Influence of integrated operating room nursing and psychological intervention on anxiety, depression, and recovery in pediatric laparoscopic appendectomy

Abstract

BACKGROUND

Laparoscopic surgery is the standard minimally invasive treatment for pediatric appendicitis. However, children with appendicitis may experience varying degrees of anxiety and depression due to the illness itself and the surgical procedure, which is not conducive to a smooth postoperative recovery.

AIM

To assess whether adding psychological intervention to standard operating room nursing improves psychological well-being and postoperative recovery in pediatric patients undergoing laparoscopic appendectomy.

METHODS

A total of 98 patients were recruited at the First Affiliated Hospital of Jinzhou Medical University between November 2023 and November 2024. Standard care was administered to 44 patients in the control group, whereas 54 patients in the research group received operating room nursing combined with psychological intervention. Outcomes compared between groups included surgical metrics (operation time and intraoperative blood loss), physiological indices (systolic blood pressure/diastolic blood pressure/diastolic blood pressure and heart rate), psychological status (Screen for Child Anxiety Related Disorders and Depression Self-Rating Scale for Children), postoperative recovery indicators (time to flatus, wound healing, and hospitalization stay), complications (hypothermia, pressure sores, and infection), and nursing satisfaction.

RESULTS

Compared with the control group, patients in the research group had reduced intraoperative blood loss, shorter operation and recovery times (earlier return of bowel function, faster wound healing, and shorter hospitalization stay), and a lower overall complication rate. Post-intervention systolic blood pressure, diastolic blood pressure, heart rate, Screen for Child Anxiety Related Disorders, and Depression Self-Rating Scale for Children scores were significantly reduced compared with baseline and were lower those in the research group. Nursing satisfaction scores were also higher in the research group.

CONCLUSION

Integrating psychological support with operating room nursing is superior to conventional care in alleviating anxiety and depression and enhancing postoperative recovery in pediatric laparoscopic appendectomy.

Key Words: Operating room nursing; Psychological intervention; Pediatric appendicitis; Laparoscopic surgery; Anxiety/depression; Postoperative recovery

Core Tip: By comparing operating room nursing combined with psychological intervention vs routine care in children undergoing laparoscopic appendectomy, this study demonstrates that the combined approach offers greater clinical advantages. Specifically, it improves psychological and physical status, promotes smoother postoperative recovery, and increases nursing satisfaction while maintaining clinical safety, supporting its use as an optimized perioperative nursing strategy for pediatric patients.

INTRODUCTION

Appendicitis is a common surgical emergency caused by inflammation of the vermiform appendix, with a reported lifetime risk of 7%-9%[1]. Although it can occur at any age, incidence peaks in younger populations, with children being particularly susceptible[2]. Epidemiological estimates from 2021 reported approximately 2.2 million new pediatric cases, accounting for approximately 13% of all appendicitis cases worldwide[3]. Common etiologies include mechanical blockage of the appendiceal lumen by fecaliths, lymphoid hyperplasia, calculi, or parasitic infection[4]. Although appendicitis typically presents with fever, vomiting, loss of appetite, localized tenderness, and migrating periumbilical pain, clinical manifestations in children are often atypical because of their still-developing anatomy and physiology. Consequently, delayed recognition may lead to suppuration or perforation[5,6]. Laparoscopic appendectomy is the current gold-standard treatment for pediatric appendicitis, offering significant advantages over open surgery, including reduced postoperative pain and faster recovery[7]. However, anxiety and depression are common in pediatric appendicitis patients, a response to both disease-related discomfort and preoperative uncertainty that may adversely affect optimal postoperative recovery[8]. This interaction is partly mediated through the brain-gut axis, whereby psychological stress alters gastrointestinal regulation and contributes to clinical manifestations such as diarrhea, constipation, or abdominal pain[9]. These considerations underscore the importance of optimizing perioperative management to improve psychological well-being and recovery outcomes in pediatric patients. Conventional nursing care primarily focuses on procedural coordination, health education, and basic care, with limited emphasis on psychological well-being and proper integration of intervention strategies, thus failing to achieve optimal clinical results[10,11]. Operating room nursing combined with psychological intervention has been proposed as an innovative, dually optimized model that advances conventional practice[12]. Its innovation lies in delivering integrated care across all surgical phases while simultaneously monitoring and responding to the patient’s psychological status and unique needs. Consequently, it effectively alleviates underlying psychological stress, which subsequently boosts treatment cooperation and accelerates postoperative recovery[13].

