Transumbilical three-port vs conventional laparoscopic appendectomy: A single-center retrospective comparative study

Abstract

BACKGROUND

Laparoscopic appendectomy (LA) is a widely accepted treatment for acute appendicitis. Conventional three-port techniques require additional abdominal incisions that may affect cosmetic outcomes, whereas transumbilical approaches may improve scar concealment. However, direct comparative evidence remains limited.

AIM

To evaluate the safety and perioperative outcomes of transumbilical three-port LA compared with conventional LA.

METHODS

This retrospective single-center comparative study included 77 patients who underwent LA between June 2022 and October 2023 at a tertiary hospital. Patients were treated with either a transumbilical three-port approach (n = 51) or conventional LA (n = 26). Baseline characteristics, operative outcomes, postoperative pain scores, complications, hospitalization costs, and cosmetic outcomes were compared. Logistic regression analysis was performed to identify predictors of prolonged hospitalization (> 3 days).

RESULTS

All procedures were completed laparoscopically without conversion or major complications. Operative time, postoperative complications, and early pain scores were comparable between groups (all P > 0.05), with a trend toward lower pain in the cosmetic group. Total hospitalization costs were higher in the cosmetic group (P < 0.05), which may partly reflect temporal variations in consumable and medication pricing. In univariate analysis, elevated preoperative white blood cell (WBC) count and C-reactive protein levels were associated with prolonged hospitalization (P < 0.05). After adjustment, preoperative WBC remained the only independent predictor (adjusted odds ratio = 11.55, 95% confidence interval: 2.28-80.44).

CONCLUSION

Transumbilical three-port LA using conventional instruments appears safe and feasible and may improve cosmetic outcomes without increasing operative risk or hospital stay. Preoperative WBC may predict hospitalization duration.

Key Words: Transumbilical laparoscopic appendectomy; Three-port technique; Conventional instruments; Cosmetic outcome; Minimally invasive surgery

Core Tip: This study evaluates the feasibility and clinical value of transumbilical three-port laparoscopic appendectomy (LA) using conventional instruments. By restoring a triangular operating configuration through the umbilicus, this technique avoids the technical limitations of single-incision surgery while achieving superior cosmetic outcomes. Perioperative safety, postoperative pain, and complication rates were comparable to conventional multiport LA. In addition, factors associated with prolonged hospitalization were explored. These findings suggest that transumbilical three-port LA is a safe, cosmetically advantageous, and practical alternative in selected patients.

INTRODUCTION

Appendicitis is one of the most common acute abdominal conditions worldwide, with a lifetime incidence of approximately 7%-8% and accounting for 5%-10% of emergency general surgery admissions[1,2]. Epidemiological studies indicate that appendicitis disproportionately affects adolescents and young adults, with peak incidence occurring around 15-19 years of age and a modest male predominance[3,4]. In China, the prevalence of appendicitis has gradually increased over the past decade, likely driven by shifts in dietary habits, lifestyle patterns, and expanding diagnostic capability[5,6]. Despite improvements in imaging and antimicrobial therapy, appendectomy remains the definitive and widely accepted treatment to prevent severe complications such as perforation, abscess, peritonitis, and sepsis[7].

Laparoscopic appendectomy (LA) has replaced open appendectomy as the mainstream treatment owing to advantages such as reduced postoperative pain, faster recovery, earlier mobilization, lower wound infection rates, and improved cosmetic outcomes[8]. However, conventional three-port LA still requires two additional abdominal incisions apart from the umbilical entry point. Although these incisions are small, they remain visible postoperatively and may diminish cosmetic satisfaction, particularly for younger patients who increasingly prioritize aesthetic outcomes. As patient-reported experiences and cosmetic expectations continue to shape surgical decision-making, the pursuit of improved aesthetics without compromising surgical safety has become a central goal in minimally invasive surgery[9].

To further improve cosmetic outcomes while maintaining surgical safety, transumbilical approaches have been explored. Single-port transumbilical appendectomy utilizes the natural contour of the umbilicus to conceal surgical scars and has gained increasing attention. However, single-port techniques are often associated with technical challenges, including instrument crowding, loss of triangulation, and the so-called “chopstick effect”, which may impair operative precision[10,11]. To overcome these limitations, specialized multichannel ports and articulating instruments are frequently required, which significantly increase procedural costs and limit the widespread adoption of single-port surgery, particularly in resource-limited hospitals.

