical single-incision laparoscopic appendectomy as the observation group, and another 124
cases underwent conventional three-port laparoscopic appendectomy as the control group. The surgical time,
intraoperative blood loss, duration of incisional pain, postoperative flatus time, length of hospital stay, surgical site
infection (SSI), satisfaction with cosmetic result, and occurrence of postoperative complications were compared
between the two groups.
Results Both groups completed the surgery smoothly, and there were no statistically significant differences ingender, age, BMI, duration of illness, white blood cell count, and preoperative CRP value between the two groups(P > 0.05). There were no statistically significant differences in surgical time and intraoperative blood loss between thetwo groups (P > 0.05). However, the observation group had shorter hospital stays, shorter duration of incisional pain,
shorter postoperative time to flatus, and lower overall postoperative complication rates compared to the control
group, with statistically significant differences (P < 0.05). The observation group had higher satisfaction with cosmetic
result compared to the control group, with statistically significant differences (P < 0.05). Both groups were followed
up for one year postoperatively, and there were no occurrences of residual appendicitis or severe adhesive intestinal
obstruction.
Conclusion When proficiently mastered, the application of transumbilical single-incision laparoscopy in thetreatment of complicated appendicitis in overweight/obese adolescents offers advantages such as minimal trauma,
rapid recovery, fewer complications, and improved aesthetic outcomes.
Keywords Single-incision laparoscopy, Adolescents, Complicated appendicitis, Overweight, Obesity†

Zhixiang Xiao, Lijing Wu, and Jun Li contributed equally to this work.

*Correspondence:
Yingquan Kang
dockang2000@163.com
1
Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian
Medical University, 134 Dongjie Road, Gulou District, Fuzhou,
Fujian Province 350001, China

2

Fuzhou University Affiliated Provincial Hospital, 134 Dongjie Road, Gulou
District, Fuzhou 350001, Fujian Province, China
3
Fujian Maternity and Child Health Hospital, Fuzhou, China
4
College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics,
Fujian Medical University, Fuzhou, China© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation
or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://
creativecommons.org/licenses/by-nc-nd/4.0/.

Xiao et al. BMC Pediatrics(2024) 24:593

Page 2 of 6

Introduction
Acute appendicitis is one of the common causes of acuteabdominal pain in adolescents [1, 2]. Due to its uniqueanatomical features, including a long, narrow, and tortuous appendiceal lumen, it is prone to fecalith impaction, obstruction, and difficult evacuation. Additionally,
the thin appendiceal wall and abundant lymphoid follicles make it susceptible to inflammation, perforation,or necrosis, leading to severe conditions such as diffuse
peritonitis. Especially in overweight or obese patients,
the symptoms of tenderness and peritonitis may not be
typical, leading to potential delays in diagnosis and treatment [3]. In recent years, laparoscopic appendectomy haslargely replaced traditional open surgery [4–6], and thesurgical approach has shifted from multi-port and multisite to single-port or single-site [7–9], offering advantages
in terms of cosmetic outcomes and patient experience.
Currently, transumbilical single-incision laparoscopy has
been widely used in the treatment of acute appendicitis
in children. However, there is limited literature on its
application in complicated appendicitis in overweight orobese adolescents. This study aims to compare the efficacy of transumbilical single-incision laparoscopy andconventional three-port laparoscopy in the treatment ofcomplicated appendicitis in overweight/obese adolescents. The findings are reported as follows.
Materials and methods
General information

Analysis of clinical data of 226 overweight and obese
adolescents with complicated appendicitis treated at our
hospital from January 2014 to June 2022. All patientswere operated on by the same medical team, and before
the surgery, the family members were fully informed of
the advantages and disadvantages of the two surgicaloptions, and the surgical method was chosen based on
the family’s wishes. Among them, 102 cases underwent
transumbilical single-incision laparoscopic appendectomy as the Observation Group (OG), while 124 cases
Table 1 Baseline patient characteristics
Group (n)Male, sexAge, year
BMI(kg/m2)

OG(n = 102)CG(n = 124)
60 (58.8%)
69 (55.6%)
12 (11, 13)
12(11,14)
23.4 (22.0,
23.4(22.5,
24.6)
24.75)
32(25, 42.75) 33(25, 45)