However, evidence regarding the effects of combined operating room nursing and psychological intervention on anxiety, depression, and recovery outcomes in children undergoing laparoscopic appendectomy remains limited. The present study aimed to evaluate this combined approach and to provide clinical evidence to support optimized perioperative nursing strategies in this pediatric population.

MATERIALS AND METHODS

Case selection

Eligibility criteria: Children aged 8-14 years who were hospitalized for abdominal pain with marked McBurney’s point tenderness and diagnosed with acute appendicitis via imaging (plain abdominal radiography, ultrasonography, or computed tomography) were included[14]. Eligible patients were first-time presentations with symptoms such as nausea and vomiting, had complete medical records, and demonstrated normal cognitive and communication skills.

Ineligibility criteria: Patients were excluded if they had contraindications to surgery or anesthesia, a history of abdominal surgery within the preceding six months, underlying chronic diseases, malignancy, immunodeficiency, coagulation dysfunction, or diagnosed psychiatric disorders.

This retrospective study enrolled 98 pediatric patients who underwent laparoscopic appendectomy between November 2023 and November 2024 and met all eligibility criteria. Patients were assigned to groups based on the nursing care actually received: (1) A control group (n = 44) receiving conventional nursing; and (2) A research group (n = 54) receiving the integrated nursing-psychological intervention. Although no pre-study power calculation was performed, a post hoc power analysis based on the primary recovery-related outcome (time to postoperative flatus) demonstrated a large effect size (Cohen’s d = 0.88). An estimated sample size of approximately 42 patients would be required to achieve 80% power, indicating that the present sample size was adequate.

Intervention methods

All patients underwent the same laparoscopic appendectomy procedure. Children in the control group received standard nursing care. Preoperative nursing included a comprehensive assessment of disease status, overall physical condition, and relevant medical, treatment, and allergy histories. On the day of surgery, nurses prepared and verified all laparoscopic instruments in advance to ensure proper function. Intraoperatively, vital signs were continuously monitored and recorded, and efficient instrument transfer was maintained to facilitate the surgeon’s work. To conclude the procedure, nurses completed a full count of surgical items, cleansed trocar sites, and applied sterile dressings. During the first three postoperative days, children were visited daily, with assessments of vital signs and surgical wounds. Parents received postoperative care education, and inappropriate behaviors observed in the child were promptly corrected.

In addition to the above measures, the research group received psychological intervention delivered throughout the perioperative period.

Preoperative care: Nursing staff collaborated with surgeons to finalize the surgical plan and schedule, followed by a preoperative visit. During this visit, families were educated on the surgical procedure’s rationale, steps, and expected cooperation, aiming to address misconceptions, questions, and concerns. Targeted psychological strategies were implemented based on the child’s emotional status, and interaction using toys and pictures were employed to build trust and reduce fear. Parallelly, nurses executed the standard preoperative checklist, which encompassed facilitating the completion of various tests, cleansing the umbilical and peri-umbilical skin, and performing surgical site hair removal. Structured psychological support was also provided for family members. The surgical process and key time points were clearly explained using visual flow charts to reduce uncertainty-related anxiety. Parents were instructed to use positive, reassuring language (e.g., replacing “don’t be afraid” with “mom is here with you”) to provide a sense of security.

Intraoperative care: To minimize environmental stress (e.g., temperature, humidity, and lighting) and maintain physiological and psychological stability, the operating room temperature was maintained at 22-26 °C with humidity at 50%-60%, and all infusion fluids were pre-warmed. Children entered the operating room only after environmental preparation was completed; older children were escorted in, whereas younger children were carried. Staff maintained verbal reassurance throughout the procedure. Proper positioned with protective padding and thermal care was ensured, including covering non-operative areas with blankets and using warm water bags as needed without compromising the surgical field. A supportive waiting environment for family members was also provided, with access to drinking water, charging equipment, and health education videos.

