Cosmetic Outcomes Following Appendectomy in Children: A Comparison of Surgical Techniques

Abstract

Background:

Although cosmetic superiority is widely stated as an advantage of single-incision laparoscopy, there are limited studies looking at cosmetic outcome. We sought to determine patients' cosmetic satisfaction after undergoing appendectomy by the single-incision laparoscopic appendectomy (SILA), multiport laparoscopic appendectomy (LA), or open appendectomy (OA) procedure.

Patients and Methods:

Five hundred eighty pediatric patients who underwent appendectomy at a single institution between February 2010 and July 2011 were identified and asked to complete the Patient Scar Assessment Scale (PSAS), a validated evaluation tool for linear scars. In addition, patients were asked the “Ultimate Question” (UQ), which correlates with a patient's overall satisfaction. Linear regression models were used to examine differences between surgical approaches with statistical significance set at P<.05. Covariates for all models included patient demographics, length of stay, and surgeon.

Results:

In total, 212 surveys were returned (SILA, 122; LA, 41; OA, 49) for a response rate of 37%. Regression models demonstrated significantly higher mean total PSAS scores for patients who underwent SILA and laparoscopic appendectomy (LA) appendectomy procedures compared with the open procedure (SILA, 8.70; LA, 8.86; OA, 8.01; β=−0.21, P<.05). Patients who experienced the SILA and LA procedures reported significantly higher mean UQ scores compared with OA (SILA, 9.79; LA, 9.75; OA, 9.39; β=–0.22, P<.05). SILA patients reported a 10 on the UQ significantly more often (91.1%) compared with either LA (81%) or OA (75.5%) (P<.05).

Conclusions:

SILA or LA appendectomy was associated with significantly increased cosmetic satisfaction by patients and their families when compared with OA. This is the first study to show that pediatric patients value attempts to minimize scarring with laparoscopic surgery. Further studies are needed to determine if specific patient factors influence satisfaction with scars.

Introduction

Appendicitis is the most common emergency abdominal procedure performed in children, with nearly 71,000 appendectomies performed in the United States yearly.¹ Minimally invasive techniques have gained rapid implementation, with up to 70% of appendectomies now performed laparoscopically in the United States² and up to 90% when performed in children's hospitals.³ The current trend is to minimize the number of port sites to further improve cosmetic satisfaction.

Laparoscopic appendectomy (LA) has rapidly become the standard of care in children over the last decade.^3,4 When compared with open appendectomy (OA), LA has been shown to decrease length of stay and lower risk of wound infection; however, this is at the expense of longer operative times and higher hospital charges.^3,4 Children who have undergone LA are more likely to recommend this procedure to their family and friends.⁵

The natural extension of minimally invasive surgery is to eliminate scarring by placing the incision in the natural umbilical scar. Single-incision LA (SILA) has been reported to be safe in both children^6–8 and adults.^9,10 A recent prospective, randomized study in children showed that SILA resulted in longer operative times, increased doses of narcotics, and increased surgical difficulty compared with LA.⁸ Several studies have also shown costs to be higher with SILA.^8,11 In adult studies, conflicting results have been reported regarding cosmetic outcomes following SILA.^10,12 We sought to determine the cosmetic outcome following three different surgical techniques (SILA, LA, and OA) in children.

Patients and Methods

Selection of patients

Following Institutional Review Board approval (Number 11-0409), we retrospectively analyzed 580 pediatric patients who underwent appendectomy (SILA, n=309; LA, n=126; OA, n=145) at a single tertiary-care children's hospital between February 2010 and July 2011. All patients under the age of 18 years who underwent appendectomy (ICD-9 codes 540, 540.1, 540.9, 541, 542, and 543.9) were included in the study.

Surgical procedure

Techniques for SILA, LA, and OA have been described elsewhere.^6,13 SILA was performed with the TriPort™ (Advanced Surgical Concepts, Bray, Ireland), standard 5-mm laparoscopic instruments, and a 5-mm, 30° telescope. LA was done with three disposable ports (Covidien, Mansfield, MA); one 12-mm port in the left lower abdomen and two 5-mm ports at the umbilicus and suprapubic locations. OA was performed through a modified Rocky–Davis incision with standard instrumentation and absorbable suture. Figure 1 shows representative pictures of the incision placement approximately 2 weeks following appendectomy.