X2/Z

P

0.231
-1.621-0.720

0.631
0.105
0.472

-1.1030.270

16.5(14.6,
17.8)
46(26, 63)-0.8280.408-0.054

0.957

Time from first symptom to surgery (h)WBC count of
16.2(14.5,
preoperative(×10^9/L) 17.5)
CRP value of preopera- 46(26, 63)
tive (mg/L)

OG, Observation Group ; CG, Control Group; BMI, Body Mass Index; WBC, Body
Mass Index; CRP, C-reactive protein

underwent conventional three-port laparoscopic appendectomy as the Control Group (CG). In the Observation
Group, there were 60 males and 42 females, with 78 overweight and 24 obese cases; in the Control Group, there
were 69 males and 55 females, with 92 overweight and32 obese cases. Data collected for both groups include:
General information such as gender, age, BMI; Timefrom initial symptoms to surgery, preoperative symptoms(abdominal pain, diarrhea, nausea, vomiting, fever), preoperative white blood cell count, neutrophil percentage,
preoperative CRP value, surgical duration, intraoperative blood loss, time to postoperative flatus or defecation,
postoperative pain VAS score, postoperative hospitalstay, short-term postoperative complications (bleeding,intestinal fistula, wound infection, residual intra-abdominal abscess, acute paralytic ileus); Long-term postoperative complications (recurrent abdominal pain, residual
appendicitis, and adhesive small bowel obstruction), andpostoperative wound satisfaction score for follow-up data
(Table 1).
Inclusion criteria: Age between 8 and 14 years old;
Clinical diagnosis of acute appendicitis, with ultrasoundor CT showing appendiceal thickening with peri-appendiceal inflammation; The Body Mass Index (BMI) is calculated by dividing weight in kilograms by the square ofheight in meters for individuals of all age groups, and all
results meet the criteria for overweight or obesity, specifically referring to the “Screening for Overweight andObesity in School-Aged Children and Adolescents” published in 2018 by the People’s Republic of China’s healthindustry standards; Intraoperative discovery of appendiceal perforation, necrosis, or pericecal abscess, accompanying localized peritonitis or generalized peritonitis.
Exclusion criteria: Simple appendicitis; Acute exacerbation of chronic appendicitis; Preoperative concomitantother infectious diseases or history of surgery or trauma
within 3 months; Intraoperative discovery of other concurrent diseases; Conversion to open surgery.
All surgeries were done by the same team. The study
was approved by the Startup Fund for scientific research,
Fujian Medical University (Approval No: 2022QH1298)
and the Fujian Natural Science Foundation (Approval
No:2022J011010).
Surgical techniques

The observation group underwent single-incision laparoscopic appendectomy through the umbilicus: After
general anesthesia in pediatric patients, standard disinfection and draping were performed. An arc-shaped incision was made at the left side skin fold of the umbilicalring, the skin and subcutaneous tissue were cut open,
and the abdominal cavity was accessed layer by layerfrom the medial side of the rectus abdominis muscle. A
single-port base and channel were installed (Fig. 1A),

Xiao et al. BMC Pediatrics(2024) 24:593

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Fig. 1 Appendectomy under single-incision laparoscopy through the umbilicus A. Installation of single-port laparoscopic device; B. Intraoperative view
showing appendiceal perforation, necrosis, and pericecal inflammation; C. Ligature of the appendiceal base with absorbable sutures; D. Postoperative
appearance of the umbilical incision

pneumoperitoneum was established, and the patient was
positioned with the head lowered and the feet elevated,tilted approximately 15–30 degrees to the left. Intraoperatively, the abdominal organs, intestinal adhesions anddilation, pelvic fluid accumulation, and appendix were
explored along the mesocolon. Confirmation was madefor appendiceal perforation, necrosis, or pericecal abscess(Fig. 1B). Pus was aspirated under single-port multichannel laparoscopy, and the appendix was gradually dissected free from surrounding adhesions, exposed, and its
mesenteric vessels were ligated with absorbable suturesusing an ultrasonic scalpel. The appendix was then dissected at its base and, if tightly adhered at the distal end,
it was retrogradely excised from the base. If there was
perforation at the base, the appendix was excised, andthe appendiceal stump was reinforced with an 8-shaped
suture at the site of normal blood supply in the ileocecal

