Clinical outcome of appendectomy: laparoscopic vs open technique

Background: Acute appendicitis is a common abdominal surgical emergency. Appendectomy has been proven to be the standard care for the treatment of acute appendicitis. Objective of the study was to compare laparoscopic and open appendectomy in terms of clinical outcome and complication rates.Methods: This was a single centric, retrospective study conducted at SKIMS, Soura from May 2018 to April 2021. Open and laparoscopic appendectomy patients were compared in terms of operative times, conversion rate, complication rates and duration of hospital stay.Results: Total 120 patients were included in this study with 40 in laparoscopic group while 80 patients in the open group. Increased operative time in laparoscopic group (p=0.033) and longer duration of hospital stay (p=0.021) with open group while as comparable complication rate in both procedures were observed. Higher rates of intra-abdominal collection in laparoscopic group as compared to open groupConclusions: Both laparoscopic and open appendectomy procedures can be performed routinely for acute appendicitis without the additional risks of complications.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

Introduction Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery. Materials and Methods Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien–Dindo classification. Results A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien–Dindo grade I to III complications (mild–moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades. Conclusion Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Study of serum bilirubin as a diagnostic method to predict acute perforated appendicitis

Background: Acute appendicitis is the commonest cause of ‘acute surgical abdomen’. Appendicectomy is the most frequently performed urgent abdominal operation and is often the first major procedure performed by a surgeon in training. The aim of the study was to whether hyperbilirubinemia might be used as a diagnostic tool to predict perforated appendicitis.Methods: This study comprised patients who presented with the condition of appendicitis and abnormal liver function tests on admission and had a laparoscopic or open appendectomy. The age information, duration of symptoms, temperature, white blood cell counts, bilirubin levels, and histology data were gathered. Peritoneal fluid was cultured and examined for sensitivity.Results: The average bilirubin level of all participating patients was 0.92 mg/dl (range, 0.1-4.3 mg/dl). The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (0.7 mg/dl and 0.4 mg/dl, p<0.001). Hyperbilirubinaemia was reported to have a specificity of 89% and a positive predictive value of 90.02% for acute appendicitis. Patients with appendiceal perforation, however, had a mean bilirubin level of 1.7 mg/dl and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 73%.Conclusions: Patients with hyperbilirubinemia with appendicitis condition should be screened for a greater risk of appendiceal perforation than those with normal bilirubin levels.

Use of the Ring Wound Protector in Open Appendectomy: A Model-Based Cost-Utility Analysis

Objective: To evaluate cost-effectiveness of ring wound protector (RWP) used in open appendectomy. Materials and Methods: The present study was a decision-tree-based analysis. Model inputs, including costs, utilities, and probabilities of surgical site infection (SSI), were retrieved from the previous studies. The incremental cost-effectiveness ratio (ICER) represented the cost of one additional quality-adjusted life day (QALD). This ratio was calculated by dividing the incremental cost [Thai Baht (THB)] by the incremental QALD. One-way sensitivity analyses were performed by varying each input parameter to see how ICER change. Monte-Carlo simulation with 5,000 replications was used to estimate probabilistic ICER and construct the acceptability curve, demonstrating how the probability of being cost-effective changed when the willingness-to-pay (WTP) threshold was shifted. Results: The deterministic ICER of 64,630.78 THB/QALD did not favor RWP use compared with the WTP threshold of 10,000 THB/QALD. However, if the threshold was shifted to 100,000 THB/QALD, it would yield approximately 75% probability of being cost-effective from RWP. Threshold analysis indicated that RWP should cost 281, 301, and 661 THB to be cost-effective at the threshold of 500, 1,000, and 10,000 THB/QALD, respectively. Conclusion: Routine RWP use might not be cost-effective when QALD is the outcome of interest. Based on the results from the present study, policy-makers could be informed that the adoption of this health technology might not be suitable. Keywords: Ring wound protector; Appendectomy; Cost-utility analysis; Decision tree model

APPENDECTOMY AT THE CONTEMPORARY STAGE (LITERATURE REVIEW)