FIG. 1.

Appearance of appendectomy scar at 2 weeks postoperatively: (A) open appendectomy, (B) laparoscopic appendectomy, and (C) single-incision laparoscopic appendectomy

Questionnaire

Patients were mailed the Patient Scar Assessment Scale (PSAS), a validated evaluation tool for linear scars.¹⁴ The PSAS consists of seven questions that are rated on a scale from 1 (worse response) to 10 (best response). The questions address different aspects of the scar, including pain, itching, color, stiffness, thickness, irregularity, and overall impression (Table 1). An additional question, labeled the “Ultimate Question” (UQ), was included that asked the patient how likely he or she was to recommend his or her experience to a family member or friend on a scale from 1 to 10.

Table 1.

Patient Scar Assessment Scale and Ultimate Question Questionnaire Filled Out by Patients

	Yes, very much (very different from normal skin)								No, not at all (same as normal skin)
1. Has the scar been painful the past few weeks?	1	2	3	4	5	6	7	8	9	10
2. Has the scar been itching the past few weeks?	1	2	3	4	5	6	7	8	9	10
3. Is the scar color different from the color of your normal skin at present?	1	2	3	4	5	6	7	8	9	10
4. Is the stiffness of the scar different from your normal skin at present?	1	2	3	4	5	6	7	8	9	10
5. Is the thickness of the scar different from your normal skin at present?	1	2	3	4	5	6	7	8	9	10
6. Is the scar more irregular than your normal skin at present?	1	2	3	4	5	6	7	8	9	10
7. What is your overall opinion of the scar compared to normal skin?	1	2	3	4	5	6	7	8	9	10

	No, would not recommend								Yes, would definitely recommend
8. Considering your overall experience, how likely are you to recommend your surgeon to a family member or friend?	1	2	3	4	5	6	7	8	9

PSAS, Patient Scar Assessment Scale; UQ, Ultimate Question.

To improve response rates, additional mailings were sent to nonresponders every month for 3 months. Patients who returned a completed survey were mailed $10 for consideration of their time.

Statistical analysis

SPSS version 20.0 software (SPSS, Inc., Chicago, IL) was used. Demographic characteristics for respondents were compared using the Wilcoxon rank sum and chi-squared tests for continuous and categorical variables, respectively. Linear regression models examined PSAS scores or UQ scores as continuous dependent variables with a categorical grouping variable as the primary predictor with three levels for single-incision, laparoscopic, and open procedure types. Covariates included age, gender, language, insurance status, race, length of stay, and surgeon. Additional models included each item from the PSAS scale as an individual outcome to examine potential differences in specific scar characteristics. The significance level was set at P<.05 for all analyses.

Results

In total, 212 surveys were returned (SILA, 122; LA, 41; OA, 49) for a response rate of 37%. Respondents had a mean age of 11±3.6 years, and 58% were male. Seventy-eight percent of respondents had acute appendicitis. Overall demographics are listed in Table 2, and results by procedure type are summarized in Table 3. Those who returned the survey were significantly more likely to speak English (P<.001), have commercial insurance (P<.001), and report their race to be white (P<.01). There was a higher proportion of returned surveys from respondents in the age grouping of 9–13 years (P<.01). There were no significant differences in length of stay (<1 day or >1 day) or diagnosis (acute versus complex) for those who returned the survey and those who did not.

Table 2.

