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Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study. Eur J Trauma Emerg Surg 2023; 49:33-44. [PMID: 36646862 DOI: 10.1007/s00068-022-02142-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/10/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, 'real-world' clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes. MATERIALS AND METHODS This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days. RESULTS A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24-46] vs 38 [26-55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS. CONCLUSION The linkage of case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.
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Anyomih TT, Jennings T, Mehta A, O'Neill JR, Panagiotopoulou I, Gourgiotis S, Tweedle E, Bennett J, Davies RJ, Simillis C. Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon. Am J Surg 2023; 225:168-179. [PMID: 35927089 DOI: 10.1016/j.amjsurg.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/23/2022] [Accepted: 07/14/2022] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Theophilus Tk Anyomih
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thomas Jennings
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alok Mehta
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Robert O'Neill
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ioanna Panagiotopoulou
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stavros Gourgiotis
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elizabeth Tweedle
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John Bennett
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Justin Davies
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Constantinos Simillis
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Doğru V, Sarıdemir Ünal D, Avanaz A, Yaprak M, Mesci A. Learning-by-teaching coming into play as a reliable trick for lower GI procedures: a learning curve analysis in 13,210 operative logs including the COVID-19 era. Updates Surg 2022; 74:1263-1270. [PMID: 35303256 PMCID: PMC8931573 DOI: 10.1007/s13304-022-01273-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/04/2022] [Indexed: 11/26/2022]
Abstract
After suspecting a plunge in the operative case logs in our clinic, we wanted to explore the COVID-19 impact on surgical training side of the lower gastrointestinal procedures to raise awareness of the possible cracks in the pillars of general surgery residency. Comparing the coronavirus impact to previous years starting from 2014, we examined the procedures of our residents for their roles in the operating room. We performed interrupted time-series analyses to get a sense of the magnitude and then used a new index to identify the trend of change in operator-to-first assistant rate of experience and searched for signs of learning-by-teaching motives. In total, 13,210 operative logs of residents were included; of procedures, 3483 (41%) were emergency. Both overall resident participations and learning-by-teaching dropped during first 3 months, followed by a rebound. The overall operator-to-first assistant rate of experience was 1.06 before and 0.86 after. Emergency procedures, obstruction, perforation, enterostomy closure, appendix, colon, anus and minimally invasive procedures, and COVID-19 were associated with learning-by-teaching (OR and 95% Cl were; 2.20, 1.76–2.75; 0.56, 0.36–0.85; 0.50, 0.38–0.67; 2.29, 1.44–3.63; 11.09, 8.33–14.75; 1.75, 1.32–2.32; 2.56, 2.03–3.22; 0.80, 0.65–0.99 and 1.93, 1.54–2.42, respectively) (p < 0.05). The study provided insights into a vastly underrated surgical education subject: learning-by-teaching. The training index introduced here was a valuable learning curve instrument that has the capacity of comparing different training parameters or different residency programs. The surge in learning-by-teaching after the pandemic was interpreted as a reflex, processing the teaching as a training tool.
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Affiliation(s)
- Volkan Doğru
- Department of Surgery, Colorectal Division, New York University Grossman School of Medicine, New York, NY, USA
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey
| | | | - Ali Avanaz
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey
| | - Muhittin Yaprak
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey
| | - Ayhan Mesci
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey
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Kim CW, Jeon SY, Paik B, Bong JW, Kim SH, Lee SH. Resident Learning Curve for Laparoscopic Appendectomy According to Seniority. Ann Coloproctol 2020; 36:163-171. [PMID: 32054238 PMCID: PMC7392570 DOI: 10.3393/ac.2019.07.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/20/2019] [Indexed: 01/04/2023] Open
Abstract
Purpose This study sought to delineate the learning curve (LC) for laparoscopic appendectomy (LA) in surgical residency according to seniority and experience. Methods Between October 2015 and November 2016, 150 patients underwent LA performed by one of 3 residents (who were in their first [A], second [B], or third [C] year of training) under supervision. The patients were nonrandomly assigned to each resident. Data from a prospectively collected database were reviewed and analyzed retrospectively. Perioperative outcomes including operation time, complications, and conversion were compared among the 3 residents. The LC was evaluated using the moving average method and cumulative sum control chart (CUSUM) for operation time and surgical completion. Results Baseline characteristics and perioperative outcomes were similar among the 3 groups except for age and location of the appendix. The operation time did not vary among the 3 residents (43.9, 45.3, and 48.4 minutes for A, B, and C, respectively; P=0.392). The moving average method for operation time showed a decreasing tendency for all residents. CUSUM results for operation time revealed peak points achieved at the 24th, 18th, and 31st cases for residents A, B, and C, respectively. In terms of surgical failure, residents A, B, and C reached steady states after their 35th, 11th, and 16th cases, respectively. Perforation of the appendix base was the only risk factor for surgical failure. Conclusion The resident LC for LA was 11 to 35 cases according to multidimensional statistical analyses. The accumulation of surgical experience among residents might influence the LC for surgical completion but not that for operation time.
