Single-incision laparoscopically assisted appendectomy performed by residents is safe and feasible: A single institution, retrospective case series

Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon

BACKGROUND

Appendectomy is a benchmark operation for trainee progression, but this should be weighed against patient safety and perioperative outcomes.

METHODS

Systematic literature review and meta-analysis comparing outcomes of appendectomy performed by trainees versus trained surgeons.

RESULTS

Of 2086 articles screened, 29 studies reporting on 135,358 participants were analyzed. There was no difference in mortality (Odds ratio [OR] 1.08, P = 0.830), overall complications (OR 0.93, P = 0.51), or major complications (OR 0.56, P = 0.16). There was no difference in conversion from laparoscopic to open surgery (OR 0.81, P = 0.12) and in intraoperative blood loss (Mean Difference [MD] 5.58 mL, P = 0.25). Trainees had longer operating time (MD 7.61 min, P < 0.0001). Appendectomy by trainees resulted in shorter duration of hospital stay (MD 0.16 days, P = 0.005) and decreased reoperation rate (OR 0.78, P = 0.05).

CONCLUSIONS

Appendectomy performed by trainees does not compromise patient safety. Due to statistical heterogeneity, further randomized controlled trials, with standardized reported outcomes, are required.

Learning curve for single-incision laparoscopic totally extraperitoneal inguinal hernia repair

INTRODUCTION

The learning curve for totally extraperitoneal repair (TEP) is longer and steeper than that for transabdominal preperitoneal repair (TAPP) due to the preperitoneal view to which the surgeon is not accustomed and the limited working space. The aim of this study was to clarify the learning curve for SILS-TEP.

METHODS

A retrospective analysis of 80 consecutive patients with unilateral inguinal hernia was performed. All patients underwent elective SILS-TEP performed by a single learning surgeon with a teaching assistant between July 2016 and March 2018 at Kinki Central Hospital.

RESULTS

The operative time decreased gradually after 20 cases and stabilized after 40 cases. The first 40 cases were categorized as the learning period group, and the remaining 40 cases were categorized as the experienced period group. More patients received antithrombotic therapy in the experienced period than in the learning period (P < 0.05). The median operative time was 107 and 60 min in the learning period and the experienced period, respectively (P < 0.05). There were no significant differences in blood loss peritoneal injury, conversion to a different procedure, postoperative hospital stay, complications, and recurrence between the two groups. No major complications or hernia recurrence were noted during follow-up.

CONCLUSIONS

The learning curve for SILS-TEP might take 40 cases to reduce the operative time. SILS-TEP can be performed safely by a learning surgeon with a teaching assistant.

Feasibility and Safety of Single-Incision Laparoscopic Appendectomy by a Surgical Resident under Supervision of a Staff Surgeon

Purpose

This study was aimed at reporting our experience with single-incision laparoscopic appendectomies (SILA) performed by a surgical resident, and to evaluate the safety and feasibility of the procedure, together with a comparison of the outcomes of the same procedure performed by a staff surgeon.

Methods

We conducted a retrospective case series analysis of 60 consecutive patients who underwent SILA. Two surgeons, an attending staff surgeon and a second-year surgical resident, performed the SILA procedures. SILA procedures performed by the resident were intraoperatively guided and supervised by the staff surgeon.

Results

A total of 60 case-matched patients with acute appendicitis underwent a SILA performed by either the resident or attending staff. There was no difference in patient demographics between the two groups of patients. The mean operation time was longer in the resident group than in the staff group (43.2±6.0 minutes vs. 32.9±10.5 minutes, p<0.001). There was no significant difference in the operative data between the two groups. No conversion to an open procedure occurred in either group. Postoperative pain, time to onset of oral intake, and number of days of postoperative hospital stay were similar in both groups.

Conclusion

SILA procedures performed by a resident are safe and feasible despite longer operation times. Perioperative supervision and guidance by an attending staff surgeon may facilitate surgical outcomes.

Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy

Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient’s factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon’s skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.