В первую очередь, острый аппендицит (ОА) - клинический диагноз. Согласно проведенному обзору, по всему миру заболеваемость острым аппендицитом составляет около 100 случаев на 100 тыс. населения в год. Острый аппендицит чаще встречается у пациентов от подросткового возраста и до 50 лет. Также определяется незначительное преобладание мужчин над женщинами. В 1894 г. McBurney описал новую по тем временам технику лечения острого аппендицита. Данный метод до сих пор используется, а во многих странах является золотым стандартом при оперативном лечении острого аппендицита. В 1981 году Семмом была произведена первая лапароскопическая аппендэктомия. В настоящее время хирургия с использованием эндовидео технологий приобретает первостепенное значение во многих хирургических учреждениях. Однако, даже с учетом большого количества проведенных операций и клинических исследований, среди хирургов возникает вопрос: является ли лапароскопическая операция оптимальным выбором при аппендэктомии. Цель. Сравнить лапароскопическую аппендектомию с открытой аппендектомией. Материалы и методы. Для поиска и отбора статей использовался принцип PRISMA (Предпочтительный Метод Отчета Для Систематических Обзоров и Метаанализов). В настоящем обзоре были использованы базы данных MedLine, Cochrane, PubMEd. Глубина поиска составила 10 лет, за исключением исторических данных. Все источники изучены без лимитирования по языку. Обзор литературы проводился в электронном и в ручном режимах. Для обзора были отобраны статьи, соответствующие ключевым словам - острый аппендицит, лапароскопическая аппендэктомия, открытая аппендэктомия. Было найдено 389 статьи, в поиск включались систематические обзоры, метаанализы, рандомизированные клинические исследования. Для удаления дубликатов и отбора статей использовался ресурс «https://rayyan.ai/» После отбора статей было выбрано 119 источников, которые были включены в итоговый синтез. Вывод. Лапароскопическая аппендектомия показывает преимущество перед открытой аппендектомией по интенсивности боли в первый день, раневым инфекциям, продолжительности пребывания в больнице и времени до возвращения к нормальной активности у взрослых. В нескольких исследованиях сообщалось о более высоких показателях качества жизни у взрослых. Однако, некоторые клинические эффекты лапароскопической аппендектомии описаны авторами как небольшие и имеющие ограниченное клиническое значение. Необходимы крупные исследования, направленные на снижение уровня систематической ошибки. First of all, acute appendicitis (OA) is a clinical diagnosis. According to the survey, the worldwide incidence of acute appendicitis is about 100 cases per 100 thousand rubles. population per year. Acute appendicitis is more common in patients from adolescence to 50 years of age. There is also a decisive predominance of men over women. In 1894, McBurney described a new technique for the treatment of acute appendicitis. This method is still used, it is used by the gold standard in the surgical treatment of acute appendicitis. In 1981, Semm performed the first laparoscopic appendectomy. Nowadays, surgery using endovideo technology is gaining paramount importance in many surgical institutions. However, even taking into account the large number of operations performed and clinical trials, the question arises among surgeons: is laparoscopic surgery the optimal choice for appendectomy? Target. Compare laparoscopic appendectomy with open appendectomy. Materials and methods. For the search and selection of articles, the PRISMA principle (Preferred Reporting Method for Systematic Reviews and Meta-analyzes) was used. In this review, the databases MedLine, Cochrane, PubMEd were used. Search depth excludes 10 years. All sources have been studied without language limitation. The literature review was carried out in electronic and manual modes. For were selected articles, the relevant keywords - acute appendicitis, laparoscopic appendectomy, open appendectomy. 389 articles were found, systematic reviews, meta-analyzes, randomized clinical trials were included in the search. To remove duplicates and select articles, the resource "https://rayyan.ai/" was used for the selection of articles, 119 sources were selected, which were included in the final synthesis. Output. Laparoscopic appendectomy shows an advantage over open appendectomy in first day pain, wound infections, length of hospital stay, and time to return to normal activity in adults. Several studies have reported higher rates of quality of life in adults. However, some of the authors' approximating effects of laparoscopic vendectomy are small and of limited clinical relevance. Large studies are needed, the error is to lower the systematic level.