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Affiliation(s)
- Chang Woo Kim
- Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sook Young Jeon
- Department of General Surgery, Graduate School, Kyung Hee University, Seoul, Korea, Seoul, Korea
| | - Bomina Paik
- Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jun Woo Bong
- Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sang Hyun Kim
- Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Suk-Hwan Lee
- Kyung Hee University Hospital at Gangdong, Seoul, Korea
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de'Angelis N, Gavriilidis P, Martínez-Pérez A, Genova P, Notarnicola M, Reitano E, Petrucciani N, Abdalla S, Memeo R, Brunetti F, Carra MC, Di Saverio S, Celentano V. Educational value of surgical videos on YouTube: quality assessment of laparoscopic appendectomy videos by senior surgeons vs. novice trainees. World J Emerg Surg 2019; 14:22. [PMID: 31086560 PMCID: PMC6507219 DOI: 10.1186/s13017-019-0241-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/25/2019] [Indexed: 02/06/2023] Open
Abstract
Background To prepare for surgery, surgeons often recur to surgical videos, with YouTube being reported as the preferred source. This study aimed to compare the evaluation of three surgical trainees and three senior surgeons of the 25 most viewed laparoscopic appendectomy videos listed on YouTube. Additionally, we assessed the video conformity to the published guidelines on how to report laparoscopic surgery videos (LAP-VEGaS). Methods Based on the number of visualization, the 25 most viewed videos on laparoscopic appendectomy uploaded on YouTube between 2010 and 2018 were selected. Videos were evaluated on the surgical technical performance (GOALS score), critical view of safety (CVS), and overall video quality and utility. Results Video image quality was poor for nine (36%) videos, good for nine (36%), and in high definition for seven (28%). Educational content (e.g., audio or written commentary) was rarely present. With the exception of the overall level of difficulty, poor consistency was observed for the GOALS domains between senior surgeons and trainees. Fifteen videos (60%) demonstrated a satisfactory CVS score (≥ 5). Concerning the overall video quality, agreement among senior surgeons was higher (Cronbach’s alpha 0.897) than among trainees (Cronbach’s alpha 0.731). The mean overall videos utility (Likert scale, 1 to 5) was 1.92 (SD 0.88) for senior examiners, and 3.24 (SD 1.02) for trainee examiners. The conformity to the LAP-VEGaS guidelines was weak, with a median value of 8.1% (range 5.4–18.9%). Conclusion Laparoscopic videos represent a useful and appropriate educational tool but they are not sufficiently reviewed to obtained standard quality. A global effort should be made to improve the educational value of the uploaded surgical videos, starting from the application of the nowadays-available LAP-VEGaS guidelines. Electronic supplementary material The online version of this article (10.1186/s13017-019-0241-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicola de'Angelis
- 1Department of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri-Mondor University Hospital, AP-HP, Université Paris Est, 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Paschalis Gavriilidis
- 2Department of General and Colorectal Surgery, Northern Lincolnshire and Goole, Diana Princess of Wales Hospital, Scartho Rd, Grimsby, DN33 2BA UK
| | - Aleix Martínez-Pérez
- 3Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Pietro Genova
- 1Department of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri-Mondor University Hospital, AP-HP, Université Paris Est, 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Margherita Notarnicola
- 1Department of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri-Mondor University Hospital, AP-HP, Université Paris Est, 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Elisa Reitano
- 1Department of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri-Mondor University Hospital, AP-HP, Université Paris Est, 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Niccolò Petrucciani
- 1Department of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri-Mondor University Hospital, AP-HP, Université Paris Est, 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Solafah Abdalla
- 4Department of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Pitié-Salpêtrière University Hospital, AP-HP, Université Pièrre et Marie Curie (UPMC) et Paris-Descartes, Paris, France
| | - Riccardo Memeo
- 5Department of General Surgery, Policlinico A. Rubino, Università di Bari, Bari, Italy
| | - Francesco Brunetti
- 1Department of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri-Mondor University Hospital, AP-HP, Université Paris Est, 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Maria Clotilde Carra
- 6University Paris Diderot, Paris France, Rothschild Hospital, AP-HP, Paris, France
| | - Salomone Di Saverio
- 7Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Valerio Celentano
- 8Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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Yamamoto R, Mokuno Y, Matsubara H, Kaneko H, Iyomasa S. Feasibility and Safety of Laparoscopic Appendectomy Performed by Residents with No Experience in Open Appendectomy. JMA J 2019; 2:54-59. [PMID: 33681513 PMCID: PMC7930708 DOI: 10.31662/jmaj.2018-0037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/12/2018] [Indexed: 01/07/2023] Open
Abstract
Introduction: Open appendectomy for acute appendicitis is a common procedure for surgical residents to perform at the beginning of their training. Recently, many programs have moved to laparoscopic appendectomy as the initial training procedure. However, the feasibility and safety of laparoscopic appendectomy for acute appendicitis performed by surgical residents without any experience of open appendectomy remains controversial. Methods: The records of patients who underwent laparoscopic appendectomy for acute appendicitis between August 2006 and March 2017 were retrospectively reviewed. Patients were assigned to two groups according to whether their procedure was performed by a surgical resident, with no experience of open appendectomy, or a surgical fellow, with adequate open appendectomy experience but no experience with laparoscopic appendectomy. Results: A total of 130 patients were included. Five residents performed 104 procedures, and three fellows performed 26 procedures. The baseline patient characteristics were comparable between groups. The median operative time was comparable (77.0 min vs. 65.5 min; p = 0.771). There were no significant differences in overall complications; with 14 patients (13%) in the resident group and five patients (19%) in the fellow group experienced complications (p = 0.535). No patient required reoperation, and there were no fatalities. The median length of stay was similar (5.0 days vs. 5.5 days; p = 0.430). Conclusions: Laparoscopic appendectomy for acute appendicitis is feasible and safe when performed by surgical residents with no prior open appendectomy experience. It may be performed as the first procedure during surgical training with no adverse effect on patients.
