Transumbilical Laparoscopic-Assisted Appendectomy (TULAA) in Children: A Single-Center Experience of 1597 Cases

Transumbilical Laparoscopic-Assisted Appendectomy (TULAA) in Children: A Single-Center Experience of 1597 Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Transumbilical Laparoscopic-Assisted Appendectomy (TULAA) in Children: A Single-Center Experience of 1597 Cases Kamilė Bagdonaitė¹, Audrius Dulskas², Geistė Tubutytė¹, Arūnas Strumila¹, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8046616/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose With acute appendicitis remaining the leading cause of emergency surgery among pediatric patients, we aimed to evaluate single centre experience, outcomes and advantages of performed transumbilical laparoscopic-assisted appendectomy (TULAA). Methods A retrospective analysis was conducted of 1,597 consecutive pediatric appendectomies performed between January 2018 and October 2023 at Vilnius University Hospital Santaros Klinikos, Children’s Hospital. Data from patients diagnosed with appendicitis (ICD-10 K35–K36) and treated using ACHI code 30572-00 were included. Demographic, operative, and postoperative parameters were analyzed. Results TULAA was performed in 576 (36.1%) patients. The mean age was 10.7 years; 56.3% were male. The most frequent histological type was phlegmonous appendicitis (74.3%). The appendix was in a typical ileocecal position in 77.8% of cases. Median hospital stay was 3 days. Mean operative time was 40 minutes; higher BMI was associated with longer duration (p = 0.05). The overall complication rate was 1.9%, mainly wound infections. Patients and parents reported high satisfaction with cosmetic outcomes. Conclusions TULAA is a safe, efficient, and cosmetically favorable technique for pediatric appendicitis, associated with a low complication rate and acceptable operative times. appendicitis TULAA children laparoscopy Figures Figure 1 Introduction Acute appendicitis is the most common cause of surgical abdominal conditions in the pediatric population [ 1 ]. It remains the most common cause for emergency surgery among children worldwide, it is important to seek innovations and strive for even better results for surgeons treating this disease every day [ 2 ]. Appendectomy is the treatment of choice, and for many years, the conventional surgical procedure was open appendectomy [ 1 ]. Innovations in surgical techniques, such as the widespread adoption of laparoscopic appendectomy, have revolutionized the approach to treating appendicitis [ 3 ]. Introduced in 1983, standard 2 or 3-port laparoscopic appendectomy (SLA), showed many advantages compared to the open technique, such as easier postoperative pain management, shorter hospitalization time, and lower rate of complications. Surgeons all over the world are still discussing the most optimal way to perform an appendectomy. Over the past years, single-site appendectomy has emerged as a first-choice technique among pediatric surgeons, achieving outcomes comparable to those of conventional laparoscopic appendectomy, particularly with respect to operative time and complication rates [ 4 ]. In 1992, Pelosi introduced a novel surgical method – transumbilical laparoscopic appendectomy – TULAA [ 5 ]. For this procedure, a telescope with a working channel is used, through which an instrument is introduced, the appendix is pulled through the umbilical incision, and an extracorporeal typical appendectomy is performed [ 6 ]. Advantages of such surgery are laparoscopic abdominal cavity visualization and open appendectomy safety and speed. Moreover, compared to adults, TULAA is especially effective in the child population since in these patients, the distance between the caecum and umbilicus is shorter and the abdominal wall is more flexible therefore it is easier to pull the appendix out. Recent studies showed TULAA effectiveness compared to the standard 2 or 3 port laparoscopic appendectomy [ 1 , 5 , 6 ]. TULAA merges the practicality of the open technique with the benefits of minimally invasive surgery. In pediatric practice, it is widely applied and has proven to be cost-effective, rapid, and to provide nearly scarless results [ 7 , 8 ].Despite the increasing use of single-trocar laparoscopic appendectomy (TULAA) in children, important uncertainties remain. The influence operative time, complication rates, and overall hospital costs has not been adequately studied. Furthermore, criteria guiding the choice between TULAA such as patient age, BMI, appendix position, and disease severity—are poorly defined. However, selection criteria, operative time determinants, and outcome data remain inconsistent, particularly in the Baltic region. In our study we aimed to evaluate the institutional experience with TULAA in children, focusing on operative time, BMI correlation, complications, and cosmetic satisfaction. Methods Study design and setting This was a retrospective observational study conducted at the Children’s Hospital of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania. The hospital is a tertiary referral centre for paediatric surgery, serving both urban and regional populations. All appendectomies performed between January 2018 and October 2023 were screened for eligibility. Participants Children under 18 years of age who underwent appendectomy during the study period were eligible. Cases were identified through hospital electronic medical records using International Classification of Diseases (ICD-10) diagnostic codes K35–K36 (acute and other appendicitis) and the Australian Classification of Health Interventions (ACHI) procedural code 30572-00 (laparoscopic appendectomy). Inclusion criteria Paediatric patients (aged < 18 years) treated in the Department of Paediatric Surgery during the study period. Underwent laparoscopic appendectomy (ACHI code 30572-00). Exclusion criteria Patients undergoing open appendectomy. Patients treated with conventional three-port laparoscopic appendectomy. Intraoperative or histopathological findings inconsistent with appendicitis. A total of 1,597 appendectomy cases were identified, of which 576 were performed using the TULAA technique. Surgeon preference and case complexity primarily guided the choice of surgical