[Open appendectomy. When do we still need it?]

[Interdisciplinary surgical spectrum in cooperation of abdominal surgery and gynecology : What must the (general/abdominal) surgeon know?]

AIM

This short overview aims to concisely outline the most important gynecological issues from a predominantly operative point of view, which could also be relevant for general and abdominal surgeons as well as important gynecological aspects of primarily visceral surgical pathologies.

METHOD

Narrative review on the topic of interdisciplinary cooperation in gynecological/general and abdominal surgery through the use of PubMed® as well as the Cochrane Library with search terms, such as "operative profile of abdominal surgery and gynecology", "interdisciplinary surgery aspects of gynecology/abdominal surgery" as well as "interdisciplinary surgical approach-surgical complication".

RESULTS (MAIN POINTS)

As the close anatomical relationship suggests, numerous primarily gynecological pathologies can also occur in abdominal organs. Likewise, predominantly surgical pathologies can result in involvement of gynecological organs. This can make an intraoperative collaboration necessary. In addition, as a result of diagnostic uncertainty or within the context of complications, interdisciplinary collaboration can also be required preoperatively and postoperatively. Multidisciplinary knowledge as well as close cooperation of the involved specialties can improve the outcome of affected patients.

CONCLUSION

Many pathologies extend not only to the boundaries of an individual discipline but can also affect physiological systems exceeding those limits. Therefore, for an optimal treatment it is necessary to be aware of such aspects of the diseases and to establish structured procedures for interdisciplinary cooperation.

Is the use of endoloops safe and efficient for the closure of the appendicular stump in complicated and uncomplicated acute appendicitis?

INTRODUCTION

There is still controversy regarding the ideal technique to close the appendicular stump in laparoscopic appendectomy (LA). The objective of this study was to determine the safety and efficiency of the use of an endoloop (EL) and endostapler (ES) in complicated and uncomplicated acute appendicitis.

METHODS

Retrospective cohort study of patients undergoing LA from February 2013 to December 2019. Acute uncomplicated and complicated appendicitis were analysed separately, establishing two groups according to the stump closure technique: EL or ES. Seven hundred-nine patients were included (535 uncomplicated and 174 complicated). In uncomplicated appendicitis, an EL was used in 447 of the patients (83.55%) and an ES was used in 88 patients (16.45%). In complicated appendicitis, an EL was used in 85 patients (48.85%) and an ES was used in 89 patients (51.15%). An analysis of effectiveness and a cost analysis of each technique were performed.

RESULTS

In uncomplicated appendicitis, we found no differences with respect to global complications, although there were significant differences in the total mean hospital stay (EL group 1.55 (SD 1.48) days; ES group 2.21 (SD 1.69) days; p = 0.046). This meant a savings of 514.12€ per patient using the EL p < 0.001). In complicated appendicitis, the reoperations classified as Clavien-Dindo IIIB in the EL group (6.4%) were greater than in the ES group (0%) (p = 0.012), although the rate of postoperative abscesses (p = 0.788) and the mean volume of abscesses (p = 0.891) were similar.

CONCLUSION

The systematic use of an EL could reduce costs in uncomplicated appendicitis, while in complicated cases, both options are valid. Prospective studies with a greater number of patients are needed to observe differences in postoperative complications.

[Appendectomy in surgical residency. What has changed over the past 10 years?]

BACKGROUND

Surgical residents need to train laparoscopic skills for minimally invasive procedures at an early stage. The aim of this study was the investigation and assessment of appendectomy carried out at a university medical center over the previous decade regarding the frequency of operations by residents in training and the type of surgical technique used (laparoscopic vs. open).

METHODS

A retrospective analysis of appendectomies carried out from 2005 to 2014 at the clinic for general, visceral and transplant surgery was performed. Operators were stratified into two groups (group 1: residents and group 2: fellows/attending surgeons). Surgery was classified as laparoscopic or open appendectomy.

RESULTS

Out of 1,587 appendectomies analyzed 946 were performed laparoscopically (59.6 %). The percentage of laparoscopic appendectomies increased significantly over the decade analyzed (p < 0.001) and reached 94.4 % in 2014. From 2005 until 2007 the rate of appendectomies by residents was 17.9 % (77 out of 430). Laparoscopic appendectomy was performed in 5.8 % and was only performed by fellows or attending surgeons. From 2008 to 2014 the rate of surgeries by residents significantly increased (p < 0.001) and accounted for 57.6 % (range 19.4-66.9 %).

CONCLUSION

Regardless of the surgical technique used, appendectomy is still a primary training operation for surgical residents. An early and focused training of minimally invasive visceral surgery in the new regulations for continuing medical education starts with laparoscopic appendectomy.

Laparoscopic-assisted single-port appendectomy in children: it is a safe and cost-effective alternative to conventional laparoscopic techniques?