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Affiliation(s)
| | - Yasuji Mokuno
- Department of Surgery, Yachiyo Hospital, Anjo, Japan
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Bhatt NR, Dunne E, Faraz M, Gillis AE, Conlon KC, Paran S, Ridgway PF. Trends in the Use of Laparoscopic Versus Open Paediatric Appendicectomy: A Regional 12-Year Study and a National Survey. World J Surg 2018; 42:3792-3802. [PMID: 29855686 DOI: 10.1007/s00268-018-4688-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND In adult patients, it is generally accepted that laparoscopic appendicectomy (LA) is the predominant operative pathway in treating acute appendicitis. The case for a similar pathway utilising LA in children is less clear. We investigate usage, trends and complications after LA in children in a single co-located adult/paediatric centre with contemporaneous adults as controls. METHODS A retrospective case-control study was conducted over 12 years including patients who underwent appendicectomy, and the paediatric series (<16 years) was divided into age-groups-based quartiles. An anonymous questionnaire-based national survey was circulated among general and paediatric surgeons. RESULTS Of the 5784 appendicectomy patients, 2960 were children. LA rate in paediatric appendicitis was 65%. Yearly trends in LA reached a steady state in both groups after 2010 (Δ 0-1%/year). Rates of LA and LA IAA (respectively) differed significantly between age groups: 60, 3% (0-9 years); 65, 1% (10-13 years); 71, 2% (14-16 years) and 93, 3% (>16 years) (p = 0.001, 0.02). The national survey showed respondents believed LA was not superior to OA in paediatric patients except in terms of cosmesis. There was strong support in the use of LA in older children and children >40 kg. CONCLUSION The use of LA in paediatric appendicectomies in the study region is similar to international rates, but not increasing over time. Irish surgeons still favour OA in younger children and prefer a case-by-case approach rather LA being the preferred pathway. This is despite the regional and international evidence showing favourable outcomes with LA in children.
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Affiliation(s)
- N R Bhatt
- Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
| | - E Dunne
- Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
| | - M Faraz
- Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
| | - A E Gillis
- Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
| | - K C Conlon
- Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
| | - S Paran
- Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
| | - P F Ridgway
- Department of Surgery, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland.
- Department of Surgery, Trinity College Dublin, Tallaght University Hospital, Dublin 24, Ireland.
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Paik KY, Yoon SH, Kim SG. Safety and feasibility of single-port laparoscopic appendectomy as a training procedure for surgical residents. J Minim Access Surg 2018; 16:13-17. [PMID: 30178766 PMCID: PMC6945334 DOI: 10.4103/jmas.jmas_136_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Single-port laparoscopic appendectomy (SPLA) is one of the most commonly performed single-port surgeries worldwide. This study aimed to determine whether the performance of SPLA by residents without sufficient experience as operators of conventional LA (CLA) is safe and feasible. Patients and Methods: Records of patients who underwent LA between March 2017 and February 2018 at a hospital in Korea were retrospectively analysed. Patients aged <18 years or >80 years were excluded from the study. SPLA and CLA were performed by two 2nd-year residents (junior group) and three 3rd-year residents (senior group). Demographic data, perioperative variables and surgical outcomes were compared. Results: During the study period, 154 patients underwent LA (104 SPLA and 50 CLA) performed by surgical residents. No differences were found between the SPLA and CLA groups in demographic data or perioperative variables, except for the drain insertion rate. The SPLA group had significantly shorter mean operation times than did the CLA group. No significant difference was observed between the junior and senior groups in the mean operation time for LA. Perioperative outcomes were not significantly different between groups. Fewer women underwent SPLA performed by 2nd-year residents compared with SPLA performed by 3rd-year residents. However, there were no differences in other general characteristics or perioperative outcomes. Conclusions: SPLA was safe and feasible when performed by junior residents. Surgical residents with sufficient experience as assistants during laparoscopic appendectomies could perform SPLA safely. Furthermore, SPLA could serve as a teaching procedure for surgical residents.
