Comparison of transumbilical laparoscopic-assisted appendectomy (TULAA) vs conventional three-port laparoscopic appendectomy (CTLA) in the pediatric population: a systematic review and meta-analysis

Abstract

Appendicitis, a pediatric emergency, is usually managed with conventional three-port laparoscopic appendectomy (CTLA). Transumbilical laparoscopic-assisted appendectomy (TULAA) offers a novel approach, matching the benefits of CTLA. This meta-analysis aims to evaluate the safety and effectiveness of TULAA versus CTLA in children by incorporating newly reported outcomes (ileus, readmission), providing separate analyses for complicated and uncomplicated appendicitis, and updating existing evidence. A thorough search of PubMed, Cochrane Library, Science Direct, and ClinicalTrials.gov databases was made from inception to May 2024. Studies comparing the results of TULAA and conventional three-port laparoscopic appendectomy (CTLA) in pediatric patients aged 0 to 18 years were included. The mean differences for continuous and risk ratios for dichotomous outcomes were combined using RevMan 5.4.1 software, with a 95% confidence interval using the random effects model. The Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool were used to ensure quality assessment. The funnel plots and Egger's regression test were used to assess the risk of publication bias in the included studies. This meta-analysis included 16 studies with 5084 pediatric patients. TULAA showed significantly shorter operative time (p = 0.00001), reduced hospital stay (p = 0.002), and lower intraabdominal infection rates (p = 0.03) compared to CTLA but required more additional ports (p = 0.00001). No significant differences were found in wound infection (p = 0.68), ileus (p = 0.38), conversion rate (p = 0.09), or readmission (p = 0.43). Separate analysis revealed shorter operative time with TULAA in both uncomplicated (p = 0.00001) and complicated cases (p = 0.002). Hospital stay was shorter only in uncomplicated cases (p = 0.01), while intraabdominal infections were lower in complicated cases (p = 0.01) in the TULAA group. Other outcomes remained comparable across both groups.

Conclusion: TULAA was superior to CTLA in operative time, hospital stay, and intraabdominal infection. Separate analysis confirmed these benefits in uncomplicated cases and demonstrated reduced intraabdominal infections in complicated cases, though with higher conversion and port use. Remaining outcomes were similar. TULAA may be a safe and effective alternative to CTLA in selected pediatric cases, especially in complicated appendicitis.

Trial registration: Prospero registration ID CRD42024563556. https://www.crd.york.ac.uk/PROSPERO/view/CRD42024563556 .

What is known: • CTLA is the standard pediatric appendectomy procedure with established safety and efficacy. • TULAA is gaining popularity as a minimally invasive alternative, offering potential benefits.

What is new: • The analysis highlights the efficacy of both TULAA and CTLA in overall appendicitis cases, while also offering a comparative assessment of their outcomes in complicated and uncomplicated appendicitis subgroups. • New insights into ileus and readmissions have not been previously addressed.

Keywords: Acute appendicitis; Conventional laparoscopic appendectomy; Conventional three-port laparoscopic appendectomy; Extracorporeal single-incision laparoscopic appendectomy; Pediatric population; Transumbilical laparoscopic-assisted appendectomy.