approach. Variables and data collection The following variables were recorded: patient age, sex, height, weight, BMI, histological type of appendicitis, anatomical appendix position, operative duration (from incision to closure), postoperative hospital stay, and complications. Complications were classified according to the Clavien–Dindo system , and postoperative wound infections were used as the principal indicator of surgical safety. Cosmetic satisfaction was evaluated during postoperative wound inspections through informal patient–parent interviews. All data were retrieved from the hospital’s electronic health records and operative reports. Cases with incomplete core variables (operative time, BMI, or outcome data) were excluded; missing data were rare (< 1%). Bias control To reduce selection bias, all consecutive appendectomy cases meeting inclusion criteria during the study period were included. Exclusion criteria were applied uniformly. As a potential bias, surgical approach decisions were influenced by surgeon experience and preference. Information bias was minimised by cross-verifying data from operative notes, histopathology reports, and discharge summaries. Data extraction and cleaning were independently performed by two investigators to ensure accuracy and reproducibility. Study size Sample size estimation was performed using a 5% margin of error, a 95% confidence level, a population size of 1,600, and an expected response distribution of 30%. The minimum required sample was 269 participants. Our analysed cohort (n = 576) substantially exceeded this threshold, providing adequate statistical power. Statistical analysis Continuous variables were reported as means ± standard deviation (SD) or medians with interquartile ranges (IQR), depending on data distribution (tested using the Shapiro–Wilk method). Categorical variables were expressed as counts and percentages. Associations between BMI and operative duration were analysed using one-way ANOVA ./ A two-tailed p value < 0.05 was considered statistically significant. Descriptive and inferential analyses were conducted in Microsoft Excel (Microsoft Corp., Redmond, WA, USA). Ethical considerations This study was approved by the Vilnius Regional Biomedical Research Ethics Committee (approval No. 2025/9-1701-1146). All procedures conformed to the principles of the Declaration of Helsinki. Informed consent for surgical treatment was obtained from parents or legal guardians prior to the operation. Given the retrospective design, additional patient consent for inclusion in this study was waived. Results Study population Of the 1,597 appendectomies performed during the study period, 576 (36.1%) were completed using the transumbilical laparoscopic-assisted appendectomy (TULAA) technique. The mean age of patients was 10.7 ± 3.8 years (range 2–17 years), and 324 (56.3%) were male. Histopathological findings and appendix position Phlegmonous appendicitis was the predominant histological diagnosis (428 cases, 74.3%), followed by gangrenous (79, 13.7%), gangrenous perforated (18, 3.1%), catarrhal (44, 7.6%), and chronic appendicitis (7, 1.2%). The appendix occupied a typical ileocaecal position in 448 (77.8%) cases, retrocaecal in 36 (6.3%), lateral canal in 36 (6.3%), medial in 23 (4.0%), ileo-inguinal in 18 (3.1%), and pelvic in 15 (2.6%). Operative outcomes Operative duration ranged from 15 to 100 minutes, with a mean of 40 minutes. The majority of procedures (83.5%) were completed between 30 and 50 minutes. A statistically significant, albeit modest, association was observed between higher BMI and longer operative duration ( p = 0.05). The median postoperative hospital stay was 3 days (IQR 2–4). No intra-operative conversions to open surgery occurred in the analysed group. Postoperative complications The overall complication rate was 1.9% (11 cases). According to the Clavien–Dindo classification, five complications were grade II (requiring pharmacological treatment) and five were grade IIIB (requiring re-intervention under anaesthesia). Most complications were superficial wound infections managed with antibiotics and dressing changes. No postoperative abscesses or mortality were recorded. Cosmetic satisfaction Patients and their parents consistently expressed high satisfaction with postoperative appearance. Although formal questionnaires were not used, all reported satisfaction with the minimal scar and rapid recovery. All the results are summarised in Fig. 1 . Discussion In our study, the median operative time for conventional appendectomy was under 40 minutes—longer than the 29.8 minutes reported by Iqbal et al.—which may help explain the higher overall cost observed. Differences in surgeon experience, teaching involvement, and institutional workflow likely contribute to these variations. Similar to other studies, we defined cost as total hospital expenditure, including operative, anesthesia, and postoperative fees. Stylianos et al. demonstrated that the transumbilical laparoscopic-assisted appendectomy (TULAA) technique significantly reduces disposable supply costs, lowering total operative expenses despite longer room utilization [ 9 ]. At our institution, admission and discharge were based on surgeon preference, though same-day discharge is feasible and safe according to recent analyses [ 7 , 10 ]. The mean operative time for TULAA in our series was comparable to previous findings (24–33 minutes) [ 10 – 12 ]. Since both TULAA and conventional laparoscopic appendectomy are commonly used as training operations, many were performed by junior residents under supervision, likely contributing to longer procedure times and slightly higher costs. Longer surgeries directly increase operative expenditure due to anesthesia and operating room time—an effect repeatedly confirmed in cost analyses and meta-reviews [ 13 , 14 ]. The incidence of surgical site infection (SSI) in our study was 1.91%, not statistically significant and consistent with Stanfill et al. [ 12 ]. Large-scale meta-analyses similarly report no difference in SSI or overall complication rates between single-incision laparoscopic appendectomy (SILA/TULAA) and conventional three-port laparoscopy (CTLA) [ 10 , 15 , 16 ]. Some pediatric meta-analyses even suggest lower intra-abdominal