Demographics

	Response	No response	Total	P
Overall	212 (36.6%)	368 (63.4%)	580 (100%)
Language
English	201 (94.8%)	321 (87.2%)	522 (90%)	<.001
Spanish	11 (5.2%)	47 (12.8)	58 (10%)	<.001
Total	212 (100%)	368 (100%)	580 (100%)
Insurance
Commercial	129 (60.8%)	128 (34.8%)	257(44.3%)	<.001
Government assist	83 (39.2%)	240 (65.2%)	323 (55.7%)
Total	212 (100%)	368 (100%)	580 (100%)
Race
White	158 (75.2%)	221 (60.5%)	379 (65.3%)	<.01
African American	15 (7.1%)	38 (10.4%)	53 (9.1%)	NS
Hispanic	29 (13.8%)	89 (24.4%)	118 (20.3%)	<.01
Other	8 (3.8%)	17 (4.7%)	25 (4.3%)	NS
Total	210 (100%)	365 (100%)	575 (100%)
Age
0–8 years	49 (23.1%)	96 (26.1%)	145 (25%)	NS
9–13 years	110 (51.9%)	138 (37.5%)	248 (42.8%)	<.01
14–18 years	53 (25%)	134 (36.4%)	187 (32.2%)	<.01
Total	212 (100%)	368 (100%)	580 (100%)
Gender
Male	123 (58%)	230 (62.5%)	353 (60.9%)	NS
Female	89 (42%)	138 (37.5%)	227 (39.1%)	NS
Total	212 (100%)	368 (100%)	580 (100%)
LOS
<1 day	139 (37.2%)	233 (62.8%)	372 (64.1%)	NS
>1 day	73 (35.1%)	135 (64.9%)	208 (35.9%)	NS
Total
Diagnosis
Acute appendicitis	165 (77.8%)	297 (80.7%)	462 (79.7%)	NS
Complicated appendicitis	47 (22.2%)	71 (19.350	18 (20.3%)	NS
Total	212 (100%)	368 (100%)	580 (100%)

LOS, length of stay; NS, not significant.

Table 3.

Outcomes by Procedure Type

	SILA	LA	OA	Overall
Total number	309	126	145	580
Response	122 (57.6)	41 (19.3)	49 (23.1)	212 (37)
Gender
Male	69 (56.6)	26 (63)	28 (57)	123 (58)
Female	53 (43.4)	15 (37)	21 (42.9)	89 (42)
Age (years)	11.2±3.7	11.4±3.4	10.3±3.4	11±3.6
LOS (days)	2.0±2	4.1±6	1.6±1.5	2.3±3.2
Diagnosis
Acute	100 (82)	28 (68)	37 (76)	165 (77.8)
Complicated	22 (18)	13 (32)	12 (24)	47 (22.2)

Data are mean±standard deviation values or number (%) as indicated.

LOS, length of stay; LA, multiport laparoscopic appendectomy; OA, open appendectomy; SILA, single-incision laparoscopic appendectomy.

When looking at length of time from operation to returned survey, there were significant differences among the procedure types, with patients undergoing LA significantly closer to the time of surgery (13.6 weeks) compared with both SILA (16.6 weeks) and OA (16.5 weeks) (P<.001). There was no significant difference between SILA and OA.

Regression models demonstrated significantly higher mean total PSAS scores for patients who underwent SILA and LA procedures compared with the open procedure (SILA, 8.70; LA, 8.86; OA, 8.01; β=–0.21, P<.05). Patients who experienced the SILA and LA procedures reported significantly higher mean UQ scores compared with OA (SILA, 9.79; LA, 9.75; OA, 9.39; β=–0.22, P<.05). These analyses controlled for age, gender, language, insurance status, race, length of stay, and surgeon. Models with each item in the PSAS as the outcome demonstrated no significant association between procedure type and pain (PS1), itching (PS2), or stiffness (PS4). However, patients who underwent OA reported significantly lower mean scores for color (PS3; β=–0.24, P<.05) compared with patients who underwent SILA. Patients who underwent OA also reported significantly lower scores for thickness (PS5; β=–0.23, P<.05), irregularity (PS6; β=−0.29, P<.01), and overall opinion (PS7; β=−0.29, P<.01) compared with patients who underwent SILA as well as patients who underwent LA. These findings are summarized in Table 4.

Table 4.

Patient Scar Assessment Scale and Ultimate Question Scores by Procedure

Parameter	SILA	LA	OA	P
PS1 Pain	9.58±0.14	9.7±0.25	9.37±0.22	NS
PS2 Itching	9.29±0.14	9.55±0.25	9.56±0.22	NS
PS3 Color	8.23±0.25	7.83±0.43	6.76±0.39	<.05^a
PS4 Stiffness	8.47±0.22	8.9±0.39	7.88±0.35	NS
PS5 Thickness	8.37±0.24	8.63±0.42	7.22±0.38	<.05^b
PS6 Irregularity	8.37±0.25	8.73±0.43	7.12±0.39	<.01^b
PS7 Overall opinion	8.58±0.22	8.7±0.38	7.16±0.35	<.01^b
Ultimate Question	9.79±0.53	9.75±0.54	9.39±1.54	<.05^b

There were no significant differences between single-incision laparoscopic appendectomy (SILA) and laparoscopic appendectomy (LA) for all parameters.