To address these limitations, a modified technique, transumbilical three-port LA using conventional instruments, has been developed. By placing three trocars along the natural folds of the umbilicus, this approach restores triangulation, improves instrument maneuverability, and minimizes instrument interference[12]. At the same time, all incisions remain concealed within the umbilical contour, resulting in minimal visible scarring[13]. Importantly, because the technique relies exclusively on standard laparoscopic instruments, it avoids the additional costs associated with specialized single-port devices and may therefore be more suitable for widespread clinical implementation[14].

Although preliminary reports have suggested that this modified approach may achieve favorable cosmetic outcomes without compromising surgical safety, clinical evidence directly comparing transumbilical three-port appendectomy with conventional LA remains limited[15]. Important questions remain regarding perioperative outcomes, postoperative recovery patterns, and the potential influence of perioperative factors on hospitalization duration.

Therefore, the present retrospective single-center study was conducted to compare transumbilical three-port LA using conventional instruments with conventional LA. The study aimed to evaluate perioperative outcomes, postoperative recovery, cosmetic outcomes, and hospitalization costs, while also exploring potential predictors of prolonged postoperative hospitalization. By providing systematic clinical evidence, this study seeks to clarify the feasibility and practical value of this modified technique as a safe, cosmetically favorable, and cost-effective alternative for the surgical management of appendicitis.

MATERIALS AND METHODS

Study design and setting

This retrospective single-center comparative study was conducted in the Department of General Surgery at Shengzhou People’s Hospital, a regional tertiary hospital serving the local population. All patients who underwent LA between June 1, 2022, and October 31, 2023 were screened through the institutional electronic medical record system. Demographic information, perioperative variables, and follow-up outcomes were independently extracted and cross-verified by two investigators to ensure data completeness and accuracy. The study was performed in accordance with the ethical standards of the Institutional Review Board of Shengzhou People’s Hospital, No. SZRY-REB-2026(011) and adhered to the Declaration of Helsinki. Written informed consent was obtained from all participants.

Study population

The diagnosis of appendicitis was established based on clinical presentation, physical examination, laboratory findings, and radiological assessment performed by experienced surgeons. Typical clinical manifestations included right lower abdominal pain, localized tenderness or rebound tenderness, and/or gastrointestinal symptoms. Laboratory evaluation included inflammatory markers such as white blood cell (WBC) count and C-reactive protein (CRP). Radiological confirmation was obtained using abdominal ultrasonography and/or computed tomography when necessary according to routine institutional practice. Imaging findings considered supportive of appendicitis included appendiceal enlargement, wall thickening, periappendiceal fat stranding, luminal obstruction, periappendiceal fluid, or localized inflammatory changes. Because of the retrospective nature of the study, a standardized clinical scoring system such as the Alvarado score was not uniformly documented and therefore was not used as an eligibility criterion.

Eligible patients were those aged 15-80 years with a diagnosis of acute appendicitis (defined as symptom duration < 72 hours) or chronic appendicitis documented in the medical record who met the indications for LA and had complete perioperative and postoperative records. Only patients undergoing emergency LA were included in this study, while patients scheduled for interval appendectomy were excluded. Patients were excluded if they had complicated appendicitis, including perforated appendicitis, intra-abdominal abscess, or diffuse peritonitis identified either preoperatively or intraoperatively. Additional exclusion criteria included severe cardiopulmonary dysfunction requiring long-term treatment, known coagulopathy, significant hepatic or renal insufficiency, pregnancy or lactation, previous abdominal surgery, severe systemic disease, contraindications to general anesthesia, or incomplete clinical documentation. American Society of Anesthesiologists classification was not used as a formal exclusion criterion. However, patients with severe systemic disease or contraindications to general anesthesia were excluded. After applying these eligibility criteria, a total of 77 patients were included in the final analysis, comprising 51 patients who underwent transumbilical three-port LA and 26 patients who underwent conventional LA.

