Laparoscopic surgery is replacing laparotomy for the treatment of several intraabdominal conditions. It provides numerous benefits over open surgery, including lesser blood loss, fewer analgesic needs and complications, faster recovery, and shorter hospital stays [1–3]. Since the introduction of laparoscopic appendectomy by Semm in 1983 [4] for appendicitis, it has grown to include more complex conditions, such as perforated appendicitis and periappendiceal abscess [5–7].

With the rapid growth of minimally invasive surgery in recent years, efforts have been made to reduce surgical trauma and enhance cosmetic outcomes, leading to the development of single-port laparoscopic surgery for various diseases [8–10]. Single-port laparoscopic appendectomy (SPLA) was initially presented by Esposito in 1998 [11] with the potential benefits of improved cosmetic outcomes, less postoperative pain, and avoidance of hemorrhagic complications from potential injury to the epigastric arteries. Thus, SPLA has become the preferred treatment choice for acute appendicitis and is considered a viable alternative to the standard multiport laparoscopic appendectomy (MPLA) [12–14].

Since the initial clinical report in 1959, the 1949-developed cyanoacrylate has been utilized as a skin adhesive [15]. There have been investigations on various skin closure techniques in laparoscopic surgery, including non-absorbable monofilament sutures [16], skin staplers [17], and wound closure strips [18] and liquid skin adhesive after subcuticular sutures [19]. Skin adhesives reportedly shorten the time required for wound closure and do not require removal, resulting in a smaller operative scar [20,21]. In addition, the protective film generated by the adhesive limits the penetration of extraneous substances and bacteria, allowing for water-dependent everyday activities. Moreover, it has superior cosmetic results compared to the other closure techniques [22–24].

Skin adhesives are not commonly used in abdominal surgery for inflammatory diseases such as appendicitis, cholecystitis, and peritonitis because of concerns that inflammatory exudate may not drain through the suture site, thereby increasing the risk of surgical site infection (SSI). There has been no research on skin adhesive use for wound closure in SPLA, despite have being assessed and utilized in numerous surgical specialties. This study aimed to evaluate the safety and feasibility of skin adhesives and to compare postoperative and cosmetic outcomes between skin adhesive and wound closure strip use for wound closure after subcuticular suturing in SPLA.

Patients

The study group included 86 patients who underwent SPLA for acute appendicitis between August, 2014 and October, 2020 (Fig. 1). The following patients were excluded: (1) those diagnosed with a disease other than appendicitis after surgery, such as appendiceal mucocele, malignancies, etc. (n = 6); (2) those who underwent surgery for appendicitis with generalized peritonitis (n = 2); (3) those with a previous major laparotomy history such as gastrectomy (n = 1); (4) those treated with analgesics for chronic pain (n = 1); (5) those with co-morbidities including cardiopulmonary failure, liver failure or chronic kidney disease (n = 2); (6) pregnant women (n = 1); and (7) those with incomplete medical records (n = 4). A total of 22 patients in whom skin adhesive was used and 47 in whom steri-strips were used for skin closure after subcuticular suturing in SPLA were included in this study.

Figure 1. Flowchart of patient selection. SPLA, single-port laparoscopic appendectomy.

Evaluation parameters

Patient demographics, including age, sex, preoperative white blood cell and C-reactive protein levels, body mass index, and American Society of Anesthesiologists (ASA) grade were collected. The operation type, total operative time, appendicitis type, presence of periappendiceal abscess, diameter and length of the resected appendix, intraabdominal drainage, and total incision length were the operative surgical outcomes recorded. Postoperative outcomes assessed included the length of hospital stay, the numeric rating scale (NRS) pain score on postoperative days 0 and 1, total number and types of analgesics used within 24 hours and 24–48 hours after surgery, complications within 30 days, Clavien-Dindo classification, and postsurgical readmission rates. SSIs were categorized according to their severity; “superficial” infection if all four skin layers were affected, “deep” infection if deep soft tissue was affected, and “organ and body cavity” infection if organs and body cavities were also affected [25].

