Patient and parental scar assessment after single incision versus standard
3-port laparoscopic appendectomy: Long-term follow-up from a prospective
Alessandra C. Gasior, E. Marty Knott, George W. Holcomb III, Daniel J. Ostlie, Shawn D. St. Peter⁎
The Children’s Mercy Hospital, Kansas City, MO
a b s t r a c ta r t i c l ei n f o
Received 20 September 2013
Accepted 30 September 2013
Background: Single site laparoscopy for appendectomy is a technique with several case series suggesting a
cosmetic advantage, but without prospective comparative data. We conducted a prospective, randomized
trial comparing single site laparoscopic appendectomy to the standard 3-port approach, including scar
assessment at early and long-term follow-up.
Methods: Enrolled patients over 12 years old and parents of patients less than 12 years old were asked to
complete the validated Patient Scar Assessment Questionnaire (PSAQ) at early follow-up around 6 weeks and
by phone after 18 months. The PSAQ consists of 4 scored subscales: Appearance, Consciousness, Appearance
Satisfaction, and Symptom Satisfaction. Each subscale has a set of questions with a 4-point categorical
response (1 = most favorable, 4 = least favorable). The sum of the scores quantifies each subscale.
Results: Early questionnaires were obtained from 98 3-port and 100 single-site patients with the single-site
approach producing superior overall scar assessment (P = 0.003). By telephone follow-up, questionnaires
were completed by 49 3-port and 56 single-site patients at a median of 25 (18–32) months. In this longer-
term follow-up, overall scar assessment was not significantly different between groups (P = 0.06).
Conclusion: Patients or parents express superior scar assessment with the single site approach at early follow-
up, but this difference disappears in the long-term.
© 2014 Elsevier Inc. All rights reserved.
Laparoscopic appendectomy has dramatically increased over the
past 12 years as the operative method of choice for appendicitis .
More recently, single site laparoscopic appendectomy has become
popular. One of the advantages of the single site approach is that it
strategically places the incision in the umbilicus so that the result is a
seemingly scarless abdomen . Comparative studies, including
prospective, randomized trials demonstrate no difference in compli-
cations with only small differences in outcomes [3–6]. We previously
reported a prospective, randomized trial comparing single site to
conventional 3-port laparoscopic appendectomy for children with
non-perforated appendicitis . In that study, we found longer
operative times and greater hospital charges with the single site
approach, however, the raw differences were of marginal clinical
relevance . The primary outcome of the trial, wound infection was
not different. Therefore, the clinical differences were small, and the
cosmetic benefit is the purported gain from single site laparoscopy
although prospective data are lacking. As a secondary outcome from
the trial, we measured cosmetic perception early in follow up and
after scar maturation to determine if there is an appreciable cosmetic
differencebetween3-portandsinglesite laparoscopic appendectomy.
After IRB approval (#1290451), patients enrolled in the previous
prospective, randomized trial comparing single site laparoscopic
the Patient Scar Assessment Questionnaire (PSAQ), which has been
validated in adults [8,9]. As the scores were not the primary outcome of
cosmesis. The patient population, surgeon involvement, technical
details and complication from the trial are previously reported .
from parents of patients less than 12 years old, at 6 weeks postoper-
atively (early follow-up) and by a phone call after 18 postoperative
months (late follow-up). The early follow-up was obtained during a
clinic visit. The late follow-up was performed by attempting telephone
contact with all patients in the original study. Those making contact
wereblindtothe individualpatientoutcomes recorded duringthe trial.
The PSAQ has five subscales, four of which are validated and used in
the scoring. The validated subscales include: Appearance, Conscious-
ness, Satisfaction with Appearance, and Satisfaction with Symptoms.
The appearance subscale is an objective assessment about the presence
Journal of Pediatric Surgery 49 (2014) 120–122
⁎ Corresponding author.Center for Prospective Clinical Trials, Children’s Mercy
Hospital, 2401 Gillham Road, Kansas City MO 64108. Tel.: +1 816 983 6479; fax:
+1 816 983 6885.
E-mail address: email@example.com (S.D. St. Peter).
