Practical Benefits of Single- vs. Three-Port Laparoscopic Appendectomy for Pain Relief and Long-Term Cosmesis in Pediatric Patients: A Prospective Comparative Study

1. Introduction

Acute appendicitis is the most prevalent cause of emergency abdominal surgery among children, impacting approximately 70,000 pediatric patients annually in the United States [1]. The surgical management of pediatric appendicitis has experienced considerable evolution over the past twenty years, with laparoscopic appendectomy becoming the preferred method due to its well-documented benefits, including diminished postoperative pain, abbreviated hospital stays, decreased rates of wound infection, and a quicker resumption of normal activities compared with open surgical procedures [2,3,4]. As advancements in minimally invasive techniques progress, single-port laparoscopic appendectomy (SLA) has been introduced as a potential enhancement of the traditional three-port laparoscopic appendectomy (TLA). SLA involves the utilization of a single transumbilical incision, concealable within the natural contour of the umbilicus, thereby offering potential functional and aesthetic benefits [5]. These advantages encompass reduced parietal trauma owing to fewer incisions, decreased postoperative pain, and improved cosmetic results through scar concealment [6]. Recent systematic reviews and meta-analyses focusing on adult populations have affirmed that SLA is a safe and feasible procedure, exhibiting comparable operative durations, conversion rates, and complication profiles to TLA [7,8].

Nevertheless, the practical advantages of SLA in pediatric populations are debated, as studies present conflicting outcomes. While some investigations have reported notable pain alleviation with SLA, indicating mean pain scores of 3.93 at 12 h postoperatively compared with 5.32 with the traditional laparoscopic approach [9], others have observed no significant differences in pain metrics or analgesic consumption between the two techniques [10,11]. A recent multicenter study conducted in China, involving experienced pediatric surgeons, found no significant differences in operative duration, early complications, or postoperative pain between SLA and TLA. Nonetheless, the study noted superior long-term cosmetic satisfaction associated with SLA [12]. Likewise, a meta-analysis of pediatric research yielded heterogeneous findings, with some studies demonstrating reduced pain and others indicating equivalence, thereby underscoring the necessity for meticulously designed prospective research to establish definitive conclusions [13].

Evaluating cosmetic outcomes presents additional challenges. Both parents and pediatric patients are often susceptible to surgical scarring, which may influence psychological well-being and self-esteem during critical developmental stages [14]. However, most prior research has relied on short-term assessments, typically conducted 1–6 months postoperatively, which may potentially overlook important long-term variations. Since scars continue to remodel and mature over 12–24 months, delayed assessments are essential to capture the whole trajectory of cosmetic outcomes [15]. Moreover, most studies utilize non-validated or surgeon-reported aesthetic scales rather than patient-reported outcome measures, thereby constraining the interpretative scope of the findings [16].

Notably, the existing literature has several methodological limitations that limit its clinical relevance. First, most studies have not incorporated the concept of the minimal clinically important difference (MCID), making it challenging to distinguish between statistical and clinical significance [17]. Second, the lack of activity-specific pain assessments (such as rest, coughing, and walking) may overlook essential functional differences between techniques [18]. Third, the absence of a detailed analysis of scar characteristics prevents understanding which specific scar features influence patient satisfaction [19]. Finally, few studies have used appropriate statistical methods to account for confounding factors in non-randomized comparisons [20].

The present study addresses these limitations using a prospective comparative design with several methodological strengths: (1) inclusion of established MCID thresholds for both pain (1.3 points) and cosmetic satisfaction (1.5 points) based on validated pediatric literature [21,22]; (2) activity-specific pain assessment at multiple time points to capture recovery patterns; (3) long-term follow-up at 3 years with validated patient-reported outcome measures, including the Visual Analog Scale for Cosmesis (VASC) and the six-item Patient and Observer Scar Assessment Scale (PSAS) [23,24]; (4) propensity score matching to control for baseline confounding factors; and (5) mediation analysis to explore the mechanistic pathway from surgical technique to patient satisfaction. We hypothesized that SLA would offer better pain control during early recovery and improved long-term cosmetic satisfaction compared with TLA in pediatric patients with uncomplicated appendicitis.