Surgical technique

Before induction of anesthesia, cefotetan (1.0 g) was administered intravenously as a prophylactic antibiotic. All surgeries were conducted under general anesthesia with the patient in the supine position. Subsequently, the patient was positioned upright at a 30° angle to the horizon, and the operating table was tilted 10°–15° to the lower right side. After abdominal disinfection with chlorhexidine, a single 2.0 cm vertical incision was made at the umbilicus. A single port was placed into the abdominal cavity through the umbilical incision, and the intraperitoneal space was secured by infusing up to 12 mmHg of CO₂. It was rinsed with normal saline, placed in a single-port sterile bag, and collected through the umbilical incision following appendectomy. After port removal, the umbilical muscle membrane was sutured with a 2-0 Vicryl (Covidien) suture, and subcuticular sutures were placed using a 4-0 Monosyn (B. Braun Aesculap AG & Co KG) cutting-needle suture. For the skin adhesive group, skin closure was achieved by breaking a capsule (Dermabond, Ethicon) and applying the bonding solution along the tip of the capsule to the wound site (Fig. 2). In the adhesive tape group, Steri-Strips (3M) was applied to the skin.

Figure 2. (A) Application of skin adhesive to the incision after single-port laparoscopic appendectomy. (B) Clinical image of the scar on postoperative day one.

Patient scar assessment questionnaire

The patient scar assessment questionnaire (PSAQ) was utilized to determine patient satisfaction with the postoperative scar. It comprises four subitems: appearance, consciousness, satisfaction with appearance, and satisfaction with symptoms [26]. ‘Appearance’ included color, length, width, flatness, texture, brightness, and overall appearance of the scar. ‘Consciousness’ included itching, pain, discomfort, numbness, unusual sensations, and general symptoms at the surgery site. ‘Satisfaction with appearance’ determines how well the surgical site scar is visible to the patient and others and the general scar awareness level. ‘Satisfaction with symptoms’ evaluates the patient’s satisfaction with the sensation, color, and overall appearance of the scar and its harmony with the surrounding skin. Each question was rated from 1 to 4 by the patient (1 point, the most favorable response; 4 points, the least favorable response). At 6 weeks postoperatively, patients completed the PSAQ at outpatient.

Statistical analysis

The results are reported as means and standard deviations for continuous variables and as frequencies and percentages for categorical variables. Categorical variables were examined using the chi-square test. Continuous variables were evaluated using independent t tests. Statistical significance was set at the p-value of <0.05. Statistical analysis was performed using IBM SPSS version 25 (IBM Corp.).

Patient characteristics

The patient demographics are shown in Table 1. There were no statistically significant differences between the two groups in terms of sex, body mass index, age, preoperative white blood cell count, and C-reactive protein level. The proportion of patients with the ASA grade I in the skin adhesive group was significantly lower than that in the wound closure strip group (59% vs. 87%, p = 0.013).

Table 1 . Patient characteristics.

Characteristic	Skin adhesive group	Wound closure strip group	p-value
No. of patients	22	47
Age (yr)	46.4 ± 22.0	42.6 ± 14.3	0.473
Sex			0.934
Male	11 (50.0)	24 (51.1)
Female	11 (50.0)	23 (48.9)
Body mass index (kg/m2)	23.2 ± 3.2	23.5 ± 3.4	0.788
Preoperative WBC (×103/µL)	9.4 ± 3.8	12.9 ± 5.2	0.090
Preoperative CRP (mg/dL)	2.0 ± 2.1	3.9 ± 5.6	0.065
ASA grade			0.013
I	13 (59)	41 (87.2)
II	9 (41)	5 (10.6)
III	0 (0)	1 (2.1)

Values are presented as number only, mean ± standard deviation, or number (%)..