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Affiliation(s)
- Kwang Yeol Paik
- Department of Surgery, College of Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Seung Hoon Yoon
- Department of Surgery, College of Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Sung Geun Kim
- Department of Surgery, College of Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Can laparoscopic appendectomy be safely performed by surgical residents without prior experience of open appendectomy? Asian J Surg 2018; 41:270-273. [PMID: 28139339 DOI: 10.1016/j.asjsur.2016.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 11/28/2016] [Accepted: 12/05/2016] [Indexed: 02/07/2023] Open
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10
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Olijnyk JG, Ferreira PW, Nácul MP, Cavazzola LT. Efficacy and safety of a new single-port model for appendectomy: Experimental study on swine. J Minim Access Surg 2016; 12:129-34. [PMID: 27073304 PMCID: PMC4810945 DOI: 10.4103/0972-9941.158951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
CONTEXT: With the cooperation of surgeons and the engineering division of the company Bhio supply© (Esteio-RS, Brazil), a permanent single port was developed. AIMS: An experimental study assessed the safety and efficacy of the device using a swine laparoscopic appendectomy model (right salpingo-oophorectomy). SETTINGS AND DESIGN: Experimental randomised study. MATERIALS AND METHODS: A total of 20 pigs were randomised for the conventional laparoscopic (CL) three-trocar technique or the single Centry port (CPort) with two working channels, aided by a transparietal thread. Operative times, surgical complications, CO2 use, and pneumoperitoneal pressure were checked. Pressure and chromopertubation tests assessed the ligatures. STATISTICAL ANALYSIS USED: For quantitative outcomes, the Fisher's exact test analysed the samples to compare the surgeons in each group, the ANOVA test for parametric data (volume and pressure) and the Student's t-test for analysis of the fascial incision length. The binaries and isolated occurrence events were described in percentages. RESULTS: For all cases, pneumoperitoneum was maintained. The CPort group, however, resulted in higher CO2 use (26.18 l; standard deviation [SD] ± 11.09) than CL group (5.69 l; SD ± 2.44) (P < 0.01). The mean pressure in CPort group (6.604 mmHg, SD ± 1.793) was comparatively lower than in CL group (7.382 mmHg, SD ± 1.833) (P = 0.363). There was no statistical difference between operative times, ligature safety or adverse surgical events between the different groups and surgeons. CONCLUSION: The surgical technique used with the single port showed no differences in safety and efficacy. Though it does require more CO2 use, its working dynamics did not lead to increased operative times. The results were similar between the two surgeons in the study, suggesting that they can be reproduced.
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Affiliation(s)
- José Gustavo Olijnyk
- Department of Surgery, Post Graduation Program in Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Department of Education and Research (IEP), Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
| | - Paulo Walter Ferreira
- Engineering Division, Nacional Service of Industrial Learning, (SENAI-RS), Porto Alegre, RS, Brazil
| | - Miguel Prestes Nácul
- Department of Surgery, Post Graduation Program in Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Department of Education and Research (IEP), Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
| | - Leandro Totti Cavazzola
- Department of Surgery, Post Graduation Program in Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Department of Education and Research (IEP), Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
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One-trocar versus multiport hybrid laparoscopic appendectomy: What's the best option for children with acute appendicitis? Results of an international multicentric study. Surg Endosc 2016; 30:4917-4923. [PMID: 26944727 DOI: 10.1007/s00464-016-4832-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 02/15/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND One-trocar laparoscopic appendectomy (OTA) is routinely adopted in children with acute appendicitis. In case of a difficult appendectomy, it is necessary to add additional trocar/s to safely complete the procedure. This technique is called multiport hybrid laparoscopic appendectomy (HLA). We aimed to compare the outcome of multiport HLA versus OTA. METHODS We retrospectively reviewed the data of 1,092 patients underwent LA in 5 European centers of pediatric surgery in the last 5 years. We compared 2 groups: G1 of 575 patients (52.6 %) (average age 10 years) underwent OTA and G2 of 517 patients (47.4 %) (average age 8.2 years) underwent multiport HLA. RESULTS No intra-operative complications occurred in both groups. An additional pathology was treated in 12 cases (8 Meckel's diverticulum, 2 carcinoids, 2 ovarian cysts) in G2. Operative time was significantly shorter in G2 compared to G1 (47.8 vs 58.6 min; p < .001). The average analgesic requirement was significantly shorter in G2 compared to G1 (44 vs 56 h; p < .001). As for postoperative complications, the incidence of port-site infections was similar between the two groups, while the incidence of postoperative abdominal abscesses (PAA) was significantly higher in G1 compared to G2 (4.7 vs 0.2 %; p < .001). The cosmetic outcome was excellent in all patients of both groups. A subgroup analysis between complicated and uncomplicated appendicitis showed that only in complicated cases, the average operative time, the average VAS pain score, the average analgesic requirements and the incidence of PAA were significantly higher in OTA group compared to multiport HLA group (p < .001). CONCLUSIONS Our results suggest that OTA is a valid and safe procedure for the uncomplicated cases, while additional trocars are required in case of complicated appendicitis. Multiport HLA significantly reduces the operative time, the incidence of abdominal abscesses and the analgesic requirements compared to OTA.