Surgical procedures

All operations were performed by senior surgeons experienced in both surgical techniques to minimize operator-dependent variability. The choice of surgical approach (transumbilical three-port LA or conventional LA) was determined by the attending surgeon based on clinical assessment, patient preference, and surgeon experience. Because of the retrospective design of the study, patients were not randomly assigned to either surgical technique. In the cosmetic group, a transumbilical three-port approach was employed using only conventional laparoscopic instruments. After induction of general anesthesia and sterile preparation, pneumoperitoneum was established using a Veress needle inserted through a small infraumbilical incision. Intra-abdominal pressure was maintained at 12 mmHg. A 10-mm camera trocar was then introduced at the umbilicus, and a 30° laparoscope was used for intra-abdominal visualization. Under laparoscopic visualization, two additional 5-mm trocars were inserted within the upper left and upper right umbilical folds, allowing optimal triangulation while maintaining a concealed cosmetic profile. The appendix and mesoappendix were mobilized using an ultrasonic scalpel, the appendiceal base was doubly ligated with loop ligatures, and the specimen was divided approximately 0.5 cm distal to the ligature. The resected appendix was removed via a retrieval bag, pneumoperitoneum was evacuated, and umbilical incisions were closed using cosmetic suturing techniques to minimize scar formation.

In the conventional group, pneumoperitoneum was established through a 10-mm trocar placed at the umbilicus, followed by insertion of two 5-mm trocars in the left lower quadrant and lower midline abdomen. The appendix was dissected and ligated following standard laparoscopic principles identical to the cosmetic group to ensure procedural consistency. All abdominal incisions were closed according to routine practice.

Data collection

Baseline variables included age, sex, body mass index, comorbidities such as hypertension, diabetes, or chronic obstructive pulmonary disease, and appendicitis type. Preoperative laboratory values, including WBC count and CRP levels, were recorded as measures of inflammatory burden. Perioperative parameters encompassed operative time, intraoperative events, and the need for additional procedures. Postoperative outcomes included length of hospitalization, total hospitalization cost, time to ambulation and oral intake, postoperative complications (wound infection, fever, diarrhea), and pain intensity measured using a visual analogue scale at 2, 6, 12, and 24 hours. Cosmetic outcomes were assessed during postoperative follow-up based on incision healing, scar visibility, and patient-reported satisfaction.

Statistical analysis

Statistical analyses were performed using R software. Continuous variables were assessed for distributional characteristics and presented as mean ± SD for normally distributed data or as median with interquartile range (Q1, Q3) for non-normally distributed data. Group comparisons for continuous variables were conducted using the t-test or Kruskal-Wallis test, as appropriate. Categorical variables were summarized as n (%) and compared using the χ² test or Fisher’s exact test when expected cell counts were small.

Comparative analyses between the cosmetic and conventional surgical approaches included operative time, postoperative pain scores, length of stay, postoperative complications, and hospitalization costs. To identify independent predictors of prolonged hospitalization, defined a priori as a postoperative stay exceeding three days, logistic regression analysis was performed. Univariable logistic regression was first used to assess demographic, clinical, inflammatory, and perioperative variables. Variables with P < 0.20 in univariable analysis were subsequently included in a multivariable logistic regression model. Adjusted odds ratios and 95% confidence intervals were calculated to estimate the independent effect of each factor. Statistical significance was defined as two-sided P < 0.05.

RESULTS

Baseline characteristics

A total of 77 patients were included in the analysis, of whom 26 underwent conventional LA (conventional group) and 51 underwent transumbilical three-port LA using conventional instruments (cosmetic group). Baseline characteristics are summarized in Table 1. Preoperative imaging examinations, including abdominal ultrasonography or computed tomography, were performed when clinically indicated as part of routine diagnostic evaluation. Sex distribution and appendicitis type were comparable between groups, with no statistically significant differences.

Table 1 Baseline characteristics of patients, n (%)/median (interquartile range).