CRP, C-reactive protein; WBC, white blood cell count; ASA, American Society of Anesthesiologists..

Perioperative outcomes

The perioperative outcomes are shown in Table 2. The total operative time was significantly longer in the skin adhesive group than in the wound closure strip group (83.0 ± 36.9 minutes vs. 55.9 ± 21.8 minutes, p = 0.003). The appendicitis severity, periappendiceal abscess presences, diameter and length of the resected appendix, need for drain placement, and total incision length did not differ significantly between the two groups.

Table 2 . Perioperative data of the two groups.

Variable	Skin adhesive group (n = 22)	Wound closure strip group (n = 47)	p-value
Type of operations			0.728
SPLA	18 (81.8)	40 (85.1)
SPLA + additional port	4 (18.2)	7 (14.9)
Total operative time (min)	83.0 ± 36.9	55.9 ± 21.8	0.003
Appendicitis type			0.718
Suppurative	14 (63.6)	29 (61.7)
Gangrenous	4 (18.2)	12 (25.5)
Perforated	4 (18.2)	6 (12.8)
Periappendiceal abscess	3 (13.6)	1 (2.1)	0.057
Diameter of resected appendix (mm)	12.8 ± 7.8	11.6 ± 3.5	0.487
Length of resected appendix (cm)	64.7 ± 20.9	66.6 ± 22.1	0.735
Drain placement	4 (18.2)	9 (19.1)	0.924
Length of incision (cm)	20.8 ± 2.7	20.0 ± 6.4	0.467

Values are presented as mean ± standard deviation or number (%)..

SPLA, single-port laparoscopic appendectomy..

Postoperative outcomes

A comparison of the postoperative outcomes of the two groups is shown in Table 3. On postoperative day 0, patients in the skin adhesive group had significantly lower NRS scores than those in the wound closure strip group (2.8 ± 0.8 vs. 3.9 ± 0.8, p < 0.001). The number of times analgesics were administered within 24 hours of surgery was significantly lower in the skin adhesive group than in the wound closure strip group (1.4 ± 0.8 vs. 2.7 ± 1.2, p = 0.013). Opioid usage was significantly lower in the skin adhesive group than in the wound closure strip group (0.3 ± 0.5 vs. 0.9 ± 0.9, p = 0.007). There were no statistically significant differences in the nonsteroidal anti-inflammatory drugs (NSAIDs) usage (1.1 ± 0.8 vs. 1.2 ± 1.2, p = 0.612). The adhesive group used significantly fewer analgesics 24 to 48 hours after surgery than the wound closure strip group (0.2 ± 0.4 vs. 0.7 ± 0.9, p = 0.002). Opioids were used significantly less (0 vs. 0.3 ± 0.6, adhesive vs. steri-strip; p = 0.002) than NSAIDs (0.2 ± 0.4 vs. 0.5 ± 0.8, adhesive vs. steri-strip; p = 0.033). There was no statistically significant difference in the hospital stay length, NRS score on postoperative day one, and postsurgical readmission between the two groups. Table 4 provides detailed information on patients who developed SSIs. Among these, three cases involved superficial SSIs. One patient in the skin adhesive group received treatment with dressing changes, while two patients in the wound closure strip group were treated with both dressing changes and antibiotics.

Table 3 . Comparison of postoperative outcomes between the two groups.