Significant difference between open appendectomy (OA) versus SILA.

Significant difference between OA versus SILA and OA versus LA.

NS, not significant; PS1–PS7, questions 1–7 of the Patient Scar Assessment Scale.

Additional chi-squared analyses examined patients who reported 10 (highest value) on the individual items on the PSAS. Patients who underwent SILA reported 10 on stiffness (PS4, P<.05), color (PS3, P<.001), and overall opinion (PS7, P<.001) significantly more compared with patients who underwent LA and OA. Those who underwent LA reported 10 on thickness (PS5) and irregularity (PS6) significantly more than patients who underwent SILA or LA (P<.05 and P<.001, respectively). There was no significant difference among the procedures on pain (PS1) or itching (PS2). Patients who underwent SILA reported 10 on the UQ significantly more often (91.1%) compared with either LA (81%) or OA (75.5%) (P<.05).

Discussion

Measuring patient satisfaction can be challenging but is an important outcome measure emphasized in healthcare quality improvement. The business world has developed a model for connecting satisfaction to improvement referred to the UQ. It is suggested that this question, phrased as “On a scale from 1 to 10, how likely are you to recommend a product or service to a colleague, family member, or friend?,” can explain 90% of a customer's satisfaction.¹⁵ A score of 9–10 can be interpreted as enthusiastic, whereas a score of less than 6 is deemed as a consumer who is unsatisfied. The UQ has also been reported in the healthcare literature, studying patient, staff, and physician satisfaction, and has been found to improve the process and ease in measuring satisfaction with healthcare delivery.¹⁶ We adapted this question and administered it along with our validated questionnaire for scar assessment. Although this is not a validated question regarding cosmetic satisfaction, it is notable that greater than 90% of patients undergoing SILA reported 10 on this measure.

Cosmetic outcomes are infrequently reported in the literature, particularly in children. The PSAS questionnaire was used to compare cosmetic outcomes between different techniques of ostomy closure in children.¹⁷ Another report used a contingent valuation technique using the willingness to pay method to establish the preferred technique of laparoscopic or open pyloromyotomy.¹⁸ That study demonstrated a wide demographic valued cosmetic outcomes, with 85% of participants hypothetically willing to pay additional expenses for their child to have smaller scars. A recent study reported on the long-term cosmetic outcomes following OA and LA in children and showed that following their operation, patients were significantly more likely to recommend LA to their family and friends compared with OA.⁵

To surgeons, the choice of an incision may seem insignificant, but to the parents and child, it is the long-lasting reminder of their operation. Incisions that are highly conspicuous may impact the child's body image years following an operation. When patients are shown options for incision placement, patients prefer techniques that leave no visible scar.¹⁹ Existing research has shown that patients who underwent a standard three-port appendectomy were generally satisfied with their cosmetic appearance; they preferred no visible scars when given the choice.¹⁹

Findings from the current study demonstrate that patients were generally satisfied with their cosmetic outcomes following appendectomy; however, the patients in this study were not made aware of the incision locations of other techniques of appendectomy. As an extension of the current findings, we are currently studying parent and child preference for scar location in a prospective manner.

Limitations of this study include that it is retrospective in nature. Also, patients were not asked about their scars at regular intervals, as demonstrated by significant differences in length of time from operation among the techniques. Despite limitations, this study also demonstrated no differences in symptomatic outcomes (pain and itching) based on surgical technique for appendectomy. However, patients expressed significantly higher satisfaction with cosmetic appearance following minimally invasive techniques for appendectomy. Taken together, results from the current study demonstrated some parameters favoring the single-incision laparoscopic technique and others favoring the standard laparoscopic technique. Overall, significantly more patients reported being likely to recommend either laparoscopic technique to their family and friends.

Footnotes

Acknowledgments

This study was supported by grant funding from the All Children's Foundation. We would also like to thank Cole Harris for assistance with data entry.

Disclosure Statement

No competing financial interests exist.

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