Variables	All patients (n = 77)	Conventional group (n = 26)	Cosmetic group (n = 51)	H	P value
Age	46 (30, 57)	36 (15.25, 53.75)	49 (35.5, 57)	4.69	0.03
Gender				1.857	0.173
Male	45 (58.4)	18 (69.2)	27 (52.9)
Female	32 (41.6)	8 (31.8)	24 (47.1)
BMI (kg/m2)	24.4 (22.4, 25.8)	22.95 (20.25, 25.7)	24.7 (23.2, 25.85)	3.89	0.0487
Preoperative WBC (10-9/L)	11.9 (10.6, 13.5)	12.65 (11.35, 13.8)	11.6 (10.3, 13.15)	3.55	0.059
Preoperative CRP (mg/L)	21.5 (15.1, 39.8)	30.3 (18.65, 44.05)	19.7 (14.05, 32.65)	4.71	0.03
Comorbidities				0.31	0.58
None	47 (61.04)	17 (65.38)	30 (58.82)
COPD	5 (6.49)	2 (7.69)	3 (5.88)
CHD	2 (2.6)	0 (0)	2 (3.92)
DM	12 (15.58)	4 (15.38)	8 (15.69)
Hypertension	26 (33.77)	8 (30.77)	18 (35.29)
Heart failure	1 (1.3)	1 (3.85)	0 (0)
Appendicitis type				0.76	0.382
Acute	42 (54.5)	16 (61.5)	26 (51.0)
Chronic	35 (45.5)	10 (38.5)	25 (49.0)

BMI: Body mass index; WBC: White blood cell; CRP: C-reactive protein; COPD: Chronic obstructive pulmonary disease; CHD: Coronary heart disease; DM: Diabetes mellitus.

Compared with the conventional group, patients in the cosmetic group were significantly older and had a higher body mass index, while exhibiting significantly lower preoperative CRP levels (P < 0.05). Preoperative WBC values were numerically higher in the conventional group than in the cosmetic group; however, this difference did not reach statistical significance (P = 0.059) and was therefore interpreted with caution in subsequent analyses.

Perioperative and postoperative data

Perioperative and postoperative outcomes are summarized in Table 2. All procedures were completed laparoscopically without conversion to open surgery. Operative time did not differ significantly between the cosmetic and conventional groups, with median values of 40 minutes and 45 minutes, respectively (P = 0.61). Postoperative length of hospital stay was identical between the two groups, with a median of 5 days in both groups (P = 0.45). A statistically significant difference was observed in total hospitalization cost. The cosmetic group showed a higher median total cost compared with the conventional group, at 10262.44 yuan (interquartile range 9181.34 to 11686.25) vs 8783.34 yuan (interquartile range 7425.83 to 9904.43), respectively (P = 0.0046). In contrast, no significant differences were observed in the costs of imported ultrasonic scalpels (P = 0.20) or domestically produced ultrasonic scalpels (P = 0.75) between the two groups.

Table 2 Surgical and postoperative outcomes, n (%)/median (interquartile range).

Variable	All patients (n = 77)	Conventional group (n = 26)	Cosmetic group (n = 51)	H	P value
Operating time (minutes)	40 (30, 60)	45 (30, 67.5)	40 (30, 60)	0.27	0.61
Length of hospital stay (days)	5 (4, 6)	5 (4, 6)	5 (4, 6)	0.58	0.45
Total hospitalization cost (yuan)	9733.44 (8852.22, 11105.50)	8783.34 (7425.83, 9904.43)	10262.44 (9181.34, 11686.25)	8.03	0.0046
Imported surgical scalpel (yuan)	10082.85 (9251.19, 11120.02)	10347.95 (9672.035, 12760.03)	10082.85 (9190.44, 10920.98)	1.63	0.2
Domestically produced surgical scalpel (yuan)	7467.36 (6883.44, 8027.50)	7467.36 (6667.32, 7924.94)	7670.31 (7338.91, 8001.71)	0.1	0.75
Postoperative complications
None	72 (95.5)	22 (84.6)	50 (98.04)
Diarrhea	2 (2.6)	1 (3.85)	1 (1.96)
Surgical wound infection	1 (1.3)	1 (3.85)	0 (0)
Fever	2 (2.6)	2 (7.7)	0 (0)
Patient satisfaction score	9 (8, 9)	8 (7.25, 9)	9 (8, 9)	0.89	0.345
Postoperative VAS at 2 hours	4 (4, 6)	5 (4, 6)	4 (4, 5)	1.66	0.198
Postoperative VAS at 6 hours	3 (3, 5)	4 (3, 5)	3 (3, 4)	1.66	0.198
Postoperative VAS at 12 hours	2 (2, 4)	3 (2, 4)	2 (2, 3)	1.66	0.198
Postoperative VAS at 24 hours	1 (1, 3)	2 (1, 3)	1 (1, 2)	1.66	0.198

VAS: Visual analogue scale.