region. The appendiceal tissue was retrieved through thesingle-port device channel(Fig. 1C). After re-establishing
the pneumoperitoneum, the base of the appendix andthe condition of abdominal effusion were inspected, andany effusion was thoroughly suctioned out. After ensuring there was no active bleeding, the laparoscopic instruments and the single-port device were removed, and theperitoneum and incision were closed(Fig. 1D). The control group underwent conventional three-port laparoscopic surgery, with a 5 mm trocar inserted at the rightlateral edge of the rectus abdominis muscle at the level ofthe umbilicus and a 10 mm trocar at the left McBurney’s
point. Intraoperative exploration and appendectomy
were performed as in the observation group. Details of
intraoperative and postoperative incisions in the observation group are shown in Fig. 1.

Xiao et al. BMC Pediatrics(2024) 24:593

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Table 2 Comparison of Surgical conditions between two groups
Group (n)Operative Time (min)Intraoperative blood loss (ml)Duration of incision pain (d)Postoperative exhaust time (h)Length of stay (d)OG (102)68(59,70)
10(8,11)2(2,3)
12(10,14)
6(6,7)CG (124)64.5(58,74)
10(9,12)3(2,3)
16(14.25,18)
7(6,8)

t-0.918-1.364-2.876-7.863-3.203

P
0.359
0.173
0.004
0.000
0.001

OG, Observation Group ; CG, Control Group

Observation indicators

Compare the two groups in terms of operation time,
intraoperative blood loss, duration of postoperative incisional pain, time to first flatus after surgery, length of
postoperative hospital stay, incisional infection rate, satisfaction with incisional appearance, and postoperativecomplications including incisional bleeding, incisional
infection, intra-abdominal abscess, enterocutaneous fistula, and adhesive small bowel obstruction. Follow-up
observations were conducted for one year postoperatively to assess the occurrence of enterocutaneous fistula,residual appendicitis, and severe intestinal obstruction.
Postoperative incision satisfaction was assessed using a
Likert scale [10], including very satisfied, satisfied, neutral, dissatisfied, and very dissatisfied. The satisfaction
rate was calculated as (very satisfied + satisfied) / total
number of cases × 100%.
Statistical analysis

The analysis was conducted using SPSS 22.0 statistical software. For continuous data, the Shapiro-Wilk test
was employed to assess normality. If the Shapiro-Wilk
test yielded a p-value > 0.05, the data were considered tofollow a normal distribution; otherwise, the data weredeemed non-normally distributed. For normally distributed data, results were expressed as mean ± standard
deviation (x ± s), and between-group comparisons were
performed using independent sample t-tests. For nonnormally distributed data, results were expressed as
median (Q1, Q3), and between-group comparisons wereconducted using the Mann-Whitney U test. Categorical
data were presented as percentages (%), and betweengroup comparisons were carried out using the chisquare test. A p-value < 0.05 was considered statisticallysignificant.

Results
Both the observation group and the control group successfully completed the surgeries. There were no statistically significant differences between the two groups interms of operation time and intraoperative blood loss
(P > 0.05). However, comparisons of hospital stay duration, duration of incisional pain, and time to first flatus
after surgery revealed that the observation group had

Table 3 Comparison of postoperative complications between
the two groups [n(%)]
Group (n)Incisional oozing
SSI
Abdominal abscess
Intestinal fistula
Paralytic ileus
Total OccurrenceOG(102)2 (1.96)
3 (2.94)
4 (3.92)
0 (0.00)
3 (2.94)
12 (11.76)

CG(124)6 (4.84)
8 (6.45)
7 (5.64)0 (0.00)
6 (4.84)
27 (21.77)

χ2

P

3.927

0.048

OG, Observation Group ; CG, Control Group; SSI, Surgical site infection

Table 4 Comparison of postoperative cosmetic result
satisfaction between the two groups [n(%)]
Group (n)Very satisfied
Satisfied
GeneralNot satisfied
Very dissatisfied
Total satisfaction

OG(102)7917
60
0
96 (94.12)

CG(124)
76
29
13
6
0
105 (84.7)

χ2

P

5.069

0.024

OG, Observation Group ; CG, Control Group

lower values than the control group, with statistically significant differences (P < 0.05) (Table 2).
Comparing the incidence of postoperative complications between the two groups, including incisional
bleeding, wound infection, intra-abdominal abscess,enterocutaneous fistula, and paralytic ileus, the overall
incidence of postoperative complications was lower inthe observation group than in the control group, withstatistically significant differences (P < 0.05) (Table 3).
Both groups were followed up for one year postoperatively, with no occurrences of recurrent abdominal pain,
residual appendicitis, or severe adhesive ileus.
Comparison of postoperative cosmetic result satisfaction between the two groups showed that the observationgroup was higher than the control group, with statistically significant differences (P < 0.05) (Table 4).