2. Materials and Methods

2.1. Study Design and Population

This prospective comparative study was conducted at Hallym University Sacred Heart Hospital from April 2016 to August 2021. The study protocol was approved by the Institutional Review Board (IRB 2014-I124, approval date: 31 August 2016) and registered at clinicaltrials.gov (Identifier: NCT03106467). Written informed consent was obtained from parents or legal guardians of all participants. The study population consisted of children aged 15 years and younger who underwent laparoscopic appendectomy for uncomplicated acute appendicitis. Acute appendicitis was diagnosed based on clinical, laboratory, and radiographic evaluation (abdominoperineal CT scan or ultrasonography), including history of right lower quadrant pain, presence of right lower quadrant tenderness on physical examination, fever > 38 °C, and/or white blood cell count > 10 × 10³ cells/mL. Exclusion criteria included radiologically and surgically confirmed panperitonitis or periappendiceal abscess requiring drainage catheter placement, previous abdominal surgery, ≥3 days of empirical antibiotic therapy before diagnosis, history of coagulation disorders, contraindication to general anesthesia, suspected or proven malignancy, and mental illness.

A total of 399 pediatric patients with suspected appendicitis were assessed for eligibility. After excluding 161 patients with complicated appendicitis, 238 patients with uncomplicated appendicitis were included: 127 underwent SLA and 111 underwent TLA (Figure 1). Pain data were collected at postoperative days 1, 2, and 7. Cosmetic satisfaction (VASC) was assessed at 1 month and at 3 years or later. Scar perception was also evaluated at the ≥3-year follow-up using the 6-item, validated Scar Assessment Questionnaire (Patient and Parental Scar Assessment Scale, PSAS) (Table A1).

2.2. Surgical Techniques

All procedures were performed by two fellowship-trained pediatric surgeons with experience of more than 100 cases each of both SLA and TLA prior to the initiation of this study. Every operation was recorded for quality control and periodic review.

Single-port laparoscopic appendectomy: A 1.5 cm curvilinear skin incision was made within the umbilicus with a 2.0 cm umbilical fascial opening. A commercially available single-port device (Glove Port; Inframed Meditech, Seoul, Republic of Korea) was introduced. After establishing pneumoperitoneum at 8 mmHg, diagnostic laparoscopy was performed using a 5 mm, 30-degree rigid laparoscope. The appendix was manipulated using roticular angulated instruments (Covidien, Mansfield, MA, USA) and conventional straight laparoscopic instruments (Ethicon, Cincinnati, OH, USA). The mesoappendix was dissected using electrocautery, and periappendiceal vessels were ligated with Hem-O-lock clips (Weck; Teleflex, Wayne, PA, USA). The appendix was then ligated using polydioxanone loops (Ethicon, Cincinnati, OH, USA). The specimen was retrieved via a transumbilical port using a retrieval pouch (LapBag; Sejong Medical, Republic of Korea).

Three-port laparoscopic appendectomy: TLA employed a 5 mm or 10 mm, 30-degree rigid scope through a 0.5 to 1.0 cm intraumbilical incision, with two additional 5 mm incisions in the left lower quadrant and the suprapubic area. Dissection and ligation techniques were identical to those used in the SLA procedure. Specimen retrieval was performed through the intraumbilical incision using the same retrieval pouch system.

2.3. Postoperative Care and Follow-Up

All patients received standardized antibiotic therapy (30 mg/kg of cefuroxime every 8 h, with a maximum dose of 750 mg) from diagnosis through postoperative day 2. Standardized analgesic protocol included single-shot fentanyl citrate (1 mcg/kg) before awakening from anesthesia and ketorolac tromethamine (0.5 mg/kg) in the recovery room. Additional analgesics were administered for VASP scores of 6 or higher, with a minimum 4 h interval between doses. Patients were discharged when tolerating a regular diet, typically on postoperative day 2. The patients were followed up at 1 week postoperatively at the outpatient clinic.

2.4. Outcome Measurements

Primary Outcome: The primary outcome was the magnitude of pain reduction during walking on postoperative day 7 (deltaVASP7_walk), calculated as the difference between preoperative and postoperative pain scores. The co-primary outcome was pain reduction during walking on postoperative day 2 (deltaVASP2_walk). Pain assessment utilized the Visual Analog Scale for Pain (VASP, 0–10 scale) measured preoperatively and on postoperative days 1, 2, and 7. Pain was evaluated during three activities: rest, coughing (three intentional coughs), and ambulation (10-step marching in place). The MCID for VASP was established at 1.3 based on pediatric literature.