Postoperative care: After surgery, nurses completed instrument counts, transferred the child to the postanesthesia care unit, and initiated close monitoring. Initial positioning was supine with lateral head tilt, followed by adjustment to a semi-recumbent position once the child awakened from the anesthesia. In addition, incision dressings were checked for cleanliness and integrity, abdominal binders were properly fitted for support, and blankets were used to maintain normothermia. Parallel attention was paid to the child’s psychological status, ensuring timely emotional reassurance. Rehabilitation guidance was given to family members, including training in the use of the pain assessment tool (Wong-Baker Scale) to help children express their feelings and ensure that discomfort was handled promptly and instruction on providing verbal praise or symbolic rewards when children completed key recovery actions (e.g., passage of flatus and ambulation).

Data collection and outcome measurement

Surgical metrics: Intraoperative blood loss and total operation time were documented for all patients.

Physiological measures: Noninvasive systolic blood pressure (SBP) and diastolic blood pressure (DBP) and heart rate (HR) were measured preoperatively and postoperatively using a standard hemodynamic monitoring system.

Anxiety and depression: Anxiety and depressive symptoms were assessed using the Screen for Child Anxiety Related Disorders (SCARED) and the Depression Self-Rating Scale for Children (DSRSC)[15]. The SCARED consists of 41 items, each scored 0-2, totaling 0-82; scores ≥ 25 indicate a significant risk of anxiety. The DSRSC consists of 18 items, each scored 0-2, totaling 0-36; scores ≥ 15 indicate depression.

Postoperative recovery: Postoperative recovery was evaluated by recording the time to first flatus, wound healing time, and hospitalization stay in both patient groups. Wound healing was evaluated daily at 09:00 by a nurse blinded to patient allocation. Wound healing was defined as fulfillment of all the following criteria: (1) The incision was well closed without redness, exudation, or purulent secretion; (2) Sutures had been removed or absorbable sutures had fallen off without dehiscence; and (3) There was no pain or only mild pain on palpation that did not cause obvious crying or avoidance. Wound healing time was defined as the interval, in days, from completion of surgery (postoperative day 0) to the day the last trocar hole met the healing criteria.

Complications: The incidence of adverse events (e.g., hypothermia, pressure sores, and infection) was recorded for each group.

Nursing satisfaction: Parental nursing satisfaction was evaluated using a self-designed questionnaire[16] scored on a 0-100 scale. The core item was: Please rate your overall satisfaction with the nursing service during this operation (0-100 points). Scores of 90-100 were defined as “very satisfied”, 60-89 as “satisfied”, and < 60 as “dissatisfied”. The overall satisfaction rate was calculated as the combined proportion of “very satisfied” and “satisfied” responses. This item was reviewed by three nursing experts and considered to adequately reflect overall nursing satisfaction.

Statistical analysis

Normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed data are presented as mean ± SD and were compared between groups using independent-samples t-tests; within-group pre-post comparisons were analyzed using paired t-tests. Non-normally distributed continuous variables are expressed as median (interquartile range) and were compared using the Mann-Whitney U tests. Categorical variables are presented as n (%) and were compared using the χ² test. All statistical analyses were performed using SPSS 20.0, with a threshold of P < 0.05 considered statistically significant.

RESULTS

Patient characteristics at baseline

Baseline characteristics were comparable between the two groups, with no significant differences in sex, age, body weight, time since symptom onset, and family history (P > 0.05; Table 1).

Table 1 Baseline data of the study groups, n (%)/mean ± SD/median (interquartile range).

Indicators	Control group (n = 44)	Research group (n = 54)	χ2/Z/t	P value
Male	24 (54.55)	28 (51.85)	0.071	0.790
Age (years)	11.00 (10.00, 12.00)	11.00 (9.75, 13.00)	-0.213	0.831
Body mass (kg)	38.07 ± 6.54	39.67 ± 7.80	1.085	0.281
Time since onset (hours)	20.50 ± 6.22	21.52 ± 6.66	0.777	0.439
Family history	7 (15.91)	7 (12.96)	0.172	0.679

Surgical metrics between groups

Significant inter-group differences were observed in surgical indicators. The research group demonstrated reduced intraoperative blood loss and shorter operative time compared with the control group (P < 0.05; Figure 1).

Figure 1 Inter-group comparison of intraoperative blood loss and operation time. A: Intraoperative blood loss comparison; B: Operation time comparison. ^bP < 0.01 vs the control group.

Physiological measures in the two groups

Baseline SBP, DBP, and HR did not differ between groups (P > 0.05). Post-intervention, all indices decreased significantly in both groups (P < 0.05), with greater reductions observed in the research group (P < 0.05; Table 2).