infection rates and shorter hospital stay with TULAA [ 7 , 10 ]. Thus, our SSI results fit the broader evidence supporting TULAA’s safety. Multiple studies and reviews highlight TULAA’s strengths: excellent visualization of the entire abdominal cavity, high diagnostic accuracy for acute abdomen, reliable therapeutic outcomes, and superior cosmetic appearance [ 12 , 16 , 17 ]. Patients often experience faster postoperative recovery, reduced analgesic needs, and improved satisfaction with cosmetic results [ 15 , 16 , 18 , 19 ]. Meta-analyses consistently show higher patient satisfaction scores and better cosmetic outcomes for single-incision approaches, although at the cost of a modest increase in incisional hernia risk [ 18 ]. Our findings confirm that operative and postoperative outcomes with TULAA are excellent in appropriately selected patients. However, TULAA’s feasibility is strongly influenced by appendix position and disease severity. In our cohort, TULAA was most often used for phlegmonous appendicitis with a typical ileocecal position. As reported elsewhere, the technique becomes technically demanding for retrocecal, subhepatic, or pelvic appendices and in perforated cases, often requiring an additional port or conversion to multi-port laparoscopy [14,21,]. Consequently, surgeons tend to prefer the three-port technique for complicated appendicitis or in overweight and obese patients [14,21,]. Our analysis identified a statistically significant correlation between BMI and operative time—higher BMI values were associated with longer procedures. This association is consistent with prior reports linking increased abdominal wall thickness and altered adipose distribution to more difficult access and dissection [ 16 , 21 ]. Nevertheless, multiple meta-analyses demonstrate that obesity does not increase complication rates or SSI after single-incision laparoscopy when performed by experienced teams [ 9 , 16 , 21 ]. These findings support the view that TULAA remains a safe and effective technique across a broad BMI spectrum. Adequate exposure and visualization of the appendix are key to a successful TULAA procedure. Proper umbilical port placement, effective traction, and careful dissection are crucial, especially when anatomic variations exist. New articulating instruments and flexible laparoscopes have improved ergonomics and broadened TULAA’s applicability. Surgeons have reported that learning curves for single-port appendectomy plateau after approximately 20–25 cases [ 18 , 21 ], suggesting the technique is reproducible once experience is gained. Beyond safety and efficiency, TULAA offers meaningful advantages from a patient-centered perspective. Single-incision access provides minimal scarring and reduced postoperative discomfort, contributing to improved psychological satisfaction—particularly in young and female patients [ 15 , 18 ]. Meta-analyses show shorter recovery and hospital stays by approximately 0.3–0.8 days compared to conventional laparoscopy [ 10 , 15 , 18 ]. These outcomes align with global trends favoring minimally invasive, cosmetically favorable surgical strategies for appendicitis management. Strengths and limitations Our study has several limitations. First, it was a single-center retrospective analysis, limiting generalizability and introducing potential selection bias. Most cases involved phlegmonous appendicitis with a typical appendix position and a median BMI of 17.7, which restricts applicability to obese or complicated cases. There was no comparative control group of conventional three-port appendectomies, preventing direct evaluation of outcome differences. Furthermore, postoperative pain scores, cosmetic satisfaction, and long-term follow-up—including incisional hernia surveillance—were not assessed. Future prospective, randomized studies with standardized selection criteria, operative protocols, and long-term outcomes are warranted to confirm the benefits and limitations of TULAA. Conclusions TULAA represents a safe and cosmetically superior option for pediatric appendicitis, achieving excellent outcomes with minimal complications. Operative duration slightly increases with BMI but remains clinically acceptable. Broader multicenter studies could help standardize patient selection and operative protocols. Declarations Competing interests The authors have no competing interests to declare that are relevant to the content of this article. Ethics approval This study was approved by the Vilnius Regional Biomedical Research Ethics Committee (No. 2025/9-1701-1146) and was conducted in accordance with the 1964 Declaration of Helsinki and its later amendments. Consent to participate Written informed consent for surgical treatment was obtained from parents or legal guardians as part of routine clinical care. Owing to the retrospective design, additional informed consent for inclusion in this analysis was waived by the ethics committee. Consent to publish Not applicable (no identifying information or images of individual participants are included). Funding The authors did not receive support from any organisation for the submitted work. All resources were provided by Vilnius University Hospital Santaros Klinikos, Children’s Hospital. Author Contribution Conceptualisation: J. Povilavičius, K. Bagdonaitė, G. Tubutytė, A. StrumilaMethodology and data curation: J. Povilavičius, K. Bagdonaitė, G. Tubutytė, A. DulskasSurgery and clinical supervision: J.Povilavičius, A.StrumilaStatistical analysis: J. Povilavičius, K. BagdonaitėWriting – original draft: J. Povilavičius, K. BagdonaitėWriting – review and editing: J. Povilavičius, K. Bagdonaitė, A. Dulskas, G. Verkauskas, All authors read and approved the final manuscript. Acknowledgements The authors thank the nursing staff and medical records unit of Vilnius University Hospital Santaros Klinikos, Children’s Hospital, for their assistance with data retrieval. Data Availability The datasets generated and analysed during the current study are not publicly available due to institutional and national data protection regulations. De-identified data may be made available from the corresponding author on reasonable request and with permission from the Vilnius University Hospital Santaros Klinikos Bioethics Committee (approval No. 2025/9-1701-1146). References Transumbilical laparoscopic- assisted appendectomy as a safe procedure for pediatric uncomplicated appendicitis: a comparison with laparoscopic and open appendectomy in a randomized clinical trial | Journal of Pediatric Endoscopic Surgery [Internet]. [cited 2025 Feb 28]. Available from: https://link.springer.com/article/ 10.1007/s42804-020-00087-1 Ayyıldız HN, Mirapoglu S, Yıldız ZA, Şahin C, Güvenç FT, Arpacık M et al (2021) What has changed in children’s appendicitis during the COVID-19 pandemic? Ulus Travma Acil Cerrahi Derg 28(12):1674–1681 Acute appendicitis in children Management - UpToDate [Internet]. [cited 2025 Feb 28]. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8046616","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":558441097,"identity":"19643ac1-806b-4c84-87d5-b20c70ee8f94","order_by":0,"name":"Kamilė Bagdonaitė¹","email":"","orcid":"","institution":"Vilnius University Hospital Santaros Klinikos, Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kamilė","middleName":"","lastName":"Bagdonaitė¹","suffix":""},{"id":558441098,"identity":"52627c9e-749a-4c15-9aaa-2abc44fc46d3","order_by":1,"name":"Audrius Dulskas²","email":"","orcid":"","institution":"National 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1","display":"","copyAsset":false,"role":"figure","size":255978,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the data.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8046616/v1/1c69f39d8186b8e41fde3871.png"},{"id":98445815,"identity":"72d0a687-4d37-4db8-9a7a-d8baedb8dbad","added_by":"auto","created_at":"2025-12-17 17:21:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":724262,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8046616/v1/43b70fcb-ea2c-469a-a66a-531398144193.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTransumbilical Laparoscopic-Assisted Appendectomy (TULAA) in Children: A Single-Center Experience of 1597 Cases\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute appendicitis is the most common cause of surgical abdominal conditions in the pediatric population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It remains the most common cause for emergency surgery among children worldwide, it is important to seek innovations and strive for even better results for surgeons treating this disease every day [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Appendectomy is the treatment of choice, and for many years, the conventional surgical procedure was open appendectomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Innovations in surgical techniques, such as the widespread adoption of laparoscopic appendectomy, have revolutionized the approach to treating appendicitis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Introduced in 1983, standard 2 or 3-port laparoscopic appendectomy (SLA), showed many advantages compared to the open technique, such as easier postoperative pain management, shorter hospitalization time, and lower rate of complications. Surgeons all over the world are still discussing the most optimal way to perform an appendectomy. Over the past years, single-site appendectomy has emerged as a first-choice technique among pediatric surgeons, achieving outcomes comparable to those of conventional laparoscopic appendectomy, particularly with respect to operative time and complication rates [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 1992, Pelosi introduced a novel surgical method \u0026ndash; transumbilical laparoscopic appendectomy \u0026ndash; TULAA [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. For this procedure, a telescope with a working channel is used, through which an instrument is introduced, the appendix is pulled through the umbilical incision, and an extracorporeal typical appendectomy is performed [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Advantages of such surgery are laparoscopic abdominal cavity visualization and open appendectomy safety and speed. Moreover, compared to adults, TULAA is especially effective in the child population since in these patients, the distance between the caecum and umbilicus is shorter and the abdominal wall is more flexible therefore it is easier to pull the appendix out. Recent studies showed TULAA effectiveness compared to the standard 2 or 3 port laparoscopic appendectomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. TULAA merges the practicality of the open technique with the benefits of minimally invasive surgery. In pediatric practice, it is widely applied and has proven to be cost-effective, rapid, and to provide nearly scarless results [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].Despite the increasing use of single-trocar laparoscopic appendectomy (TULAA) in children, important uncertainties remain. The influence operative time, complication rates, and overall hospital costs has not been adequately studied. Furthermore, criteria guiding the choice between TULAA such as patient age, BMI, appendix position, and disease severity\u0026mdash;are poorly defined. However, selection criteria, operative time determinants, and outcome data remain inconsistent, particularly in the Baltic region.\u003c/p\u003e \u003cp\u003eIn our study we aimed to evaluate the institutional experience with TULAA in children, focusing on operative time, BMI correlation, complications, and cosmetic satisfaction.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis was a retrospective observational study conducted at the Children\u0026rsquo;s Hospital of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania. The hospital is a tertiary referral centre for paediatric surgery, serving both urban and regional populations. All appendectomies performed between \u003cem\u003eJanuary 2018 and October 2023\u003c/em\u003e were screened for eligibility.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eChildren under 18 years of age who underwent appendectomy during the study period were eligible. Cases were identified through hospital electronic medical records using International Classification of Diseases (ICD-10) diagnostic codes \u003cem\u003eK35\u0026ndash;K36\u003c/em\u003e (acute and other appendicitis) and the Australian Classification of Health Interventions (ACHI) procedural code \u003cem\u003e30572-00\u003c/em\u003e (laparoscopic appendectomy).