Variable	Skin adhesive group (n = 22)	Wound closure strip group (n = 47)	p-value
Hospital stay (hr)	75.9 ± 103.3	62.1 ± 38.0	0.551
Numeric rating scale
POD 0	2.8 ± 0.8	3.9 ± 0.8	<0.001
POD 1	3.4 ± 0.6	3.4 ± 1.2	0.877
Analgesic usage <4 hr	1.4 ± 0.8	2.7 ± 1.2	0.013
Opioids	0.3 ± 0.5	0.9 ± 0.9	0.007
NSAIDs	1.1 ± 0.8	1.2 ± 1.2	0.612
Analgesics usage 24–48 hr	0.2 ± 0.4	0.7 ± 0.9	0.002
Opioids	0 (0)	0.3 ± 0.6	0.002
NSAIDs	0.2 ± 0.4	0.5 ± 0.8	0.033
Complications within 30 days of surgery	5 (14.3)	5 (14.7)	0.960
Surgical site infection	1 (4.5)	2 (4.3)	0.956
Clavien-Dindo classification			0.215
I	1 (4.5)	0 (0)
≥II	0 (0)	2 (4.3)
Readmission after surgery	0 (0)	2 (4.3)	0.326

Values are presented as mean ± standard deviation or number (%)..

POD, postoperative day..

Table 4 . Clinical data of the patients with SSI.

Case No.	Age (yr)	Sex	Closure method	Appendicitis type	SSI classification	Treatment
Case 1	43	Female	Skin adhesive	Suppurative	Superficial	Dressing
Case 2	60	Male	Subcuticular suture	Suppurative	Superficial	Antibiotics, dressing
Case 3	40	Female	Subcuticular suture	Suppurative	Superficial	Antibiotics, dressing

SSI, surgical site infection..

Patient scar assessment questionnaire scores

Of the 69 patients, 13 and 42 in the skin adhesive and wound closure strip groups, respectively, were able to participate in a telephone survey. According to the patients’ responses, a total of 28 questions were scored from 1 to 4, and the results are displayed in Table 5. Total PSAQ scores were lower in the skin adhesive group compared to the wound closure strip group (38.8 ± 9.2 vs. 49.4 ± 15.1, p = 0.020). Subitems including ‘Satisfaction with appearance’ and ‘Satisfaction with symptoms’ were significantly lower in patients who underwent skin closure with skin adhesive (11.3 ± 3.0 vs. 15.1 ± 4.5, p = 0.006 and 6.5 ± 1.8 vs. 9.5 ± 3.3, p = 0.003), whereas ‘Appearance’ and ‘Consciousness’ subitems revealed no statistically significant differences between groups (p = 0.159 and p = 0.151, respectively).

Table 5 . Comparison of patient scar assessment questionnaire scores between the two groups.

Variable	Skin adhesive group (n = 13)	Wound closure strip group (n = 42)	p-value
Total	38.8 ± 9.2	49.4 ± 15.1	0.020
Appearance	13.7 ± 3.5	15.7 ± 4.6	0.159
Consciousness	7.3 ± 2.4	9.1 ± 4.2	0.151
Satisfaction with appearance	11.3 ± 3.0	15.1 ± 4.5	0.006
Satisfaction with symptoms	6.5 ± 1.8	9.5 ± 3.3	0.003

Values are presented as mean ± standard deviation..

Our study is the first to report the feasibility and safety of using adhesive agents as opposed to a wound closure strip for skin closure in patients with SPLA and acute appendicitis. The pain score on the day of surgery and the number of analgesics taken within 48 hours after surgery were significantly lower in the skin adhesive group than in the wound closure strip group. In particular, it was possible to significantly reduce the amount of opioids used in skin adhesives. The incidence rates of SSI did not differ significantly between the two groups, and only one patient in the skin adhesive group developed mild SSI. There was no difference in the appearance and consciousness questionnaires between the two groups; however, the skin adhesive group was cosmetically superior to the wound closure strip group in terms of cosmetic satisfaction.