0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery
journal homepage: www.elsevier.com/locate/jpedsurg
of a scar by asking about the presence and severity of scar color, width,
flatness, texture, shininess, and overall appearance. The consciousness
subscale inquires about itchiness, pain, discomfort, numbness, odd
appearance was ascertained by how noticeable the scar is to oneself, to
others, and overall self-consciousness of scar. Satisfaction with
symptoms was assessed by satisfaction with scar sensation, color,
4-point response where 1 = most favorable, 4 = least favorable.
The sum of the scores within each subscale was used for
comparisons between groups. Data in tables are expressed as mean
± standard deviation. Because of the asymmetric distribution of
responses toward favorable responses, Mann-Whitney U test was
used for comparisons between groups.
In the early follow-up cohort, there were 198 questionnaires
completed, representing 100 single-port and 98 3-port patients. There
were no differences in age, weight, body mass index, gender
distribution, or the percentage of patients who answered in each
group as opposed to parent, in the cohorts who responded to the
questionnaires at early or late follow up (Table 1). Further, there were
no statistically significant differences between male and female
responses or between patient or parent responses at early or late
follow up. There were 7 patients in the 3 port group and 6 patients in
the single site group who had scores given by a parent at early follow
up and by self at late follow up.
There were significant differences in appearance, consciousness,
satisfaction with appearance, and overall score, all favoring single site
appendectomy (Table 2). The median overall score for the 3-port
group was 43 with an interquartile range of 12 compared to 36 and 14
in the single site group.
In the late follow-up cohort, there were a total of 105 participants
representing 56 single site and 49 3-port patients. The median
response was 25 (18–32) months after the appendectomy. Only
appearance reached the significance threshold which favored the
single-site group (P = 0.05, Table 3). There was no significant
difference in the other subscales, and overall score did not reach the
significance threshold (P = 0.06). The median and interquartile
ranges for overall scores were 29 and 2 in the 3-port group compared
to 28 and 1 for the single site group.
Singlesiteappendectomy isa safeprocedurethatdoesnotleave an
appreciable scar when the incision can be hidden within the
umbilicus. In the literature, conventional laparoscopic surgery has
been upstaged by single site laparoscopy for its presumed improved
cosmesis [10–14]. In our previously reported prospective, random-
ized trial, there was no difference between the wound infection rate,
time to regular diet, length of hospitalization, or time to return to
full activity between 3-port and single site laparoscopic appendec-
tomy . However, operative time, doses of narcotics, operative
difficulty, and hospital charges were greater with the single-site
approach. One adult trial in 200 patients also found greater doses of
analgesics . These differences are small and of questionable
clinical relevance. Therefore, the next logical question was whether
a substantial cosmetic advantage existed for the single site
technique, which may tip the overall results toward single site
appendectomy. While the short-term results demonstrated signifi-
cantly more favorable scores with the single site approach, follow-
up at over two years showed no significant difference noted by
patients or parents between conventional and single site laparo-
scopic appendectomy. While one adult trial in 200 patients found a
cosmetic advantage with the single site approach in the short term,
another adult trial in 248 patients found no significant difference in
cosmetic satisfaction between groups [5,6]. Taking these data into
consideration with our own, it appears the difference created in
cosmesis by the single site approach is not glaring which is why
some authors have found an advantage, others do not, and our
results shifted with time.
These data do not undermine the good cosmetic outcomes
produced by single site laparoscopy, but simply demonstrate that a
standard 3-port laparoscopic appendectomy also produces an
excellent cosmetic outcome. In this study, the overall scar assess-
ment approached a significant difference favoring the single site
technique which suggests that adding more patients might create a
statistical difference. Particularly, if the same number of patients
could have been attained as there had been in the early follow up,
perhaps significance would be attained. However, the raw difference
would still be small and not likely overwhelming in clinical
relevance as the long-term cosmetic scores in both groups approach
the best possible score in all the subscales (Table 3). This is in sharp
contrast to the early results in Table 2 and emphasizes the
Patient variables at the time of appendectomy for each of the answering cohorts.