Postoperative complications occurred infrequently in both groups. The majority of patients experienced no postoperative complications, while diarrhea, surgical wound infection, and fever were observed at low rates. No major postoperative complications were recorded. Patient satisfaction scores were comparable between the cosmetic and conventional groups, with median scores of 9 and 8, respectively (P = 0.345). Postoperative pain, assessed using the visual analogue scale at 2, 6, 12, and 24 hours after surgery, showed numerically lower median scores in the cosmetic group at all time points. However, none of these differences reached statistical significance (all P = 0.198).

Logistic regression analysis

Logistic regression analysis was performed to evaluate factors associated with prolonged hospitalization, defined as a postoperative stay longer than 3 days (Table 3). In the univariate analysis, higher preoperative WBC count and CRP levels were associated with prolonged hospitalization. Variables with a univariate P < 0.20 were entered into the multivariable logistic regression model. After adjustment, only preoperative WBC count remained independently associated with prolonged hospitalization (adjusted odds ratio = 11.55, 95% confidence interval: 2.28-80.44, P = 0.0052), whereas CRP and other variables were not significant in the multivariable model.

Table 3 Univariate and multivariate logistic regression analysis.

Variable	Univariate analysis, OR (95%CI)	P value	Multivariate analysis, OR (95%CI)	P value
Gender	1.5 (0.43-5.29)	0.5201
Age	1 (0.96-1.03)	0.8652
Operating time	1.03 (1-1.08)	0.1313	0.99 (0.95-1.05)	0.7943
BMI	1.05 (0.82-1.33)	0.7147
Preoperative WBC (10-9/L)	3.63 (1.85-9.56)	0.0017	11.55 (2.28-80.44)	0.0052
Preoperative CRP (mg/L)	1.16 (1.05-1.35)	0.0181	0.86 (0.73-1.06)	0.0696
Appendicitis type
Chronic	1.2 (0.35-4.42)	0.7744
Comorbidities
None	0.26 (0.04-1.1)	0.1021	1.26 (0.12-11.32)	0.832
Hypertension	6.87 (1.22-129.5)	0.073
DM	0.91 (0.2-6.49)	0.91

OR: Odds ratios; CI: Confidence intervals; BMI: Body mass index; WBC: White blood cell; CRP: C-reactive protein; DM: Diabetes mellitus.

Cosmetic outcomes

Cosmetic outcomes were evaluated among the 51 patients in the cosmetic group who underwent transumbilical three-port LA. Within this group, 42 patients received the curved “smile” umbilical incision and 8 patients received a vertical “sting-like” incision, while one patient required intraoperative conversion to a standard port configuration due to marked adhesions.

Postoperative follow-up demonstrated satisfactory wound healing in the majority of patients in the cosmetic group. Photographic documentation at 18 days, 4 months, and 8 months after surgery showed that the umbilical incisions were well concealed within the natural umbilical contour, with only minimal and progressively fading scars. By 8 months, most scars were minimally visible and well integrated with the surrounding skin. Patient-reported satisfaction with the cosmetic outcome was generally high, supporting the aesthetic advantage of concentrating all port sites within the umbilical region. Representative images of postoperative incisions and their evolution over time are illustrated in Figure 1.

Figure 1  Representative cosmetic outcomes following transumbilical three-port laparoscopic appendectomy.

DISCUSSION

The present study examined the clinical performance, safety, and cosmetic value of transumbilical three-port LA performed with conventional instruments. Several key findings were identified. First, the modified technique appeared to achieve perioperative outcomes comparable to those of conventional LA, with similar operative times, low complication rates, and no prolongation of hospital stay. Second, although postoperative visual analogue scale scores did not differ significantly between groups, the cosmetic group consistently demonstrated lower pain intensity within the first 24 hours after surgery, consistent with the reduced abdominal wall trauma associated with avoiding additional trocar incisions. Third, differences in hospitalization costs were observed between the two groups. Although no significant differences were found in the costs of key surgical instruments, the overall cost variation may also reflect temporal or institutional factors. Given the retrospective design of this study, the potential influence of surgical approach on total hospitalization cost cannot be completely excluded and should therefore be interpreted with caution. Finally, logistic regression analysis suggested that higher preoperative WBC levels were associated with prolonged hospitalization, consistent with the recognized role of inflammatory burden in appendicitis. Taken together, these findings suggest that the transumbilical three-port technique is a feasible and cosmetically favorable alternative.

