EP.TU.203COVID-19 related myocarditis following laparoscopic appendicectomy

We report a 23 year-old male patient who presented to the emergency department with 2 days of central abdominal pain, with associated pyrexia, lethargy and nausea. Of note he had had COVID-19 in November 2020 which self-resolved. Examination revealed right sided abdominal and epigastric tenderness. His C-reactive protein was 302U/L but the remaining bloods unremarkable. The working diagnosis was unclear and a computed tomograph of the abdomen and pelvis arranged which revealed uncomplicated appendicitis with mesenteric lymphadenopathy. He underwent laparoscopic appendicectomy, revealing a macroscopically inflamed appendix without perforation or peritoneal contamination. Day 1 post-operatively, he deteriorated with acute hypoxia, tachypnoea and rigors. Additionally his inflammatory markers had increased. Respiratory physician advice was sought and an urgent computed tomograph pulmonary artertiogram performed, showing no pulmonary embolus but did show bilateral lower lobe consolidation and groundglass opacities in both lungs suspicious of COVID-19. Furthermore given his persistently low blood pressure, he underwent echocardiogram which revealed the presence of COVID-19 myocarditis and impaired left ventricular systolic dysfunction with an ejection fraction of 35%. He was admitted to the intensive care unit for blood pressure support and monitoring from a respiratory perspective. With such measures both his chest and cardiovascular function improved markedly and he was discharged on long-term cardioprotective medication. This highly rare long COVID-19 related complication following laparoscopic appendicectomy is highlighted for surgeons to be aware of and consider in cases of post-operative deterioration in patients with prior COVID-19 infection.

SP3.1.13 Does Single-port laparoscopic appendicectomy provide better outcomes compared to conventional (three-ports) laparoscopic appendicectomy?

Aims To evaluate comparative outcomes of single port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis. Methods A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted following PRISMA standards. Post-operative pain, cosmesis, need for an additional port(s), operative time, Post-operative complications, length of hospital stay(LOS), readmission, and reoperation were the evaluated outcome parameters. Results Sixteen RCTs reporting a total number of 2017 patients who underwent SPLA(n = 1009) or CLA(n = 1008) were included. SPLA showed higher cosmetic score (Mean Difference (MD) 1.11,P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, there was no significant difference between SPLA and CLA group in the postoperative pain score at 12 hours (MD -0.13,P=0.69), need for additional port(s) (Risk Ratio (RR)0.03, P = 0.07), postoperative ileus (RR 0.74,P=0.51), SSI ( RR 1.38, P = 0.28), Post-operative intra-abdominal collection (RR 0.00,P=0.62), LOS ( MD -2.41, P = 0.16), readmission to the hospital ( RR 0.45,P=0.22), and return to theatre (RR -0.00, P = 0.49). Subgroup analysis showed that operative time was comparable in adults only subgroup (P = 0.18) while it was significantly loner in paediatrics only subgroup(P = 0.00001). Moreover, LOS was shorter in adults only subgroup (P = 0.003) and no difference observed in paediatrics only subgroup (P = 0.93). Conclusion SPLA is associated with a slightly longer operative time; however, its efficacy and safety are comparable to CLA. Subgroup analysis showed that SPLA has better outcome in adults than paediatrics. Additionally, SPLA offers better post-operative cosmesis.

SP3.1.6 Operative difficulty grading scale for laparoscopic appendicectomy: A novel tool

