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

Background/Objectives: Comparative studies examining postoperative pain and cosmetic outcomes between single-port laparoscopic appendectomy (SLA) and three-port laparoscopic appendectomy (TLA) in pediatric patients with appendicitis have produced inconsistent results. We aimed to determine whether SLA offers practical benefits over TLA in terms of recovery-phase pain relief and long-term cosmetic satisfaction in pediatric patients. Methods: This prospective comparative study included children aged 15 years or younger who underwent laparoscopic appendectomy for uncomplicated acute appendicitis. The degree of pain reduction was compared between the SLA and TLA groups on postoperative days (PODs) 1, 2, and 7, both at rest and during coughing and ambulation, using the Visual Analog Scale for Pain (VASP). Global cosmetic satisfaction was assessed at 1 month and 3 years postoperatively using the Visual Analog Scale for Cosmesis (VASC). Scar perception was evaluated with the Patient and Parental Scar Assessment Scale (PSAS). The primary outcome was the degree of pain reduction during ambulation on POD7. The secondary outcome was global cosmetic satisfaction at 3 years. Propensity score matching (PSM) was used as a sensitivity analysis to control for baseline differences. Results: Baseline characteristics were similar among 238 patients (127 SLA and 111 TLA). SLA showed significantly greater pain reduction during ambulation on POD7 (deltaVASP7_walk: −6.22 ± 2.60 vs. −5.06 ± 3.23, p < 0.01) and during coughing (deltaVASP7_cough: −6.01 ± 2.75 vs. −4.83 ± 3.35, p < 0.01). However, these differences did not reach the minimal clinically important difference (MCID) threshold of 1.3. PSM analysis with 82 matched pairs confirmed these results, with even larger effect sizes. At 3 years, SLA demonstrated significantly higher cosmetic satisfaction (VASC: 9.39 ± 0.83 vs. 7.47 ± 1.98, p < 0.01), surpassing the MCID of 1.5. The TLA group scored worse in scar perception regarding color, stiffness, thickness, and irregularity. Mediation analysis indicated that 66% of the overall effect on cosmetic satisfaction was mediated through scar perception. Conclusions: Although SLA offers statistically significant yet clinically marginal benefits in early postoperative pain reduction, it provides substantial benefits in long-term cosmetic satisfaction compared with TLA in pediatric patients.