\u003c/p\u003e \u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePaediatric patients (aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years) treated in the Department of Paediatric Surgery during the study period.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUnderwent laparoscopic appendectomy (ACHI code 30572-00).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion criteria\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients undergoing open appendectomy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients treated with conventional three-port laparoscopic appendectomy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIntraoperative or histopathological findings inconsistent with appendicitis.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eA total of \u003cem\u003e1,597\u003c/em\u003e appendectomy cases were identified, of which \u003cem\u003e576\u003c/em\u003e were performed using the TULAA technique. Surgeon preference and case complexity primarily guided the choice of surgical approach.\u003c/p\u003e\n\u003ch3\u003eVariables and data collection\u003c/h3\u003e\n\u003cp\u003eThe following variables were recorded: patient age, sex, height, weight, BMI, histological type of appendicitis, anatomical appendix position, operative duration (from incision to closure), postoperative hospital stay, and complications.\u003c/p\u003e \u003cp\u003eComplications were classified according to the \u003cem\u003eClavien\u0026ndash;Dindo system\u003c/em\u003e, and postoperative wound infections were used as the principal indicator of surgical safety. Cosmetic satisfaction was evaluated during postoperative wound inspections through informal patient\u0026ndash;parent interviews.\u003c/p\u003e \u003cp\u003eAll data were retrieved from the hospital\u0026rsquo;s electronic health records and operative reports. Cases with incomplete core variables (operative time, BMI, or outcome data) were excluded; missing data were rare (\u0026lt;\u0026thinsp;1%).\u003c/p\u003e\n\u003ch3\u003eBias control\u003c/h3\u003e\n\u003cp\u003eTo reduce selection bias, all consecutive appendectomy cases meeting inclusion criteria during the study period were included. Exclusion criteria were applied uniformly. As a potential bias, surgical approach decisions were influenced by surgeon experience and preference. Information bias was minimised by cross-verifying data from operative notes, histopathology reports, and discharge summaries. Data extraction and cleaning were independently performed by two investigators to ensure accuracy and reproducibility.\u003c/p\u003e\n\u003ch3\u003eStudy size\u003c/h3\u003e\n\u003cp\u003eSample size estimation was performed using a 5% margin of error, a 95% confidence level, a population size of 1,600, and an expected response distribution of 30%. The minimum required sample was 269 participants. Our analysed cohort (n\u0026thinsp;=\u0026thinsp;576) substantially exceeded this threshold, providing adequate statistical power.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were reported as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or medians with interquartile ranges (IQR), depending on data distribution (tested using the Shapiro\u0026ndash;Wilk method). Categorical variables were expressed as counts and percentages.\u003c/p\u003e \u003cp\u003eAssociations between BMI and operative duration were analysed using \u003cem\u003eone-way ANOVA\u003c/em\u003e./ A two-tailed \u003cem\u003ep\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Descriptive and inferential analyses were conducted in \u003cem\u003eMicrosoft Excel\u003c/em\u003e (Microsoft Corp., Redmond, WA, USA).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThis study was approved by the \u003cem\u003eVilnius Regional Biomedical Research Ethics Committee\u003c/em\u003e (approval No. 2025/9-1701-1146). All procedures conformed to the principles of the Declaration of Helsinki. Informed consent for surgical treatment was obtained from parents or legal guardians prior to the operation. Given the retrospective design, additional patient consent for inclusion in this study was waived.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eOf the 1,597 appendectomies performed during the study period, 576 (36.1%) were completed using the transumbilical laparoscopic-assisted appendectomy (TULAA) technique. The mean age of patients was 10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 years (range 2\u0026ndash;17 years), and 324 (56.3%) were male.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eHistopathological findings and appendix position\u003c/h2\u003e \u003cp\u003ePhlegmonous appendicitis was the predominant histological diagnosis (428 cases, 74.3%), followed by gangrenous (79, 13.7%), gangrenous perforated (18, 3.1%), catarrhal (44, 7.6%), and chronic appendicitis (7, 1.2%).\u003c/p\u003e \u003cp\u003eThe appendix occupied a typical ileocaecal position in 448 (77.8%) cases, retrocaecal in 36 (6.3%), lateral canal in 36 (6.3%), medial in 23 (4.0%), ileo-inguinal in 18 (3.1%), and pelvic in 15 (2.6%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eOperative outcomes\u003c/h2\u003e \u003cp\u003eOperative duration ranged from 15 to 100 minutes, with a mean of 40 minutes. The majority of procedures (83.5%) were completed between 30 and 50 minutes. A statistically significant, albeit modest, association was observed between higher BMI and longer operative duration (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe median postoperative hospital stay was \u003cem\u003e3 days\u003c/em\u003e (IQR 2\u0026ndash;4). No intra-operative conversions to open surgery occurred in the analysed group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative complications\u003c/h2\u003e \u003cp\u003eThe overall complication rate was \u003cem\u003e1.9%\u003c/em\u003e (11 cases). According to the Clavien\u0026ndash;Dindo classification, five complications were grade II (requiring pharmacological treatment) and five were grade IIIB (requiring re-intervention under anaesthesia). Most complications were superficial wound infections managed with antibiotics and dressing changes. No postoperative abscesses or mortality were recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCosmetic satisfaction\u003c/h2\u003e \u003cp\u003ePatients and their parents consistently expressed high satisfaction with postoperative appearance. Although formal questionnaires were not used, all reported satisfaction with the minimal scar and rapid recovery.