Secondary Outcome: The secondary outcome was global cosmetic satisfaction assessed using the Visual Analog Scale for Cosmesis (VASC, 0–10 scale) at 1 month and 3 years postoperatively. The MCID for cosmetic satisfaction was set at 1.5.

Scar perception was evaluated at 3 years using the validated Patient and Parental Scar Assessment Scale (PSAS), assessing six items: pain, itchiness, color, stiffness, thickness, and irregularity (each scored 0–10, with 10 representing the worst imaginable outcome).

2.5. Sample Size Calculation

For the primary outcome, assuming a pain reduction MCID of 1.3, standard deviation of 3.2, power of 80%, and 10% dropout rate, 106 patients per group were required. For the secondary outcome, assuming a cosmetic satisfaction MCID of 1.5, standard deviation of 2.0, power of 80%, and 20% dropout rate at 3 years, 35 patients per group were required.

2.6. Statistical Analysis

Continuous variables were expressed as mean ± standard deviation and compared using Welch’s t-test. Categorical variables were compared using Fisher’s exact test. Statistical significance was set at p < 0.01. Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS, Version.27.0 (IBM Corp., Armonk, NY, USA).

Propensity Score Matching: To address potential selection bias inherent in the non-randomized design, propensity score matching (PSM) was performed as a sensitivity analysis. Propensity scores were estimated using a logistic regression model including baseline covariates: age, sex, weight, BMI, white blood cell count, neutrophil percentage, and CRP. Nearest-neighbor matching with a caliper of 0.10 was used to create matched pairs. The quality of matching was assessed by comparing standardized mean differences before and after matching, with differences < 0.1 indicating good balance.

Mediation Analysis: Causal mediation analysis was performed to evaluate the relationship between surgical technique, scar perception, and cosmetic satisfaction using bias-corrected bootstrapping (5000 resamples). The analysis decomposed the total effect into the Average Causal Mediation Effect (ACME), representing the indirect effect through scar perception, and the Average Direct Effect (ADE), representing the direct effect not mediated through scar perception.

3. Results

3.1. Patient Characteristics and Surgical Outcomes

Baseline characteristics were comparable between groups (Table 1). Mean age was 10.1 ± 3.0 years in the SLA group and 9.8 ± 3.1 years in the TLA group (p = 0.407). Gender distribution, weight, BMI, laboratory parameters (WBC, neutrophil percentage, and CRP), operation time, and postoperative length of stay showed no significant differences between groups. There was no conversion to laparotomy or adverse event during the operation in either group. Postoperative seroma collection and ileus were managed conservatively.

3.2. Pain Outcomes

Pain reduction outcomes are summarized in Figure 2 and Table A2. For the primary outcome, SLA demonstrated significantly greater pain reduction during ambulation on POD7 compared with TLA (deltaVASP7_walk: −6.22 ± 2.60 vs. −5.06 ± 3.23, difference: −1.16, 95% CI: −1.95 to −0.37, p = 0.004). However, this difference did not reach the predefined MCID threshold of 1.3. Similarly, SLA showed significantly greater pain reduction during coughing on POD7 (deltaVASP7_cough: −6.01 ± 2.75 vs. −4.83 ± 3.35, difference: −1.18, 95% CI: −2.01 to −0.35, p = 0.005) but again did not meet the MCID threshold. For the co-primary outcome (deltaVASP2_walk), no significant difference was observed between groups (−2.65 ± 2.72 vs. −2.55 ± 3.56, p = 0.820). Pain at rest showed no significant differences between groups at any time point; however, pain at rest on postoperative day 7 (POD7) approached significance (p = 0.065).

PSM analysis for pain reduction: PSM analysis created 82 matched pairs with excellent balance achieved across all baseline covariates (all standardized mean differences < 0.1). In the matched cohort, the pain reduction advantages of SLA were amplified (Table A3):

• deltaPOD7_walk: SLA showed greater pain reduction (−6.46 ± 2.28 vs. −4.80 ± 3.06, MD: −1.66, 95% CI: −2.49 to −0.83, p = 0.000)
• deltaPOD7_cough: SLA demonstrated superior pain reduction (−6.10 ± 2.22 vs. −4.77 ± 3.35, MD: −1.33, 95% CI: −2.20 to −0.46, p = 0.003)
• deltaPOD7_rest: The difference became statistically significant (−6.96 ± 2.30 vs. −5.95 ± 2.73, MD: −1.01, 95% CI: −1.78 to −0.24, p = 0.011)

These PSM results suggest that the pain benefits of SLA, while still below the MCID threshold, are robust and not explained by confounding baseline factors.