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Transition towards laparoscopic appendicectomy at a UK center over a 7-year period. Surg Laparosc Endosc Percutan Tech 2015; 25:59-63. [PMID: 24732741 DOI: 10.1097/sle.0000000000000017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute appendicitis remains the most common indication for emergency abdominal surgery in the United Kingdom. Although laparoscopic appendicectomy has demonstrable advantages over open appendicectomy, uptake has not been universal. The aims of this study were to describe trends in laparoscopic appendicectomy in a District General Hospital in Scotland. METHODS Retrospective review of appendix histopathology records within NHS Fife between 2003 and 2010. Note review of cases of acute appendicitis managed with laparoscopic appendicectomy was performed. Perioperative variables in perforated and nonperforated appendicitis were compared. A multivariate logistic regression analysis to determine factors associated with developing complications was performed. RESULTS Between 2003 and 2010, 237 laparoscopic appendicectomies were performed. The rate of laparoscopic appendicectomy increased from 2.5% in 2003 to 78% in 2010. In 50% of cases, the trainee surgeon was the primary operator. Complications occurred in 9.6% and the mortality rate was 0.4%. No factors on multivariate logistic regression predicted development of complications. CONCLUSIONS We describe a change in practice towards laparoscopic appendicectomy for the treatment of acute appendicitis over a 7-year period. Furthermore, laparoscopic appendicectomy is associated with acceptable morbidity rates.
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Szasz P, Louridas M, Harris KA, Aggarwal R, Grantcharov TP. Assessing Technical Competence in Surgical Trainees. Ann Surg 2015; 261:1046-55. [DOI: 10.1097/sla.0000000000000866] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Use of Failure Modes, Effects, and Criticality Analysis to Compare the Vulnerabilities of Laparoscopic Versus Open Appendectomy. J Patient Saf 2015; 11:105-9. [PMID: 23860194 DOI: 10.1097/pts.0b013e318297febc] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shaikh FM, Bajwa R, McDonnell CO. Management of appendiceal stump in laparoscopic appendectomy--clips or ligature: a systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A 2014; 25:21-7. [PMID: 25548964 DOI: 10.1089/lap.2014.0470] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Appendicular stump closure is a crucial step during laparoscopic appendectomy. Recently, endoclips (ECs) have been described for ligation of the appendicular stump. The objective of this review was to compare outcomes with EC versus endoligature (EL) for appendiceal stump closure during laparoscopic appendectomy. MATERIALS AND METHODS A literature search of Medline, Embase, Cochrane Database, and Google Scholar was performed to identify studies comparing use of EL versus EC in laparoscopic appendectomy between January 1992 and September 2013. Reviews of each study were conducted, and data were extracted. The random-effects model was used to combine data, and between-study heterogeneity was assessed. RESULTS Seven of the 101 identified studies met the inclusion criteria: four randomized controlled trials and three case controlled series. For the primary outcome of perioperative and postoperative complications, there was no significant difference between the EC versus EL groups. No differences were noted in length of hospital stay. However, a significant reduction in operative time was observed with EC as opposed to EL (standardized mean difference=-0.90, 95% confidence interval=-1.26 to -0.54, P=.001). Moreover, EC procedures were less expensive than EL procedures. CONCLUSIONS EC application in the management of appendiceal stump during laparoscopic appendectomy appears to be simple, efficacious, safe, and a cost-effective alternative.
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Affiliation(s)
- Faisal M Shaikh
- Department of Surgery, Royal College of Surgeons in Ireland , Dublin, Republic of Ireland
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Olijnyk JG, Pretto GG, da Costa Filho OP, Machado FK, Silva Chalub SR, Cavazzola LT. Two-port laparoscopic appendectomy as transition to laparoendoscopic single site surgery. J Minim Access Surg 2014; 10:23-6. [PMID: 24501505 PMCID: PMC3902554 DOI: 10.4103/0972-9941.124460] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 05/22/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND: According to the precepts of reduced surgical trauma and better cosmesis, an intermediate laparoscopic appendectomy technique between the conventional three-trocar procedure and Laparoendoscopic Single Site Surgery (LESS) was performed, based on literature review and experience of the surgical team. PATIENTS AND METHODS: Patients with early stage acute appendicitis and a favourable anatomical presentation were selected. The procedure was performed with two ports: A 10 mm trocar at the umbilicus site for laparoscope and a 5 mm one just above the pubic bone for grasper. The appendix was secured by external wire traction through a right iliac fossa puncture with 14-gauge intravenous catheter. RESULTS: From August 2009 to December 2012, we performed 42 cases; two required conversion to a conventional laparoscopic technique. There were no complications in the remaining, no wound infections and a mean operation time of 64.5 minutes. CONCLUSION: The use of two-port laparoscopic appendectomy can act as a LESS intermediate step procedure, without loss of instrumental triangulation and maintenance of appropriate counter-traction. This technique can be used as an alternative to the three-port laparoscopic procedure in patients with initial presentation of appendicitis and a favourable anatomical position.