\u003c/p\u003e \u003cp\u003eAll the results are summarised in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, the median operative time for conventional appendectomy was under 40 minutes\u0026mdash;longer than the 29.8 minutes reported by Iqbal et al.\u0026mdash;which may help explain the higher overall cost observed. Differences in surgeon experience, teaching involvement, and institutional workflow likely contribute to these variations. Similar to other studies, we defined cost as total hospital expenditure, including operative, anesthesia, and postoperative fees. Stylianos et al. demonstrated that the transumbilical laparoscopic-assisted appendectomy (TULAA) technique significantly reduces disposable supply costs, lowering total operative expenses despite longer room utilization [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt our institution, admission and discharge were based on surgeon preference, though same-day discharge is feasible and safe according to recent analyses [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The mean operative time for TULAA in our series was comparable to previous findings (24\u0026ndash;33 minutes) [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Since both TULAA and conventional laparoscopic appendectomy are commonly used as training operations, many were performed by junior residents under supervision, likely contributing to longer procedure times and slightly higher costs. Longer surgeries directly increase operative expenditure due to anesthesia and operating room time\u0026mdash;an effect repeatedly confirmed in cost analyses and meta-reviews [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe incidence of surgical site infection (SSI) in our study was 1.91%, not statistically significant and consistent with Stanfill et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Large-scale meta-analyses similarly report no difference in SSI or overall complication rates between single-incision laparoscopic appendectomy (SILA/TULAA) and conventional three-port laparoscopy (CTLA) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Some pediatric meta-analyses even suggest lower intra-abdominal infection rates and shorter hospital stay with TULAA [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Thus, our SSI results fit the broader evidence supporting TULAA\u0026rsquo;s safety.\u003c/p\u003e \u003cp\u003eMultiple studies and reviews highlight TULAA\u0026rsquo;s strengths: excellent visualization of the entire abdominal cavity, high diagnostic accuracy for acute abdomen, reliable therapeutic outcomes, and superior cosmetic appearance [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Patients often experience faster postoperative recovery, reduced analgesic needs, and improved satisfaction with cosmetic results [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Meta-analyses consistently show higher patient satisfaction scores and better cosmetic outcomes for single-incision approaches, although at the cost of a modest increase in incisional hernia risk [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings confirm that operative and postoperative outcomes with TULAA are excellent in appropriately selected patients. However, TULAA\u0026rsquo;s feasibility is strongly influenced by appendix position and disease severity. In our cohort, TULAA was most often used for phlegmonous appendicitis with a typical ileocecal position. As reported elsewhere, the technique becomes technically demanding for retrocecal, subhepatic, or pelvic appendices and in perforated cases, often requiring an additional port or conversion to multi-port laparoscopy [14,21,]. Consequently, surgeons tend to prefer the three-port technique for complicated appendicitis or in overweight and obese patients [14,21,].\u003c/p\u003e \u003cp\u003eOur analysis identified a statistically significant correlation between BMI and operative time\u0026mdash;higher BMI values were associated with longer procedures. This association is consistent with prior reports linking increased abdominal wall thickness and altered adipose distribution to more difficult access and dissection [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Nevertheless, multiple meta-analyses demonstrate that obesity does not increase complication rates or SSI after single-incision laparoscopy when performed by experienced teams [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These findings support the view that TULAA remains a safe and effective technique across a broad BMI spectrum.\u003c/p\u003e \u003cp\u003eAdequate exposure and visualization of the appendix are key to a successful TULAA procedure. Proper umbilical port placement, effective traction, and careful dissection are crucial, especially when anatomic variations exist. New articulating instruments and flexible laparoscopes have improved ergonomics and broadened TULAA\u0026rsquo;s applicability. Surgeons have reported that learning curves for single-port appendectomy plateau after approximately 20\u0026ndash;25 cases [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], suggesting the technique is reproducible once experience is gained.\u003c/p\u003e \u003cp\u003eBeyond safety and efficiency, TULAA offers meaningful advantages from a patient-centered perspective. Single-incision access provides minimal scarring and reduced postoperative discomfort, contributing to improved psychological satisfaction\u0026mdash;particularly in young and female patients [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Meta-analyses show shorter recovery and hospital stays by approximately 0.3\u0026ndash;0.8 days compared to conventional laparoscopy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These outcomes align with global trends favoring minimally invasive, cosmetically favorable surgical strategies for appendicitis management.