3.3. Cosmetic Satisfaction Outcomes

Long-term cosmetic satisfaction results are presented in Figure 3 and Table A2. At 1 month postoperatively, both groups showed high satisfaction with no significant difference (SLA: 9.47 ± 0.86 vs. TLA: 9.29 ± 1.03, p = 0.177). However, at 3 years postoperatively, SLA demonstrated significantly superior cosmetic satisfaction compared with TLA (VASC_3yrs: 9.39 ± 0.83 vs. 7.47 ± 1.98, difference: 1.93, 95% CI: 1.48 to 2.37, p = 0.000). This difference substantially exceeded the predefined MCID threshold of 1.5, indicating clinically meaningful improvement.

PSM analysis for cosmetic satisfaction: the cosmetic superiority of SLA was even more pronounced in the matched cohort (63 pairs with complete cosmetic follow-up, Table A3):

• One month: A significant difference emerged that was not apparent in the unmatched analysis (9.57 ± 0.82 vs. 9.16 ± 1.12, MD: 0.41, 95% CI: 0.07 to 0.76, p = 0.020)
• Three years: The difference remained highly significant and clinically meaningful (9.56 ± 0.56 vs. 7.71 ± 1.63, MD: 1.84, 95% CI: 1.42 to 2.27, p = 0.000)

These PSM findings suggest that when baseline factors are balanced, the cosmetic advantages of SLA become apparent even at 1 month and are sustained over the long term.

3.4. Scar Perception Outcomes

Detailed scar perception assessment at 3 years revealed significant differences across multiple domains (Figure 4, Table A2). The TLA group demonstrated significantly worse perception:

• Color: 1.28 ± 0.65 vs. 3.67 ± 2.75 (p = 0.000);
• Stiffness: 1.14 ± 0.40 vs. 2.32 ± 2.13 (p = 0.000);
• Thickness: 1.04 ± 0.24 vs. 3.08 ± 2.91 (p = 0.000);
• Irregularity: 1.36 ± 1.15 vs. 2.34 ± 2.33 (p = 0.000).

No significant differences were observed in pain (1.14 ± 0.35 vs. 1.24 ± 0.75, p = 0.218) or itchiness (1.09 ± 0.29 vs. 1.12 ± 0.39, p = 0.498) domains. Total PSAS score was significantly higher (worse) in the TLA group (vs. 7.05 ± 1.69 vs. 13.11 ± 8.37, p = 0.000).

PSM analysis for scar perception: The PSM analysis (63 matched pairs) confirmed all scar perception findings with consistent or larger effect sizes (Table A3):

• Color: Difference of −2.02 (95% CI: −2.56 to −1.47, p = 0.000);
• Stiffness: Difference of −0.89 (95% CI: −1.38 to −0.40, p = 0.001);
• Thickness: Difference of −1.48 (95% CI: −2.07 to −0.88, p = 0.000);
• Irregularity: Difference of −0.86 (95% CI: −1.38 to −0.34, p = 0.002);
• Total PSAS: Difference of −5.11 (95% CI: −6.87 to −3.36, p = 0.000).

3.5. Mediation Analysis

Mediation analysis demonstrated that 66% of the total effect of surgical technique (SLA vs. TLA) on 3-year cosmetic satisfaction was mediated through overall scar perception (PSAS_total) (Figure 5, Table A4). The average causal mediation effect (ACME) was 1.12, with a direct impact (ADE) of 0.58 and a total effect of 1.70. Multivariable regression analysis identified color, thickness, and irregularity as the most influential negative predictors of cosmetic satisfaction, with standardized beta coefficients of −0.19, −0.30, and −0.30, respectively (Figure 5, Table A4). Pain and itchiness had minimal impact on long-term satisfaction (β = −0.07 and −0.05, respectively).

4. Discussion

This prospective comparative study provides comprehensive evidence of the practical benefits of single-port versus three-port laparoscopic appendectomy in pediatric patients. While SLA offers statistically significant improvements in postoperative pain reduction, these benefits fall short of clinical significance. Conversely, SLA demonstrates substantial and clinically meaningful advantages in long-term cosmetic satisfaction that persist at the 3-year follow-up.