Aim. Laparoscopic-assisted single-port appendectomy (SPA), although combining the advantages of open and conventional laparoscopic surgery, is still not widely used in childhood. The aim of this study was to evaluate the safety and the cost effectiveness of SPA in children. Methods. After institutional review board approval, we retrospectively evaluated 262 children who underwent SPA. The appendix was dissected outside the abdominal cavity as in open surgery. For stump closure, we used two 3/0 vicryl RB-1 sutures. Results. We identified 146 boys (55.7%) and 116 girls (44.3%). Median age at operation was 11.4 years (range, 1.1–15.9). Closure of the appendiceal stump using two sutures (cost: USD 15) was successful in all patients. Neither a stapler (cost: USD 276) nor endoloops (cost: USD 89) were used. During a follow-up of up to 69 months (range, 30–69), six obese children (2.3%, body mass index >95th percentile) developed an intra-abdominal abscess after perforated appendicitis. No insufficiency of the appendiceal stump was observed by ultrasound. Five of them were treated successfully by antibiotics, one child required drainage. Conclusion. The SPA technique with conventional extracorporal closure of the appendiceal stump is safe and cost effective. In our unit, SPA is the standard procedure for appendectomy in children.

Cost-effectiveness of open versus laparoscopic appendectomy: a multilevel approach with propensity score matching

OBJECTIVE

To compare postoperative complications and cost of treatment of laparoscopic (LA) versus open appendectomy (OA) and to identify the most cost-effective treatment method.

METHODS

Patients treated for appendectomy in US veterans health administration (VHA) hospitals in 2005 were included into our study. Direct medical cost and postoperative complications during hospitalization were used as outcomes. Propensity score matching was employed to adjust for baseline imbalances between treatment groups. It was adjusted for the severity of appendicitis, comorbidities according to Charlson Comorbidity Index, and demographic variables. 1:1 optimal matching with replacement was performed. Based on the matched samples, we estimated generalized linear mixed regression models for costs (gamma model) and postoperative complications (logit model). Besides patients' covariates, predictors of hospital resource use and quality of care at the hospital level were considered as explanatory variables.

RESULTS

The total study population comprised of 1,128 patients (370 LA, 758 OA) from 95 VHA hospitals. Type of appendectomy had a significant influence on total costs (P=0.005), with predicted costs for LA being 17.1% lower in comparison to OA (OA: 10,851 US$ [95%CI: 9,707 US$; 12,131 US$] vs. LA: 8,995 US$ [95%CI: 8,073 US$; 10,022 US$]). Differences in the predicted overall postoperative complication were not significant between LA and OA (P=0.6311). Severity of appendicitis had a significant impact on costs and postoperative complications.

CONCLUSION

Predicted costs for LA were 1,856 US$ lower than for OA while the postoperative complication rate did not differ significantly. Thus, LA is the treatment of choice from a provider's perspective.

Trend, variability, and outcome of open vs. laparoscopic appendectomy based on a large administrative database

The aim of this study was to ascertain the variability and 9-year trends in the use of laparoscopic surgery for appendicitis using data from a large administrative database, to compare the effectiveness and efficiency of laparoscopic (LA) and open appendectomy, and to ascertain whether different choices of surgical approach stem from evidence-based recommendations. This was a retrospective cohort study based on administrative data collected from 2000 to 2008 in the Veneto Region (northeastern Italy). Funnel plots were used to display variability between local health units (LHUs). A total of 38,314 appendectomies were performed from 2000 to 2008 in the Veneto Region, 53% of them in males. The laparoscopic procedure was used more often for females than for males of fertile age. There was a significant rising linear trend in the use of LA, with a higher increment among females. The overall regional standardized appendectomy rate was 82.9/10,000. The mean proportion of LAs (27.3%) ranged from 2.8 to 59.4% at different LHUs, and there was no relationship between the volume of procedures undertaken and the proportion of LAs. The proportion of LAs performed in females of reproductive age also varied considerably, on no apparent evidence-based grounds. The analysis of aggregate clinical data is a powerful tool for supporting regional health management units in efforts to improve the quality of medical care and assess the appropriateness of therapeutic or diagnostic approaches in the light of practical guidelines. Variability in the treatment of a given disease that lacks any evidence-based justification remains an important issue in national health systems.

The evolution of the appendectomy: from open to laparoscopic to single incision

Beginning with its initial description by Fitz in the 19th century, acute appendicitis has been a significant long-standing medical challenge; today it remains the most common gastrointestinal emergency in adults. Already in 1894, McBurney advocated for the surgical removal of the inflamed appendix and is credited with the initial description of an Open Appendectomy (OA). With the introduction of minimally invasive surgery, this classic approach evolved into a procedure with multiple, smaller incisions; a technique termed Laparoscopic Appendectomy (LA). There is much literature describing the advantages of this newer approach. To name a few, patients have significantly less wound infections, reduced pain, and a reduction in ileus compared with the OA. In the past few years, Single Incision Laparoscopic Appendectomy (SILA) has gained popularity as the next major evolutionary advancement in the removal of the appendix. Described as a pioneer in the era of "scarless surgery," it involves only one transumbilical incision. Patients are postulated to have reduced post-operative complications such as infection, hernias, and hematomas, as well as a quicker recovery time and less post-operative pain scores, in comparison to its predecessors. In this review, we explore the advancement of the appendectomy from open to laparoscopic to single incision.

[Pediatric appendicitis : Open or laparoscopic appendicectomy in a specialized visceral surgical clinic?]

Following the first description of open appendicectomy using a lateral incision in the right lower abdomen by McBurney in 1894, this intervention was considered to be the standard method for treatment of appendicitis for nearly 100 years. In 1983 the gynecologist Semm presented a new option for the surgical therapy of appendicitis with the implementation of laparoscopic appendicectomy. Since then the indications for laparoscopic therapy have developed from young adults through elderly patients to children, pregnant women and finally to infants and newborns.