Table 2 Comparative evaluation of systolic blood pressure, diastolic blood pressure and heart rate, mean ± SD.

Indicators		Control group (n = 44)	Research group (n = 54)	t value	P value
Systolic blood pressure (mmHg)	Before	131.57 ± 14.21	129.83 ± 14.98	0.585	0.560
	After	124.70 ± 11.55a	118.30 ± 13.37b	2.504	0.014
Diastolic blood pressure (mmHg)	Before	78.23 ± 6.86	76.15 ± 8.25	1.337	0.184
	After	73.77 ± 6.47a	70.07 ± 5.71b	3.005	0.003
Heart rate (times/minute)	Before	79.55 ± 8.06	79.04 ± 4.63	0.393	0.696
	After	75.34 ± 6.45a	71.22 ± 4.91b	3.589	< 0.001

^aP < 0.05, within-group comparisons vs pre-interventional levels.

^bP < 0.01, within-group comparisons vs pre-interventional levels.

Anxiety and depression in the two groups

Baseline SCARED and DSRSC scores were similar between groups (P > 0.05), with the research group showing lower post-intervention scores than the control group (P < 0.05; Figure 2).

Figure 2 Screen for Child Anxiety Related Disorders and Depression Self-Rating Scale for Children scores across groups. A: Pre-intervention and post-intervention Screen for Child Anxiety Related Disorders scores; B: Changes in Depression Self-Rating Scale for Children scores from baseline to post-intervention. DSRSC: Depression Self-Rating Scale for Children; SCARED: Screen for Child Anxiety Related Disorders; ^aP < 0.05, ^bP < 0.01 (within-group comparisons vs pre-interventional levels; ^cP < 0.05 vs the control group at the identical time point.

Postoperative recovery across groups

All recovery-related outcomes differed significantly between groups (P < 0.05). The research group exhibited significantly shorter time to first flatus, faster wound healing, and hospitalization stay compared with the control group (P < 0.01; Table 3).

Table 3 Comparison of postoperative recovery (time to first flatus, wound healing time, and hospitalization duration), mean ± SD/median (interquartile range).

Indicators	Control group (n = 44)	Research group (n = 54)	Z/t	P value
Time to first flatus (hours)	38.66 ± 9.25	31.83 ± 6.04	4.398	< 0.001
Wound healing time (days)	6.00 (5.00, 7.00)	4.00 (3.00, 5.00)	-3.881	< 0.001
Hospitalization duration (days)	6.00 (5.00, 7.00)	5.00 (4.00, 6.00)	-2.519	0.012

Complication outcomes

A significant inter-group difference was identified in the total complication rate (P < 0.05), with the research group showing a significant reduction in the incidences of hypothermia, pressure sores, and postoperative infection compared with the control group (P < 0.05; Table 4).

Table 4 Comparison of complication incidence between the groups (hypothermia, pressure sores, and infection), n (%).

Indicators	Control group (n = 44)	Research group (n = 54)	P value
Hypothermia	5 (11.36)	0 (0.00)
Pressure sores	2 (4.55)	0 (0.00)
Infection	3 (6.82)	2 (3.70)
Total	10 (22.73)	2 (3.70)	0.005

Nursing satisfaction ratings

Nursing satisfaction differed significantly between groups (P < 0.05). The research group showed a significantly higher overall satisfaction rate than the control group (P < 0.05; Table 5).

Table 5 Comparative analysis of nursing satisfaction ratings, n (%).

Indicators	Control group (n = 44)	Research group (n = 54)	P value
Very satisfied	25 (56.82)	38 (70.37)
Satisfied	9 (20.45)	12 (22.22)
Dissatisfied	10 (22.73)	4 (7.41)
Total satisfaction	34 (77.27)	50 (92.59)	0.042

DISCUSSION

Despite its favorable safety profile, laparoscopic appendectomy in children still causes bodily injury, which may trigger both physiological and psychological stress responses that impair postoperative recovery[17]. Therefore, providing higher-quality nursing care to pediatric patients undergoing this procedure is of considerable clinical importance.