Our study demonstrated that SLA resulted in statistically significant reductions in pain during ambulation (deltaVASP7_walk: −1.16, p = 0.004) and coughing (deltaVASP7_cough: −1.18, p = 0.005) at postoperative day 7. However, these differences did not reach the predetermined MCID threshold of 1.3 points, suggesting limited clinical relevance. The propensity score matched analysis amplified these differences (walking: −1.66; coughing: −1.33), indicating robust findings not explained by confounding, yet still below the MCID threshold. These findings align with several recent studies questioning the pain benefits of SLA. Boo et al. compared transumbilical laparoscopic-assisted appendectomy with single-incision techniques in 142 children and found no significant differences in pain scores or analgesic requirements, concluding that the theoretical advantage of fewer incisions may not translate to meaningful pain reduction [25]. Similarly, a randomized controlled trial by Kang et al. (SCAR trial) involving 200 patients found mean pain score differences of only 0.8 points between SLA and TLA, below commonly accepted MCID thresholds [26].

In contrast, our results differ from studies reporting substantial pain benefits with SLA. Sozutek et al. reported mean pain scores of 3.93 versus 5.32 (difference: 1.39) in favor of SLA at 12 h postoperatively [9]. Several factors may explain these discrepancies. The umbilical fascial incision in SLA (typically 2.0–2.5 cm) is larger than individual port sites in TLA (5–10 mm each), potentially offsetting the benefit of fewer incisions [27]. Additionally, the technical complexity of SLA may lead to increased tissue manipulation and traction, particularly during the learning curve period [28]. Studies showing larger pain differences often assessed pain only at rest or used non-validated scales [29]. Our activity-specific assessment revealed that pain differences emerged primarily during provocative activities (coughing, walking) rather than at rest, suggesting that functional pain assessment is critical for detecting differences between techniques [30]. Children have variable pain expression influenced by age, anxiety, and parental presence [31]. Studies with younger cohorts or different cultural contexts may report different pain outcomes independent of surgical technique [32]. Variations in perioperative analgesia, including regional blocks, wound infiltration, and systemic medications, can mask or amplify differences between surgical techniques [33]. Our standardized protocol (fentanyl and ketorolac) may have minimized baseline pain sufficiently that the incremental benefits of fewer incisions became negligible.

In marked contrast to pain outcomes, our study demonstrated clinically meaningful cosmetic benefits with SLA. The 1.93-point difference in VASC scores at 3 years substantially exceeded the MCID of 1.5, with PSM analysis confirming robustness (difference: 1.84, p = 0.0001). Notably, while 1-month satisfaction scores were similar in the unmatched analysis, PSM revealed an early difference (0.41 points, p = 0.020), suggesting that cosmetic benefits may manifest earlier than previously recognized when baseline factors are controlled. Our findings strongly support previous reports of cosmetic superiority with single-port techniques. A systematic review by Aly et al. analyzing 11 studies found consistently higher cosmetic satisfaction scores with SLA across different assessment tools and time points [34]. St. Peter et al. reported that 94% of parents preferred the single-incision scar appearance compared to 68% for multi-port scars at 6-month follow-up [35]. Zhang et al.’s long-term study found that cosmetic satisfaction scores continued to diverge between SLA and TLA groups from 6 months to 2 years, suggesting progressive benefit over time [36].

However, some studies have reported minimal cosmetic differences. Ostlie et al. found no significant differences in scar satisfaction between SLA and TLA at 1-year follow-up using the Patient Scar Assessment Scale [37]. Gasior et al. reported that while parents initially preferred single-incision scars, this preference diminished by 6 months postoperatively [16]. There are key factors explaining these disparate findings. Our 3-year follow-up captured complete scar maturation, whereas studies with shorter follow-up (≤ 12 months) may miss late differences [38]. Pediatric scars undergo prolonged remodeling, with erythema and thickness evolving over 18 to 24 months [39]. Studies using surgeon-reported scales or non-validated measures may not capture patient-perceived differences [40]. Our use of both global satisfaction and domain-specific assessment provided a comprehensive evaluation of cosmetic outcomes. The cosmetic advantage of SLA depends on meticulous umbilical placement and closure technique [41]. Centers with standardized protocols and experienced surgeons may achieve superior results compared with those in the early stages of learning curves [42].