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Affiliation(s)
- José Gustavo Olijnyk
- Department of Surgery, Hospital Militar de Área de Porto Alegre, Rio Grande do Sul, Brazil ; Department of Surgery, Hospital de Clínicas, Federal University of Rio Grande do Sul State, Porto Alegre, Rio Grande do Sul, Brazil
| | - Guilherme Gonçalves Pretto
- Department of Surgery, Hospital Militar de Área de Porto Alegre, Rio Grande do Sul, Brazil ; Department of Surgery, Hospital de Clínicas, Federal University of Rio Grande do Sul State, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Fernando Koboldt Machado
- Institute of Education and Research, Hospital Moinhos de Vento de Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Leandro Totti Cavazzola
- Department of Surgery, Hospital de Clínicas, Federal University of Rio Grande do Sul State, Porto Alegre, Rio Grande do Sul, Brazil
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Wang CC, Tu CC, Wang PC, Lin HC, Wei PL. Outcome comparison between laparoscopic and open appendectomy: evidence from a nationwide population-based study. PLoS One 2013; 8:e68662. [PMID: 23874710 PMCID: PMC3709901 DOI: 10.1371/journal.pone.0068662] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 05/31/2013] [Indexed: 02/06/2023] Open
Abstract
Background Mounting evidence supports the use of laparoscopic techniques for the treatment of simple appendicitis. However, most of the advantages of these techniques are of limited clinical relevance. This study compares the treatment outcomes of laparoscopic appendectomies and open appendectomies performed in Taiwan. Methods This study uses data from the 2007 to 2009 Taiwan National Health Insurance Research Database. The study sample included 65,339 patients, hospitalized with a discharge diagnosis of acute appendicitis (33.8% underwent laparoscopic appendectomy). A generalized estimated equation (GEE) was performed to explore the relationship between the use of laparoscopy and 30-day re-admission. Hierarchical linear regressions were performed to examine the relationship between the use of laparoscopy, the length of stay (LOS), and the cost per discharge. Results A significantly lower proportion of patients undergoing laparoscopic appendectomies were re-admitted within 30 days of their index appendectomy, in comparison to patients undergoing open appendectomies (0.66% versus 1.925, p<0.001). Compared with patients undergoing open appendectomies, patients undergoing laparoscopic appendectomies had a shorter LOS (4.01 versus 5.33 days, p<0.001) and a higher cost per discharge (NT$40,554 versus NT$38,509, p<0.001. In 2007, the average exchange rate was US$1 = NT$31.0). GEE revealed that the odds ratio of 30-day readmission for patients undergoing laparoscopic appendectomy was 0.38 (95% CI = 0.33–0.46) that of patients undergoing open appendectomies, after adjusting for surgeon, hospital, and patient characteristics, as well as for the clustering effect of particular surgeons and the propensity score. Conclusion This study found that laparoscopic appendectomies had a lower 30-day re-admission rate, and a shorter LOS, but a slightly higher cost per discharge than open appendectomies.
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Affiliation(s)
- Chien-Che Wang
- Department of General Surgery, PoJen General Hospital, Taipei, Taiwan,
| | - Chao-Chiang Tu
- Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Pi-Chieh Wang
- Department of Family Medicine, PoJen General Hospital, Taipei, Taiwan
| | - Herng-Ching Lin
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Po-Li Wei
- Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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van der Leeuw RM, Lombarts KMJMH, Arah OA, Heineman MJ. A systematic review of the effects of residency training on patient outcomes. BMC Med 2012; 10:65. [PMID: 22742521 PMCID: PMC3391170 DOI: 10.1186/1741-7015-10-65] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 06/28/2012] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes. METHODS The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes. RESULTS Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design. Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained. CONCLUSIONS The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.