SSI is an important safety indicator in relation to the skin closure method [27]. In a study comparing skin adhesive and subcuticular suture for maxillofacial incision, the incidence of postoperative infection with skin adhesive was one patient (7.69%), which did not differ significantly from that with the conventional suture method [28]. A randomized controlled trial comparing the suture method using skin adhesive and wound closure strip after cesarean section reported a wound infection rate of 7.6% in the patient group using skin adhesive and 7.9% in the patient group using wound closure strip [29]. Another study involving colorectal surgery found that the skin adhesive group had a significantly lower incidence of superficial SSI, with no patients in the skin adhesive group and five patients (2.4%) in the skin staple group [19]. In studies on acute appendicitis, St Peter et al. [30] reported wound infection rates of 3.3% and 1.7% for single-port and multiport laparoscopic appendectomies, respectively, and Jin et al. [31] also reported wound complications in 8.7% of cases in the single-port method compared to 5.6% in the conventional method. In the present study, the incidence of SSI was 4.5% in the skin adhesive group, and there were no significant differences between the wound closure strip and the skin adhesive groups. These findings demonstrate the safety of skin adhesives in SPLA for appendicitis. However, in diseases with severe inflammation, such as perforated appendicitis, skin adhesives should be used with caution and further research is required.

Postoperative discomfort may vary based on the suture technique used to close the surgical incision. In a study comparing the pain caused by a skin adhesive, a stapler, and a simple suture after surgery, the group of patients using a skin adhesive demonstrated statistically significantly lower pain scores at 12, 24, 48, and 72 hours after surgery compared to the other skin closure methods [32]. In a prospective randomized study comparing traditional sutures and skin adhesives for the repair of first-degree peripheral tears, the skin adhesive group had a considerably lower pain score and a shorter time to become pain-free [33]. In the current study, the skin adhesive group demonstrated a significantly lower pain score on the day of surgery and decreased use of analgesics, including opioids and NSAIDs, within 48 hours after surgery, when compared to the wound closure strip group. The improvement in pain cannot be attributed solely to the skin adhesive; however, it can be inferred that this is because the skin adhesive applies more tension to the suture site than the steri-strips and can alleviate the pain of the subcuticular suture on the skin.

Cosmesis is increasingly regarded as a significant surgical outcome measure, in addition to functional outcomes and quality of life. The postoperative scarring and discomfort at the incision site are closely related to the quality of life after thyroidectomy, appendectomy, and colon resection, and body image—a person’s impression of, satisfaction with, and attitude towards his or her own body—has been thoroughly studied [34–37]. Some studies have demonstrated that patients who underwent SPLA, rather than MPLA, achieved superior cosmetic outcomes [38,39]. However, to date, there has been no research comparing the suture method using skin adhesives to other suture methods after SPLA. A randomized controlled trial on skin closure after robotic urogynecologic procedures revealed that the skin adhesive group using cyanoacrylate agents received higher cosmesis ratings than the suture group [40]. In our study, the skin adhesive group demonstrated significantly better PSAQ outcomes than the wound closure strip group in terms of satisfaction with the scar’s appearance and symptoms as well as the total PSAQ score, although there was no difference between the two groups in terms of appearance and consciousness. We believe that these results were the result of a high level of satisfaction after the application of the skin adhesive, such as less pain and water resistance, which allowed patients to shower after surgery, in addition to the satisfaction of cosmesis.

Our research is limited by its retrospective design, small sample size, single-center design, and lack of long-term cosmetic outcomes. In addition, the PSAQ relies on the subjective thoughts of the patient. A multicenter randomized prospective study comparing SSI, cosmetic outcomes, and pain assessments using more objective parameters between SPLA and MPLA is needed. In conclusion, this study demonstrated that liquid skin adhesive closures were safe and feasible and caused less postoperative pain, resulting in greater patient satisfaction with postoperative scars than wound closure strip closure after subcuticular suture in SPLA.

Ethical statement

The current study was performed in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Keimyung University Dongsan Medical Center (No. DSMC 2022-10-036). Written consent was obtained from patients prior to any study-specific screening procedures.

Authors’ contributions

Conceptualization, Data curation, Formal analysis, Methodology: KEK, RJY, SUB

Writing–original draft: KEK, RJY, SUB

Writing–review & editing: WKJ, SKB

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.