Discussion
Acute appendicitis is one of the most common acuteabdominal emergencies in general surgery, which canoccur at any age, especially in adolescents. Often, signsof peritonitis are already present at the time of consultation. Conservative treatment at this stage is lengthy withmoderate efficacy, and there is a high risk of perforation
leading to worsening of the condition. Therefore, surgical treatment should be prioritized [11]. With the continuous development and innovation of laparoscopic
minimally invasive techniques, the treatment of appendicitis has transitioned from open surgery to laparoscopic
surgery. Initially, from three-port laparoscopic surgery tosingle-incision or single-port laparoscopic surgery, minimizing surgical trauma, optimizing aesthetic outcomes,

Xiao et al. BMC Pediatrics(2024) 24:593

speeding up recovery, reducing complications, andimproving the surgical experience [12].
In clinical practice, for complex appendicitis in overweight or obese patients, most often the three-port
laparoscopic surgical approach is chosen [13–15].
This decision primarily considers the thickening of theabdominal wall fat and concerns regarding incisional
infections. However, based on the author’s experience, the application of single-port laparoscopy in thesepatients does not increase the risk of incisional infections [16–18]. Incisional infections generally stem fromcontamination of the abdominal wall channel during
appendiceal specimen retrieval. The single-port device
can isolate contact between the abdominal wall andthe appendix and provide sufficient space for specimen
retrieval. Retrieving complex appendices with a diameter
exceeding 10 mm during three-port laparoscopic surgery
can be particularly challenging and may lead to appendix
rupture, contaminating the abdominal wall or cavity withpus, thereby increasing the risk of incisional infections or
intra-abdominal abscesses. Additionally, in overweight orobese patients with thickened abdominal wall fat, inserting the trocar or puncture sheath during three-port laparoscopic surgery can be relatively difficult. In such cases,
single-port laparoscopic surgery allows for direct visualization and stepwise entry into the abdominal cavity,
reducing the risk of abdominal cavity injury associatedwith punctures.
For overweight or obese adolescents with complicatedappendicitis, undergoing single-incision laparoscopic
appendectomy via the umbilicus, the author has summarized their surgical experiences as follows: First, selectionof umbilical incision: Choosing a left-sided circumumbilical incision with a circumference of approximately
half of the umbilical ring is recommended. Due to thedeeper umbilical fossa in obese children, the incision
should be placed closer to the inner side or along skincreases. Postoperatively, the incision should be closedwith intracutaneous sutures for better concealment andaesthetics. Utilizing the natural anatomical advantageof the umbilicus, the incision allows for a layered entry
into the abdominal cavity from the medial aspect of therectus abdominis muscle, minimizing muscle irritationand damage, thus reducing postoperative pain. Compared to the multi-port approach, the single umbilicalincision results in a smaller perceived area of pain forthe patient, contributing to a better surgical experience.
Second, chopstick effect in single-port laparoscopy: The
close proximity of the camera and instrument shafts
passing through the same channel creates a chopstickeffect, necessitating skilled coordination between thesurgeon and assistant [19]. The assistant’s scope should
lag behind the surgeon’s operative forceps, positioned
centrally between the two operative forceps. Gentle andPage 5 of 6