EARLY FOLLOW UP
3 Port (N = 98) Single Site (N = 100)P value
Body mass index (kg/m2)
Gender (% male)
Respondent (% patient)
11.3 ± 3.2
40.8 ± 17.7
19.2 ± 4.6
11.3 ± 3.4
43.0 ± 17.6
19.2 ± 4.4
LATE FOLLOW UP
3 Port (N = 49) Single Site (N = 56)P value
Body mass index (kg/m2)
Gender (% male)
Respondent (% patient)
11.2 ± 3.2
40.3 ± 16.1
19.2 ± 4.4
11.2 ± 3.4
44.7 ± 18.8
20.1 ± 5.3
PSAQ scores – early follow up (6 weeks).
(N = 98)
(N = 100)
15.34 ± 3.77
9.27 ± 2.35
11.78 ± 3.80
13.46 ± 3.24
8.59 ± 2.42
10.77 ± 3.72
5 6.70 ± 2.46 6.25 ± 2.050.17
2843.08 ± 9.20 39.07 ± 9.23
PSAQ scores – late follow up (18–32 months).
(N = 49)
(N = 56)
10.39 ± 2.03
6.41 ± 1.08
8.08 ± 0.34
9.64 ± 1.29
6.29 ± 0.85
8.20 ± 1.10
55.00 ± 0.00 5.02 ± 0.130.87
28 29.86 ± 2.9729.12 ± 2.37 0.06
A.C. Gasior et al. / Journal of Pediatric Surgery 49 (2014) 120–122
importance of long-term data in assessing cosmetic outcomes to give Download full-text
time for the scars to mature.
The only subscale of significance in the long-term follow-up was
the subscale objectively assessing appearance which favored single
site as fewer patients have a scar that can be seen. However, in the
subscale on satisfaction with appearance, the scores were nearly
identical. Particularly interesting is the subscale on scar symptoms,
where every patient in the 3-port group and all but one patient in the
single site group gave a perfect score. These data objectify that neither
group appears concerned with the scars over time. Subjectively,
patients in the 3-port appendectomy group at long-term follow-up
had comments such as “Where do I look for the scars, on the left or the
rightside?”“I almostforgotI hadscars”,“I canbarelyfind them”and“I
don’t have a scar”. With the single-port group, comments included “I
can’t even see the scar, it’s like he never had surgery.” One boy
complained that “I had no scar; no one believed I had surgery.”
In some patients, the single site approach is associated with
objectively measureable drawbacks. In a subset analysis of our trial,
we found obese children undergoing the single site laparoscopic
appendectomy had longer operative times, more doses of postoper-
ative analgesics, longer length of hospitalizations, and increased
hospital charges compared to normal or overweight children .
Furthermore, there was no difference in any outcome variables
between obese and normal weight patients when comparing the 3-
port laparoscopy technique with the single site approach. Therefore,
these equivocal cosmetic outcomes found in this current study which
employed all patients should emphasize the lack of benefit to the
single site approach in obese patients.
Pragmatically, the single site operation can be a remarkably
quick, simple procedure that avoids expensive equipment in right
patient. From this study, now that we understand that 2 additional
5 mm instruments positioned low in the abdomen do not translate
into a substantial cosmetic detriment when evaluated long-term by
the patient or parent, our group has become more selective in the
use of the single site approach for appendectomy. Generally, we
now utilize the single site approach in lean children with non-
perforated appendicitis. However, if the appendix is retrocecal, well
stuck, or requires more dexterous dissection, we will often add one
or 2 ports to prevent a lengthy operating time, which translates to
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Discussant: Dr Julie Long (Hollywood, FL): I enjoyed your paper. I think
your results reflect what we already know, which is the scars for
laparoscopy are very nice but you didn’t talk at all about cost. We
have found lower cost with single-port. We only use one trocar
thatis disposable. Everythingelseis reusable.I alsothink thatitis a
very safe easy technique to teach residents whereas teaching with
– I think one of the hardest things to teach residents is inserting
trocars. I think there really is advantage beyond what you
suggested with the single-port technique.
Response: Dr Alessandra Gasior: Thank you for your comments.
A.C. Gasior et al. / Journal of Pediatric Surgery 49 (2014) 120–122