Aims Acute appendicitis is a common emergency surgical presentation accounting for approximately 30,000 emergency operations annually in Australia. There is need for a clinical grading tool that can quickly and reliably assess the severity of appendicitis at the time of surgery and predict the difficulty of the operation. Methods Over 12 months, 111 questionnaires relating to the difficulty of laparoscopic appendicectomy operation, anatomical and pathological features, time taken, and need for senior assistance were completed by surgeons and trainees of varying seniority. Construction of a scale of the difficulty of operation was by the method of summated ratings. The final scale was generated utilising further item analysis, principal components analysis, internal consistency reliability analysis and concurrent validity analysis. Results A scale of 8 anatomical and pathological features that predict the difficulty of laparoscopic appendicectomy was formed. These include the presence of acute adhesions, gross pathology of the appendix, quality of the appendix, mesoappendix, appendix base and retroperitoneum, visibility of the appendix artery, and adherence of the appendix to adjacent structures. The scale has high internal consistency reliability, and both individual items and the scale has been validated by comparison with the surgeons’ perceived difficulty, the length of the operation and the need to call for senior assistance. Conclusions This appendicectomy grading scale based entirely on readily identifiable laparoscopic findings is able to predict the difficulty of the operation and can be used to facilitate operative planning as well as to improve criteria for assessing operative competency in trainee surgeons.

SP3.1.12 A Comparison of Polymeric Clips vs Endoloops to Secure Appendicular Stump in Adult Emergency Laparoscopic Appendicectomy

Aims To assess the use of polymeric clips (PC) as an alternative to Endoloops (EL) to secure appendicular stump in adult emergency laparoscopic appendicectomy. Method A retrospective analysis of all patients who underwent emergency laparoscopic appendicectomy from 1/11/19 to 31/10/20, following introduction of polymeric clips in our institute as a safe alternative to endoloops to secure appendicular stump in October 2019. Patient demographics, operative duration, intraoperative findings, methods to control the appendicular mesentery and stump, post-operative length of stay, complications and grade of operating surgeon were compared in both groups (PCvsEL) and data analysed using SPSS. Results A total of 333 patients were included, who underwent laparoscopic appendicectomy and satisfied the inclusion criteria. PC were used in 160 (48%) patients and EL in 173 (52%). Patient demographics, surgeon grade and intra-operative severity of disease were statistically similar between both groups. Mean operative time was 10 minutes shorter in PC group (71 vs 81minutes, p = 0.001). Mesoappendix was ligated by applying laparoscopic titanium clips in EL group 25%, vs 6% PC group (p < 0.001), while 42% of the PC group, used PC on mesoappendix, which was without any additional cost. Post-operative complication rates were similar in both groups, apart from post-operative ileus, which was more in EL group (p = 0.003). Conclusion The use of PC in emergency laparoscopic appendicectomy is a safe and effective way to secure the appendicular stump, which results in, not only reduced operating time, but also a significant cost saving (£49/3x Endoloops vs £21/pack of 6x Polymeric clips) to NHS.

EP.FRI.792 Laparoscopic port positioning in paediatric appendicectomy - a closed loop audit

Aims Laparoscopic appendicectomy is the most common laparoscopic procedure performed in children, typically with a suprapubic (SP) left-hand port position. This has been associated with bladder injury. Pre-operative bladder emptying can reduce the risk of this complication. The aim of this study was to evaluate compliance with local policy mandating left iliac fossa port placement (LIFPP) rather than SP. We assessed the rate of LIFPP before and after an educational intervention, and also audited if voiding status was included as part of the paediatric WHO checklist. Methods Retrospective data was collected before and after implementation of education, for 50 consecutive patients aged <16 years undergoing laparoscopic appendicectomy. The education programme targeted operating department practitioners, paediatric nurses and surgeons, and included seminars and regular dissemination of the local protocol. Data analysis was performed using GraphPad Prism. Results Patients were evenly distributed by gender with 94% above the age of 10. Mean age was 13.8 years. There was a statistically significant improvement in compliance with LIFPP, from 72% to 100% (p < 0.0001) after introduction of improved education, as well as significantly improved documentation of pre-operative voiding status from 12% to 40% (p = 0.0026). The rate of catheterisation intra-operatively was reduced from 20% to 8% (p = 0.1478). Conclusions Improved education has led to a significantly increased compliance with local port placement policy. Documentation of pre-operative voiding status has been included in the paediatric WHO checklist ‘SIGN IN’ section locally.