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Affiliation(s)
- Renée M van der Leeuw
- Professional Performance Research Group, Department of Quality Management and Process Innovation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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Vettoretto N, Gobbi S, Corradi A, Belli F, Piccolo D, Pernazza G, Mannino L. Consensus conference on laparoscopic appendectomy: development of guidelines. Colorectal Dis 2011; 13:748-54. [PMID: 21651696 DOI: 10.1111/j.1463-1318.2011.02557.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Laparoscopic appendectomy (LA) is not yet unanimously considered the gold standard treatment for appendicitis, despite the increasing use of advanced laparoscopic operations and the high incidence of the disease. METHOD Due to the results of an audit which classified LA as widespread in Italy, a Consensus Conference was organized, in order to give evidence-based answers to the most debated problems regarding the operation. After researching the literature, a panel of 20 experts were selected and interviewed on hot topics; a subsequent discussion using the Delphi methodology was utilized in the course of the consensus conference and submitted to the evaluation of an audience of surgeons. RESULTS Checkpoint statements were formulated whenever an agreement was reached. A level of evidence was then assigned to single statements and the process revised by two external reviewers. CONCLUSION Consensus development guidelines are herein reported and regard diagnostic pathway, diagnostic laparoscopy, indications, behaviour in case of innocent appendix, technical aspects, learning curve; however, some questions remain unsolved due to the lack of evidence.
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Affiliation(s)
- N Vettoretto
- Laparoscopic Surgery Unit, M Mellini Hospital, Chiari, Italy.
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A brief review of laparoscopic appendectomy: the issues and the evidence. Tech Coloproctol 2010; 15:1-6. [PMID: 21086013 DOI: 10.1007/s10151-010-0656-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 10/28/2010] [Indexed: 01/09/2023]
Abstract
Laparoscopic appendectomy was first performed more than 25 years ago. We performed a systematic literature search on laparoscopic appendectomy and selected related topics. The technique should be considered the gold standard for surgical removal of the appendix in women of childbearing age (level of evidence Ia). There is minor but consistent evidence that it should also be advocated for men (level of evidence III), obese (level of evidence III), and elderly (level of evidence IIb) patients, while there is some evidence of unfavorable results on pregnant women (level of evidence IIb). Studies reporting higher incidence of intra-abdominal abscesses after laparoscopic appendectomy are difficult to interpret due to a lack of standardization of the operative technique and lack of uniformity related to the different grades of disease (ranging from uninflamed appendix to diffuse peritonitis, gangrene, or perforation of the organ). As far as surgical technique, the three-port procedure is superior to needleoscopy and single port access (level of evidence Ia). Costly high-tech instruments for dissection are mostly unnecessary (level Ib). Mechanical closure of the stump might prove safer (level Ib). The quantity of peritoneal lavage fluid is generally scanty (level III), and abdominal drains are not useful (level Ia). Fast-track protocols should be implemented (level Ic). Training and technical standardization are the key to devising future trials on this topic.
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Kim SY, Hong SG, Roh HR, Park SB, Kim YH, Chae GB. Learning curve for a laparoscopic appendectomy by a surgical trainee. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2010; 26:324-8. [PMID: 21152134 PMCID: PMC2998026 DOI: 10.3393/jksc.2010.26.5.324] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 09/28/2010] [Indexed: 11/17/2022]
Abstract
Purpose The laparoscopic appendectomy has been a basic part of the principal of a more complex laparoscopic technique for the surgical trainee. As the number of laparoscopic appendectomies performed by surgical trainees has increased, we are trying to check the stability of, which is controversial, and the learning curve associated with a laparoscopic appendectomy. Methods We studied the demographics, histologic diagnoses, operative time, the number of complicated cases, and hospital duration of one hundred and three patients who underwent an open appendectomy (group A, 53) or a laparoscopic appendectomy (group B, 50) retrospectively through a review of their medical records. The learning curve for the laparoscopic appendectomy was established through the moving average and ANOVA methods. Results There were no differences in the operative times (A, 64.15 ± 29.88 minutes; B, 58.2 ± 20.72 minutes; P-value, 0.225) and complications (A, 11%; B, 6%; P-value, 0.34) between group A and group B. Group B was divided into group C who underwent the operation in the early period (before the learning curve) and group D who underwent the operation in the later period (after the learning curve). The average operative time for group C was 66.83 ± 21.55 minutes, but it was 45.25 ± 10.19 minutes for group D (P-value < 0.0001). Although this difference was statistically significant, no significant difference in the complication rate was observed between the two groups. Conclusion A laparoscopic appendectomy, compared with an open appendectomy, performed by a surgical trainee is safe. In this study, the learning curve for a laparoscopic appendectomy was thirty cases.