Association of treatments for acute appendicitis with pregnancy outcomes in the United States from 2000 to 2016: Results from a multi-level analysis

Background Open appendectomy, laparoscopic appendectomy, and non-surgical treatment are three options to treat acute appendicitis during pregnancy. Previous studies on the association of different treatment methods for acute appendicitis with pregnancy outcomes have been limited by small sample sizes and residual confounding, especially with respect to hospital-level factors. This study aimed to investigate the association of treatment method for acute appendicitis with pregnancy outcomes using a multi-level analysis. Methods A retrospective cohort study was conducted based on a large electronic health records database in the United States during the period 2000 to 2016. All pregnancies diagnosed with acute appendicitis and treated in participating hospitals during the study period were included. We conducted multi-level hierarchical logistic regression to analyze both individual- and hospital-level factors for abortion, preterm labor, and cesarean section. Results A total of 10,271 acute appendicitis during pregnancy were identified during the study period. Of them, 5,872 (57.2%) were treated by laparoscopic appendectomy, 1,403 (13.7%) by open appendectomy, and 2,996 (29.2%) by non-surgical treatment. Compared with open appendectomy, both laparoscopic appendectomy (adjusted OR, 0.6, 95% CI, 0.4, 0.9) and non-surgical treatment (adjusted OR, 0.4; 95% CI, 0.3–0.7) showed a decreased risk of preterm labor. Other important individual-level determinants of adverse pregnancy outcomes included maternal age, gestational hypertension, and anemia during pregnancy, the hospital-level determinant included the number of beds. Conclusions Compared with open appendectomy, both laparoscopic appendectomy and non-surgical treatment may be associated with a lower risk of preterm labor, without increased risks of abortion and cesarean section.

AMPATH Surgical App: Open Appendectomy

Background/Objective: Due to a geographic shortage of surgical providers within Kenya, doctors without surgical training are expected to complete emergency surgical procedures. The Academic Model Providing Access to Healthcare (AMPATH) surgical team is developing an education module, delivered via mobile phone app and self-made simulators, dedicated to the skills necessary to complete open appendectomy. We hypothesize that our model and curriculum will provide a low-cost method of effectively simulating the open appendectomy. Methods: After developing a step-based curriculum, an initial prototype of a model for the appendectomy was constructed. Expert academic surgeons from Indiana University were identified to test the prototype by performing an open appendectomy on the model. Feedback on both the model and the procedure was obtained via recorded video and REDCap. Results: A total of 8 expert surgeons were consulted on the model, each presented with an updated version of the appendectomy model and procedure based on feedback. Experts provided feedback on the model and each substep of the curriculum. Overall, the curriculum was clear with each substep receiving a median score of at least 82 out of 100 for clarity. While the model received lower scores in utility and “realism, expert feedback was incorporated in an iterative process such that latter models demonstrated net improvement in the realism and utility of several substeps, including “the appendectomy”. Conclusion: A low-cost appendectomy model with corresponding curriculum was developed, and refined with expert feedback, to facilitate this project’s transition to its next stage – testing on medical trainees. Additionally, the model and curriculum will enable the development of an AI algorithm to give the learner real-time feedback as they perform the simulation. Implications: Ultimately, this study may create a platform that increases access to best possible practice and improves outcomes in settings where surgical education is limited.

Impact of the SARS-CoV-2 pandemic on the course and treatment of appendicitis in the pediatric population