Effect of intrathecal buprenorphine on the haemodynamic response in patients undergoing laparoscopic appendicectomy under general anaesthesia

: Combined regional and general anaesthesia for laparoscopic appendicectomy offers better intraoperative haemodynamic stability. Buprenorphine is a long acting opioid which can be administered intrathecally and provides excellent analgesia intraoperatively and post operatively while allowing early ambulation without prolonged motor block. The study aimed to compare the haemodynamic response during laparoscopic appendicectomy using combined general anaesthesia with intrathecal buprenorphine and general anaesthesia alone. In this observational study 80 patients who underwent laparoscopic appendicectomy were divided into two groups of 40 each by random sampling. The patients in the GA group received general anaesthesia whereas patients in the GA+SAB group received intrathecal buprenorphine along with general anaesthesia. The heart rate, systolic and diastolic blood pressures and SpOwere noted after induction of general anaesthesia, immediately after endotracheal intubation, after creating pneumoperitonium and post extubation. Student’s t test was used for comparing the haemodynamic variables There were no statistically significant differences between GA and GA+SAB group in the heart rate, systolic and diastolic blood pressure after pneumoperitonium was created. When compared to general anaesthesia alone, addition of intrathecal burenorphine provides little advantage in preventing stress response during laparoscopic appendicectomy.

1073 Synchronous Cholecystitis and Appendicitis: A Case Report Highlighting Learning Points on Medical Imaging and Consent

Laparoscopic appendicectomy and laparoscopic cholecystectomy are separately two of the most common emergency surgical procedures carried out in the UK. Only a small number of synchronous presentations of acute appendicitis and acute cholecystitis have been reported in surgical literature and this rare co-existent pathology gives rise to several valuable learning points with regards to laparoscopy, medical imaging interpretation and the consent process. Our case report involves a 58-year-old female patient presenting with both RUQ and RIF pain and positive Murphy’s sign on clinical examination. US scan demonstrated several gallstones within a thin-walled gallbladder. Subsequent CT scan reported acute appendicitis which was treated definitively with laparoscopic surgery. Intraoperatively a perforated gangrenous gallbladder containing multiple calculi was discovered, and the decision was made to perform a double procedure of laparoscopic appendicectomy and cholecystectomy. Histopathology confirmed synchronous pathology of appendicitis with faecolith and calculus cholecystitis. This case demonstrates the importance of considering multiple pathologies when assessing a patient with ambiguous and migratory abdominal pain. It reinforces the importance of diagnostic laparoscopy to rule out multiple pathologies. This acts as a cautionary case against over-reliance on medical imaging and reminds surgeons of their obligation to maintain competence in CT interpretation plus correlation of imaging with clinical assessment of the patient. Readers should also be reminded that the consent process for surgical interventions should be undertaken meticulously in patients with ambiguous abdominal pain.

1320 Evaluation of Routine Group and Save Testing Prior To Appendicectomy

Introduction Group and save (G&S) testing is often performed prior to emergency appendicectomy. However, there are no standard national guidelines regarding the routine use of preoperative G&S. We performed a Trust Audit to review the need for G&S prior to appendicectomy in order to recommend new guidelines. Method Retrospective review of all patients that underwent appendicectomy at Chelsea and Westminster Hospital between October 2019 and March 2020. We evaluated the existing literature on blood transfusion rate and the need for G&S prior to appendicectomy. Results One hundred and seventy-three patients (female 56%, median age 26 years) underwent appendicectomy (94% laparoscopic, 6% open). One hundred and thirty-four (77%) patients had a valid G&S and none of the patients received a blood transfusion perioperatively. The estimated total cost of G&S sampling for laparoscopic appendicectomy over one year in the Trust is £6825 (excluding all other laparoscopic surgery). Conclusions Based on the audit findings and literature review, routine G&S testing is not necessarily required for all patients undergoing laparoscopic appendicectomy. G&S should be requested on a patient case-specific basis (for example, chronic anaemia or haematological conditions) with discussions between the anaesthetist and surgeon. This would reduce delays in emergency lists, have financial implications and there is no evidence to support that the routine use of G&S benefits patient outcomes. These recommended guidelines have been presented at Surgery/Anaesthetics Clinical Governance and have been rolled out in the Trust with the aim to perform a re-audit in 3-6 months.