Our study provides novel mechanistic insights through detailed scar perception analysis and formal mediation testing. The finding that 66% of cosmetic satisfaction differences were mediated through scar perception establishes a clear causal pathway from surgical technique to patient satisfaction. Within PSAS domains, thickness, irregularity, and color emerged as primary drivers, while pain and itchiness contributed minimally to the overall assessment. These findings align with fundamental principles of wound healing and scar formation. The single umbilical incision in SLA benefits from several anatomical advantages: (1) placement within a natural skin depression minimizes visibility; (2) circular tension vectors around the umbilicus distribute stress evenly, reducing hypertrophy; (3) embryological scar tissue at the umbilicus may have different healing characteristics than normal skin [43].

In contrast, the peripheral incisions in TLA are subject to several disadvantages: (1) placement across Langer’s lines increases tension and scar widening; (2) movement-related stress during recovery may promote hypertrophic changes; (3) multiple scars increase the statistical probability of at least one poor cosmetic outcome [44]. Our findings, that thickness and irregularity dominate satisfaction, align with studies in plastic surgery, which show that raised, irregular scars are most bothersome to patients, while flat, well-contoured scars are often acceptable, regardless of color [45,46]. These have important clinical implications, suggesting that interventions targeting scar thickness (such as silicone sheets and compression) and contour (including massage and taping) may be particularly beneficial for TLA patients [47].

Based on our findings, we propose the following evidence-based recommendations for clinical practice. SLA should be particularly considered for families prioritizing long-term cosmetic outcomes, adolescents with high body image concerns, and patients with a history of hypertrophic scarring [48]. The modest pain differences may not be a primary indication for SLA. Families could be counseled that SLA offers minimal short-term pain benefits but substantial long-term cosmetic advantages. Quantifying these differences (pain difference < 1.3 points; cosmetic difference > 1.5 points) helps frame realistic expectations [49]. For centers performing TLA, our domain analysis suggests specific strategies to optimize cosmetic outcomes, including minimizing port size (3–5 mm when feasible), aligning incisions with skin tension lines, ensuring meticulous layered closure, and implementing scar management protocols [50]. Programs should track long-term cosmetic outcomes beyond traditional surgical metrics. Patient-reported outcome measures at 1–3 years post-surgery provide valuable feedback for refining the technique [51].

This study has several methodological strengths: prospective design with a priori power calculation, long-term follow-up with high retention (>80%), validated patient-reported outcome measures, incorporation of MCID thresholds for clinical interpretation, comprehensive scar assessment across multiple domains, propensity score matching to address confounding, and formal mediation analysis to establish causal pathways. However, essential limitations merit consideration. The non-randomized design introduces potential selection bias, though PSM analysis provided reassurance. Single-center experience may limit generalizability to different practice settings or populations. The subjective nature of pain and cosmetic assessment, while using validated instruments, remains inherently variable. The 3-year follow-up, while comprehensive for scar assessment, cannot capture very long-term outcomes into adulthood.

Several research priorities emerge from our findings. Randomized controlled trials with standardized techniques and long-term follow-up, as well as multi-center studies to enhance generalizability, would provide definitive evidence. The development of pediatric-specific cosmetic outcome measures that incorporate developmental considerations would enhance assessment and treatment. Investigation of scar prevention strategies (technique modifications, adjuvant therapies) could benefit both SLA and TLA patients. A cost-effectiveness analysis that incorporates long-term satisfaction and potential revision procedures would inform health policy. Additionally, studies examining outcomes in complicated appendicitis, as well as the evaluation of new single-port techniques and instruments, would be valuable. Ultimately, exploring the determinants of patient and parent preferences could inform the development of shared decision-making tools.

5. Conclusions

This prospective comparative study demonstrates that single-port laparoscopic appendectomy provides statistically significant but clinically marginal benefits in early postoperative pain reduction compared with three-port laparoscopic appendectomy in pediatric patients. However, SLA offers substantial and clinically meaningful advantages in long-term cosmetic satisfaction, primarily mediated through improved scar characteristics, including reduced thickness, irregularity, and color mismatch. These findings support SLA as a valuable option for pediatric appendectomy, particularly when families prioritize long-term cosmetic outcomes.