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eOur study has several limitations. First, it was a single-center retrospective analysis, limiting generalizability and introducing potential selection bias. Most cases involved phlegmonous appendicitis with a typical appendix position and a median BMI of 17.7, which restricts applicability to obese or complicated cases. There was no comparative control group of conventional three-port appendectomies, preventing direct evaluation of outcome differences. Furthermore, postoperative pain scores, cosmetic satisfaction, and long-term follow-up\u0026mdash;including incisional hernia surveillance\u0026mdash;were not assessed. Future prospective, randomized studies with standardized selection criteria, operative protocols, and long-term outcomes are warranted to confirm the benefits and limitations of TULAA.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTULAA represents a safe and cosmetically superior option for pediatric appendicitis, achieving excellent outcomes with minimal complications. Operative duration slightly increases with BMI but remains clinically acceptable. Broader multicenter studies could help standardize patient selection and operative protocols.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e This study was approved by the Vilnius Regional Biomedical Research Ethics Committee (No. 2025/9-1701-1146) and was conducted in accordance with the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003eWritten informed consent for surgical treatment was obtained from parents or legal guardians as part of routine clinical care. Owing to the retrospective design, additional informed consent for inclusion in this analysis was waived by the ethics committee.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003eNot applicable (no identifying information or images of individual participants are included).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors did not receive support from any organisation for the submitted work. All resources were provided by Vilnius University Hospital Santaros Klinikos, Children\u0026rsquo;s Hospital.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualisation: J. Povilavičius, K. Bagdonaitė, G. Tubutytė, A. StrumilaMethodology and data curation: J. Povilavičius, K. Bagdonaitė, G. Tubutytė, A. DulskasSurgery and clinical supervision: J.Povilavičius, A.StrumilaStatistical analysis: J. Povilavičius, K. BagdonaitėWriting \u0026ndash; original draft: J. Povilavičius, K. BagdonaitėWriting \u0026ndash; review and editing: J. Povilavičius, K. Bagdonaitė, A. Dulskas, G. Verkauskas, All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors thank the nursing staff and medical records unit of Vilnius University Hospital Santaros Klinikos, Children\u0026rsquo;s Hospital, for their assistance with data retrieval.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to institutional and national data protection regulations. De-identified data may be made available from the corresponding author on reasonable request and with permission from the Vilnius University Hospital Santaros Klinikos Bioethics Committee (approval No. 2025/9-1701-1146).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTransumbilical laparoscopic- assisted appendectomy as a safe procedure for pediatric uncomplicated appendicitis: a comparison with laparoscopic and open appendectomy in a randomized clinical trial | Journal of Pediatric Endoscopic Surgery [Internet]. [cited 2025 Feb 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://link.springer.com/article/\u003c/span\u003e\u003cspan address=\"https://link.springer.com/article/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s42804-020-00087-1\u003c/span\u003e\u003cspan address=\"10.1007/s42804-020-00087-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyyıldız HN, Mirapoglu S, Yıldız ZA, Şahin C, G\u0026uuml;ven\u0026ccedil; FT, Arpacık M et al (2021) What has changed in children\u0026rsquo;s appendicitis during the COVID-19 pandemic? Ulus Travma Acil Cerrahi Derg 28(12):1674\u0026ndash;1681\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcute appendicitis in children Management - UpToDate [Internet]. [cited 2025 Feb 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.uptodate.com/contents/acute-appendicitis-in-children-management?search=laparoscopic%20appendectomy\u0026amp;source=search_result\u0026amp;selectedTitle=3%7E16\u0026amp;usage_type=default\u0026amp;display_rank=3#H7\u003c/span\u003e\u003cspan address=\"https://www.uptodate.com/contents/acute-appendicitis-in-children-management?search=laparoscopic%20appendectomy\u0026amp;source=search_result\u0026amp;selectedTitle=3%7E16\u0026amp;usage_type=default\u0026amp;display_rank=3#H7\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuensterer OJ, Puga Nougues C, Adibe OO, Amin SR, Georgeson KE, Harmon CM (2010) Appendectomy using single-incision pediatric endosurgery for acute and perforated appendicitis. Surg Endosc 24(12):3201\u0026ndash;3204\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKılı\u0026ccedil; S Transumbilical single-incision laparoscopic appendectomy in pediatric appendicitis: A single-surgeon experience. Laparosc Endosc Surg Sci [Internet]. 2023 [cited 2025 Feb 28]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://jag.journalagent.com/less/pdfs/LESS-90912-RESEARCH_ARTICLE-KILIC.pdf\u003c/span\u003e\u003cspan address=\"https://jag.journalagent.com/less/pdfs/LESS-90912-RESEARCH_ARTICLE-KILIC.