This study demonstrated that integrating psychological intervention with operating room nursing in pediatric laparoscopic appendectomy resulted in improved surgical outcomes, including reduced blood loss and shorter operative time. These benefits may be attributable to enhanced physiological and psychological preparation, which improved patient compliance and procedural efficiency. Similar findings were reported by Qi and Li[18], who showed that a combined nursing-psychological approach more effectively reduced blood loss and operation time compared with conventional care in patients undergoing hematoma removal after traumatic brain injury. A further observation was its superior efficacy in mitigating stress responses in children, indicated by greater reductions in physiological markers (SBP, DBP, and HR) and psychological assessment scores (SCARED and DSRSC) compared with conventional nursing. This effect likely stems from the holistic perioperative focus on psychological well-being, achieved through preoperative education, creation of a secure intraoperative environment, and provision of consistent postoperative reassurance, all of which reduced the child’s stress response. Consistent with our findings, Wang et al[19] reported stabilized vital signs and shortened times to flatus, defecation, ambulation, and feeding in pediatric patients receiving combined nursing care during minimally invasive digestive endoscopy. Similarly, Yang[20] demonstrated that a comparable approach in patients with appendicitis effectively mitigated anxiety and depression while improving nursing satisfaction and sleep quality.

The efficacy of the intervention in promoting postoperative recovery was further demonstrated through significantly shortened times to first flatus, wound healing, and hospital discharge. Psychological intervention may help restore intestinal homeostasis by relieving the psychological stress and regulating the microbiota-intestine-brain axis, thereby facilitating gastrointestinal function recovery and shortening postoperative flatus time[21]. Although the absolute differences in incision healing time and hospitalization stay (approximately 1 day), even such reductions may lessen discomfort for children and their families and reduce the risk of hospitalization-associated cross-infections. Future studies should further evaluate the cost-effectiveness of this care model by quantifying the additional resources compared with reductions in hospitalization stay. These findings are supported by Chen et al[22], who observed similar improvements in recovery timelines (time to bowel sound recovery, first flatus/defecation/oral intake, and hospital discharge) after laparoscopic appendectomy with a combined nursing strategy. Furthermore, the integrated approach contributed to reducing the overall risk of complications (e.g., hypothermia, pressure sores, and postoperative infection) and enhanced nursing satisfaction. These effects may be partly explained by standardized pressure management in operating room nursing, such as the use of pressure-relieving pads to disperse pressure over bony prominences (e.g., sacrococcygeal, heels, and occiput), thereby helping to prevent pressure ulcers. Additionally, careful posture management and stabilization using protective pads help minimize friction and sliding during surgery. However, routine nursing often focuses on procedural cooperation while neglecting targeted prevention of posture-related stress injuries. Supporting this interpretation, Xue et al[23] reported a lower overall complication rate in pediatric acute appendicitis surgery using a combined intervention and suggested a potential associated between elevated C-reactive protein levels and postoperative complications. Reportedly, surgical site infection, with an incidence of 1.2%-20.0%, remains the most common complication following laparoscopic appendectomy and is frequently associated with fever, preoperative antibiotic use, and postoperative drainage[24]. Consistently, Pei and Song[25] found that standardized operating room nursing combined with psychological intervention in orthopedic patients improved wound healing, reduced surgical site infection rates, and increased nursing satisfaction, further supporting this study’s results.

Further refinement of this study is needed due to several limitations. First, the age range of participants was limited to 8-14 years. Given the significant differences in psychological development, cognitive ability, and stress responses across pediatric age groups, future studies should incorporate age-based subgroup analyses to minimize potential confounding effects. Second, nursing satisfaction was evaluated using a single-item overall scoring method. Although this approach is simple to operate and provides a direct measure of overall satisfaction, it does deeply analyze the influence of specific satisfaction dimensions (e.g., technology, communication, or environment). Future research should consider using a structured, validated multidimensional scale for more detailed evaluation. Third, no cost-benefit analysis was conducted; incorporating such analyses would help determine the clinical value of operating room nursing combined with psychological intervention. Fourth, given the single-center design, limited sample size, and lack of long-term follow-up, the conclusions drawn require validation through larger, multi-center randomized controlled trials. Finally, the nursing intervention did not include standardized scripts or clearly defined skills for targeted psychological counseling; prospective studies should further optimize these nursing intervention strategies.

CONCLUSION

Collectively, integrating operating room nursing with psychological intervention demonstrates clear advantages in pediatric laparoscopic appendectomy. These benefits include improved physical and psychological preparedness, more efficient postoperative recovery, a reduced incidence of adverse events, and higher nursing satisfaction, supporting its potential value in perioperative pediatric care.