SARS-CoV-2 is a highly contagious virus causing mainly respiratory track disease called COVID-19, which dissemination in the whole world in the 2020 has resulted in World Health Organisation (WHO) announcing the pandemic. As a consequence Polish Government made a decision to go into a lockdown in order to secure the population against SARS-CoV-2 outbreak what had its major influence on the Polish Health Care System. All of the social and medical factors caused by the pandemic might influence children’s health care, including urgent cases. The aim of this survey was the analysis of medical charts with focus on the course and results of surgical treatment of children who underwent appendectomy before and during the COVID-19 pandemic. Material and methods: We performed analysis of charts of 365 subjects hospitalized in the Pediatric Surgery Department from 1st January 2019 to 31st December 2020 because of acute appendicitis. Patients were divided into two groups—those treated in 2019—before pandemic outbreak, and those treated in 2020 in the course of pandemic. Results: the most common type of appendicitis was phlegmonous (61% of cases in 2019 and 51% of cases in 2020). Followed by diffuse purulent peritonitis (18% of cases in 2019 vs 31% of cases in 2020), gangrenous (19% of cases in 2019 vs 15% of cases in 2020) and simple superficial appendicitis (1% of cases in 2019 vs 3% of cases in 2020). There was statistically significant difference in the length of hospitalization: in 2019 the mean length of hospi-talization was 4.761 vs 5.634 in 2020. Laparoscopic appendectomy was performed more frequently before the COVID period (63% of cases treated in 2019 vs 61% of cases treated in 2020). In the pandemic year 2020, there was double increase in the number of conversion from the laparoscopic approach to the classic open surgery. In the year 2019 drainage of abdominal cavity was necessary in 22% of patients treated with appendectomy, in 2020 the amount of cases threated with appendectomy and drainage increased to 32%. Conclusions: fear of being infected, the limited availability of appointments at General Practitioners and the new organisation of the medical health care system during pandemic, delay proper diagnosis of appendicitis. Forementioned delay leads to higher number of complicated cases treated with open appendectomy and drainage of abdominal cavity, higher number of conversions from the laparoscopic to classic open technique, and longer hospitalization of children treated with appendectomy in the year of pandemic.

Single incision laparoscopic appendectomy: A prospective study

Background: Appendicitis is one of the common pathologies encountered in surgical practice. Except in minority of the cases, the treatment is usually surgical. Till recent past, open appendectomy has been the procedure of choice for appendicitis. With increasing expertise in laparoscopic surgeries more and more surgeons are utilizing the laparoscopic approach for appendectomy. Laparoscopic surgeries have distinct advantages such as less surgical trauma, improved and quick postoperative recovery, and esthetic results. Single-incision laparoscopic surgery (SILS) is rapidly gaining acceptability in young population because of its cosmetic advantages. Moreover, these surgeries also avoid the risk of port-site hernias and the possibility of wound infection. Aims and Objective: The purpose of this study is to present our initial experience with this surgery using a single incision laparoscopic appendectomy (LA) using conventional instruments. Materials and Methods: This was a prospective cohort study conducted in the department of surgery of a tertiary care medical college situated in an urban area. The duration of the study was 2 years. All adult patients diagnosed to be having uncomplicated appendicitis and undergoing appendectomy by SILS were included in this study on the basis of a predefined inclusion and exclusion criteria. Pre-operative data collected included age, sex, weight, duration of complaint, concomitant medical conditions (like ischemic heart disease, chronic obstructive airway disease, diabetes mellitus, pancreatitis, and liver cirrhosis) and previous upper or lower abdominal surgery. All patients were treated by SILS except 1 patient in whom the procedure was converted to open surgery. Mean surgical time, Intraoperative procedure details and postoperative complications were studied in all the cases. p < 0.05 was taken as statistically significant. Statistical analysis was done using SSPS 21.0 software. Results: Out of 30 patients in this study 26 patients were female and 4 patients were male. The male to female ratio was found to be 1:6.15. Mean age of studied cases was found to be 26.2 years. Operative time required for the first 15 cases in an average was 120.00 min however it was reduced for the next 15 cases was 73.73 min. Overall time required in an average was 96.86 min. Out of 30 cases, The procedure was completed with Single Incision LA in 23 Patients, i.e., 76.6 %. In the initial cases, we started with two 5 mm and one 10mm port. To reduce crowding we replaced the 5 mm port to 3 mm port. The 10 mm port was also replaced by 5 mm in the past few cases in 1 patient the procedure was converted to open surgery. The analysis of postoperative complications showed that five patients had Post-Operative wound Infection. One patient had post-operative peritonitis. Conclusion: SILS is a feasible and safe surgical method for appendectomy and is being increasingly preferred particularly by young patients due to its excellent cosmetic results.