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang PCY, Lin SC, Duh YC, Huang H, Fu YW, Hsu YJ et al (2020) Should single-incision laparoscopic appendectomy be the new standard for pediatric appendicitis? Pediatr Neonatology 61(4):426\u0026ndash;431\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStylianos S, Nichols L, Ventura N, Malvezzi L, Knight C, Burnweit C (2011) The all-in-one appendectomy: quick, scarless, and less costly. J Pediatr Surg 46(12):2336\u0026ndash;2341\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulaylat AN, Podany AB, Hollenbeak CS, Santos MC, Rocourt DV (2014) Transumbilical laparoscopic-assisted appendectomy is associated with lower costs compared to multiport laparoscopic appendectomy. J Pediatr Surg 49(10):1508\u0026ndash;1512\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAly OE, Black DH, Rehman H, Ahmed I (2016) Single incision laparoscopic appendicectomy versus conventional three-port laparoscopic appendicectomy: A systematic review and meta-analysis. Int J Surg 35:120\u0026ndash;128\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheema AH, Ahmed A, Waseem MH, Abideen ZU, Sajid B, Huda Ramzan NU et al (2024) S2130 Comparison of Trans Umbilical Laparoscopic-Assisted Appendectomy (TULAA) vs Conventional Laparoscopic Appendectomy (CLA) In the Pediatric Population: A Systematic Review and Meta-Analysis. Official J Am Coll Gastroenterol | ACG 119(10S):S1523\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai YL, Xiong XZ, Wu SJ, Cheng Y, Lu J, Zhang J et al (2013) Single-incision laparoscopic appendectomy vs conventional laparoscopic appendectomy: Systematic review and meta-analysis. World J Gastroenterol 19(31):5165\u0026ndash;5173\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Chen G, Mao X, Jiang Z, Jiang N, Xia N et al (2023) Single-incision laparoscopic appendectomy versus traditional three-hole laparoscopic appendectomy for acute appendicitis in children by senior pediatric surgeons: a multicenter study from China. Front Pediatr [Internet]. July 10 [cited 2025 Oct 28];11. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.frontiersin.org/journals/pediatrics/articles/\u003c/span\u003e\u003cspan address=\"https://www.frontiersin.org/journals/pediatrics/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fped.2023.1224113/full\u003c/span\u003e\u003cspan address=\"10.3389/fped.2023.1224113/full\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan Y, Yuan H, Li S, Wang WF (2024) Single-incision versus conventional three-port laparoscopic appendectomy for acute appendicitis: A meta-analysis of randomized controlled trials. 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Updates Surg 77(2):287\u0026ndash;296\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohan A, Guerron AD, Karam PA, Worley S, Seifarth FG (2016) Laparoscopic Extracorporeal Appendectomy in Overweight and Obese Children. JSLS 20(2):e201600020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003efar SS, Miraj S (2016) Single-incision laparoscopy surgery: a systematic review. Electron Physician 8(10):3088\u0026ndash;3095\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdullah M, Al-Taher R, Abdin B, Abbad M, Khris I, Atieh D et al (2025 June) Is Transumbilical Laparoscopic-assisted Appendectomy Better than Laparoscopic Appendectomy in Children? A Randomized Controlled Study. J Indian Association Pediatr Surg 30(3):369\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuman L Comparative Analysis of Epidemiological and Clinical Characteristics of Appendicitis Among Children and Adults. Ulus Travma Acil Cerrahi Derg [Internet]. 2020 [cited 2025 Oct 28]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://jag.journalagent.com/travma/pdfs/UTD_27_5_526_533.pdf\u003c/span\u003e\u003cspan address=\"https://jag.journalagent.com/travma/pdfs/UTD_27_5_526_533.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinutolo V, Licciardello A, Di Stefano B, Arena M, Arena G, Antonacci V (2014) Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital. BMC Surg 14(1):14\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"appendicitis, TULAA, children, laparoscopy","lastPublishedDoi":"10.21203/rs.3.rs-8046616/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8046616/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eWith acute appendicitis remaining the leading cause of emergency surgery among pediatric patients, we aimed to evaluate single centre experience, outcomes and advantages of performed transumbilical laparoscopic-assisted appendectomy (TULAA).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted of 1,597 consecutive pediatric appendectomies performed between January 2018 and October 2023 at Vilnius University Hospital Santaros Klinikos, Children\u0026rsquo;s Hospital. Data from patients diagnosed with appendicitis (ICD-10 K35\u0026ndash;K36) and treated using ACHI code 30572-00 were included. Demographic, operative, and postoperative parameters were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTULAA was performed in 576 (36.1%) patients. The mean age was 10.7 years; 56.3% were male. The most frequent histological type was phlegmonous appendicitis (74.3%). The appendix was in a typical ileocecal position in 77.8% of cases. Median hospital stay was 3 days. Mean operative time was 40 minutes; higher BMI was associated with longer duration (p\u0026thinsp;=\u0026thinsp;0.05). The overall complication rate was 1.9%, mainly wound infections. Patients and parents reported high satisfaction with cosmetic outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTULAA is a safe, efficient, and cosmetically favorable technique for pediatric appendicitis, associated with a low complication rate and acceptable operative times.\u003c/p\u003e","manuscriptTitle":"Transumbilical Laparoscopic-Assisted Appendectomy (TULAA) in Children: A Single-Center Experience of 1597 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 07:07:03","doi":"10.21203/rs.3.rs-8046616/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-19T09:38:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-03T10:24:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62851179278392163040910598453814944224","date":"2025-12-29T14:31:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200748858094184186439198432457979318914","date":"2025-12-26T19:31:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36044650857921549784675904341596251483","date":"2025-12-23T09:57:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-10T20:17:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-10T08:47:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-10T03:02:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2025-11-06T09:53:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8f0c4432-64cd-47c8-b20e-25069d56fc45","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T09:39:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 07:07:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8046616","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8046616","identity":"rs-8046616","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}