When positioned within the context of existing literature, the results of this study reinforce the growing evidence supporting umbilical access as an effective and cosmetically superior route for minimally invasive abdominal surgery. Prior studies comparing single-incision or umbilical-concealed LA with conventional multiport techniques have demonstrated improved patient satisfaction and similar clinical outcomes[10]. The present findings extend this body of work by showing that the cosmetic benefits of umbilical access can be achieved without specialized single-port devices or articulating instruments. This observation may have clinical relevance, because common limitations of single-port surgery, including loss of triangulation and the so-called “chopstick effect”, can be mitigated by distributing trocars within the natural folds of the umbilicus, as was done in this technique[16,17]. Importantly, distributing the trocars along the natural umbilical folds preserves a degree of triangulation that is often lost in single-incision surgery. This configuration improves instrument separation and reduces external hand collision, thereby enhancing surgical ergonomics and facilitating more precise dissection. Furthermore, the trend toward reduced postoperative pain in the cosmetic group aligns with data indicating that minimizing abdominal wall incisions decreases somatic pain. The observed association between preoperative WBC levels and prolonged hospitalization is also consistent with earlier reports demonstrating the influence of inflammatory burden on postoperative recovery in appendicitis.

In addition to reinforcing established principles, this study contributes several unique insights to current surgical practice. First, it provides a structured technical evaluation of the transumbilical three-port method, including practical considerations that enhance surgical efficiency[18]. The choice of incision, either the curved “smile” incision or the vertical “sting” incision, may be individualized according to intraoperative exposure and specimen retrieval requirements while maintaining cosmetic concealment within the umbilical contour. The selection of trocars also warrants attention. Metal trocars reduce instrument interference and improve procedural precision, whereas plastic trocars facilitate specimen extraction[19]. The ability to use either option without compromising safety highlights the adaptability of the technique. Furthermore, strategies to minimize instrument collision, such as adjusting trocar depth and angle and optimizing laparoscopic camera trajectories, contribute to smoother intraoperative manipulation. Technical refinements such as the use of ultrasonic energy rather than intracorporeal knot tying for vascular control reduce procedural difficulty and the risk of bleeding, particularly within the limited operative space of the umbilical region[20]. These practical considerations may contribute to the operative safety and efficiency observed with the modified approach in this study.

Second, the concentration of all port sites within the umbilical region produced favorable cosmetic outcomes, while preserving adequate instrument triangulation and operative exposure. Follow-up images demonstrated minimal visible scarring at 18 days, faint scars at 4 months, and almost imperceptible scars by 8 months. These findings confirm the cosmetic value of this technique and support its use among young or cosmetically conscious patients. Importantly, the technique achieves these benefits without requiring costly single-port platforms[21,22]. This finding has direct implications for primary and secondary medical centers, where the budgetary constraints often limit access to specialized equipment. The technique therefore represents an economical and practical enhancement of conventional LA.

Despite the strengths of this study, several limitations should be acknowledged. First, the retrospective design introduces an inherent risk of selection bias. In addition, baseline differences between the two groups, including age, body mass index, and preoperative CRP levels, may reflect underlying selection bias. Because comparative analyses between surgical techniques were not fully adjusted for these baseline imbalances, the findings should be interpreted with caution. Second, this study was conducted at a single center, which may limit the generalizability of the findings to other institutions, patient populations, and healthcare settings. Third, the relatively small sample size may reduce the statistical power to detect subtle between-group differences in pain scores and postoperative complications. In addition, cosmetic outcomes were assessed primarily using descriptive evaluation and photographic documentation rather than standardized validated patient-reported cosmetic assessment tools, which may limit the objectivity of cosmetic evaluation. Finally, long-term functional and cosmetic outcomes beyond eight months were not evaluated. Future studies with prospective designs, larger multicenter cohorts, and standardized aesthetic assessment tools are warranted to further validate these findings.

CONCLUSION

In summary, transumbilical three-port LA using conventional instruments appears to be a safe and feasible alternative to conventional LA. The technique provides comparable perioperative outcomes while offering improved cosmetic concealment through concentration of the port sites within the umbilicus. This approach may represent a practical and cosmetically favorable minimally invasive option for the surgical management of appendicitis.