steady advancement of the operative maneuvers is recommended to avoid overreaching. Third, handling of theappendiceal mesentery and base during surgery: Given
the varied morphology of the appendix in complicatedappendicitis, careful identification and handling of theappendiceal mesentery, especially in cases of congested
and severely adherent tissue, are crucial to prevent inadvertent injury to adjacent structures such as the ureter and bowel. In cases of appendiceal base perforation,
options include base closure or purse-string closure; fornon-perforated bases, ligature with absorbable sutures ispreferred to avoid premature detachment of the appendix
and subsequent fistula formation. The appendix was disassembled with an ultrasonic knife and removed directlyfrom a single orifice channel without the need for a bag.
Fourth, management of intra-abdominal pus: A threestep approach is employed for handling intra-abdominalpus during surgery. Firstly, after induction of anesthesia,
the patient is positioned in a head-up, feet-down tilt tofacilitate drainage, and intra-abdominal pus, particularly
from the pelvic region, is aspirated upon entry of the laparoscope. Secondly, a left lateral tilt with head-down, feetup positioning is adopted for appendectomy, with prompt
suction of any surrounding exudate. Finally, following
appendectomy, thorough inspection and aspiration of
intra-abdominal spaces, including perihepatic recesses
and the pelvic floor, are conducted to ensure complete
drainage. Both groups of cases did not have abdominal
drainage tubes placed, except for those who could nothave their appendix removed during surgery and underwent simple abdominal drainage.The placement of intraabdominal drainage tubes is not advocated, as observedin our study cohort, with one case in the observationgroup and three cases in the control group developing
postoperative intra-abdominal abscesses, likely attributed
to the severity of preoperative intra-abdominal inflammation. Among the control group, two cases with significant
pelvic fluid underwent ultrasound-guided percutaneous
drainage, with drainage tubes removed five days postoperatively, while the remaining two cases of intra-abdominal abscesses resolved following antimicrobial therapy
with subsequent absorption of pus.
In this study, the observation group showed shorter
hospital stays, duration of incision pain, and postoperative gas discharge time compared to the control group.
The analysis attributes this to the less pronounced pain at
the umbilical incision site in single-port laparoscopy, early
mobilization of pediatric patients, and faster intestinal
recovery, resulting in shorter hospital stays. As for postoperative SSI, single-port laparoscopy allows for larger specimen retrieval through a single port, whereas in three-port
laparoscopy, retrieving significantly swollen appendix
specimens can lead to secondary rupture, contaminationof the abdominal wall channel by pus, and subsequentXiao et al. BMC Pediatrics(2024) 24:593

infection. On the other hand, direct spread of intraperitoneal pus may contaminate the abdominal wall channel
and cause incisional infection. For such patients, specimen retrieval requires the use of retrieval bag inserted
into the channel before retrieval. If the specimen is excessively swollen, the incision may be appropriately extended
to avoid repeated squeezing of the specimen, which could
lead to pus extravasation [20].Of course, the cost of singleincision surgery will be slightly higher than that of threeport surgery, but it is still within the family’s affordability.
In conclusion, for adolescents with complicated appendicitis who are overweight or obese, single-incision laparoscopic surgery can be utilized for treatment, offering
advantages such as minimal trauma, fast recovery, fewer
complications, and aesthetic incisions, providing patientswith a better surgical experience. However, limitationsof this study include a small number of cases, short follow-up duration, and being a single-center study. Future
efforts should focus on expanding the sample size, prolonging the follow-up period, and participating in multicenter studies to further validate the findings.
Author contributions
Zhixiang Xiao and Lijing Wu wrote the main manuscript text, Jun Li andShaohua He and Jingyi Chen prepared Fig. 1, Lizhi Li and Di Xu prepared
Tables 1, 2, 3 and 4. Yingquan Kang is the main surgeon of these surgeries. All
authors reviewed the manuscript.
Funding
This work was supported by Startup Fund for scientific research, Fujian
Medical University(Grant Number: 2022QH1298)and the Fujian Natural
Science Foundation (Grant Number: 2022J011010).

Page 6 of 6

2.

3.

4.
5.
6.

7.

8.

9.
10.

11.
12.
13.

Data availability
The datasets used and/or analysed during the current study available from thecorresponding author on reasonable request.

14.

Declarations

15.

Ethics approval and consent to participate
The retrospective medical review was approved by the institutional review
board (IRB) of the Fujian Provincial Hospital.And the study was performedin accordance with the principles stated in the Declaration of Helsinki. All
patients were managed with standard of care; and the parents or guardiansof the patients were thoroughly informed about the procedure, its associatedrisks, and complications before the surgery. The study obtained informed
consent from parents or legal guardians of all participants under the age of 16.
Consent for publication
All data in this study do not involve patient sensitive information, so thissection is not applicable.
Competing interests
The authors declare no competing interests.
Received: 19 March 2024 / Accepted: 11 September 2024

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