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Affiliation(s)
- Song Yi Kim
- Department of Surgery, Kangwon National University School of Medicine, Chuncheon, Korea
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Lin YY, Shabbir A, So JBY. Laparoscopic appendectomy by residents: evaluating outcomes and learning curve. Surg Endosc 2010; 24:125-30. [PMID: 19760332 DOI: 10.1007/s00464-009-0691-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 05/01/2009] [Indexed: 12/23/2022]
Abstract
BACKGROUND Laparoscopic appendectomy is being performed increasingly, worldwide. To the resident, it provides a valuable opportunity to master basic laparoscopic skills. Studies have shown that laparoscopic appendectomy performed by residents is safe. However, to date, there is no clear evidence for the minimum number of these operations required to achieving proficiency and safety. The aim of this study is to assess the outcome of laparoscopic appendectomies performed by surgical residents and to evaluate the effect of learning curve on patient outcome. METHODS All patients undergoing laparoscopic appendectomies performed by six residents during the study period were reviewed. Data on patient demographics,clinical and histological diagnosis, and outcome variables including operative duration, conversion to open surgery, complications, and length of stay were analyzed. We evaluated the effect of the learning curve by dividing patients into two groups: a first group consisting of the initial 20 patients and a second group consisting of the next 20 patients operated upon independently by each resident. Variables were analyzed to determine any difference between the two groups. RESULTS Three hundred six patients with the clinical diagnosis of acute appendicitis underwent laparoscopic appendectomy by residents. Mean operative time was 83.8 min. Of patients, 14.6% required conversion to open surgery. Mean length of hospitalization was 2.82 days. Operative duration and complication rate were significantly reduced with increasing experience of residents. The length of hospital stay and conversion rate to open surgery remained unchanged. CONCLUSION Operative duration and complications can be reduced with increasing experience of a resident.
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Affiliation(s)
- Yap Yan Lin
- Department of Surgery, National University Hospital, Singapore, Singapore
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Hsieh CS, Chen YL, Lee MH, Chang HC, Chen ST, Kuo SJ. A lower costly laparoscopic appendectomy: our experience of more than 2000 cases. Int J Surg 2009; 8:140-3. [PMID: 20005313 DOI: 10.1016/j.ijsu.2009.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 11/26/2009] [Indexed: 11/18/2022]
Abstract
Many authors emphasize the advantages of laparoscopic techniques in their experience, including the excellent cosmetic results, reduced postoperative pain, rapid functional recovery, lower incidence of adhesions, wound infections and believe that laparoscopic appendectomy is a reliable operation for treating acute appendicitis. Laparoscopic appendectomy has become a standard procedure in the treatment of acute appendicitis in our department since it was introduced in 2003. There are 414 patients underwent laparoscopic appendectomy and 37 patients underwent open appendectomy in our department in 2008. More than 2000 laparoscopic appendectomies were performed in our department during 2003-2009. However, open appendectomy is still the standard procedure in many Taiwan and worldwide hospitals. One of the reasons is that the operating costs incurred for laparoscopic appendectomy are higher than that of open appendectomy. We describe, herein, an access technique utilizing existing instrumentation that is reliable and easy.
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Affiliation(s)
- Ching-Shui Hsieh
- Department of General Surgery, Changhua Christian Hospital, Taiwan
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Hussain A, Mahmood H, Singhal T, Balakrishnan S, El-Hasani S. Laparoscopic appendectomy in a district hospital: does the technique influence the outcome? J Laparoendosc Adv Surg Tech A 2008; 18:204-8. [PMID: 18373444 DOI: 10.1089/lap.2007.0077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Laparoscopic appendicectomy (LA) has proved to be a safe, effective procedure for appendicitis. However, its application in the current surgical practice is still far less than the laparoscopic cholecystectomy. Therefore, its role as a gold standard operation for acute appendicitis (AA) is less well established. METHODS Between September 1999 and January 2007, a series of 200 patients (112 female, 88 male) with AA underwent LA in our surgical unit. A single consultant surgeon performed all the cases. Outcomes, including the length of stay, operative time, and complications, were evaluated. Follow-up assessment of patients was performed by outpatient appointment. RESULTS The indications for LA were clinical diagnosis of AA for 177 patients (85%) and interval appendicectomy for 23 patients (15%). The mean age of these patients was 18.8 years (range, 8-83). Operative diagnosis of inflamed appendix, including perforated appendicitis in 9 patients (7.5%), was made in 139 patients (69.5%), and the appendix was macroscopically normal in 40 patients (20%). Different pathologies were found in 21 patients (11.5%). Of the 40 (20%) macroscopically normal appendices, 10 (5%) appendices were reported as inflamed by histopathology examination. The operative time ranged from 13 to 62 minutes, with a mean of 18 minutes. Minor morbidity was reported in 11 patients (5.5%) CONCLUSION In experienced hands using a meticulous technique, LA provides diagnostic and therapeutic options, decreased operative time, rapid recovery, short hospital stay, fewer postoperative complications, and no intra-abdominal abscesses. Appendicectomy has cured right iliac fossa pain in almost all the patients.
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Affiliation(s)
- Abdulzahra Hussain
- Department of General Surgery, Princess Royal University Hospital, Kent, UK.
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Paterson HM, Qadan M, de Luca SM, Nixon SJ, Paterson-Brown S. Changing trends in surgery for acute appendicitis. Br J Surg 2008; 95:363-8. [PMID: 17939131 DOI: 10.1002/bjs.5961] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Laparoscopic appendicectomy (LA) offers faster recovery times and a reduced rate of wound infection compared with open appendicectomy (OA) but may be associated with more intra-abdominal abscesses. This study examines the changing trends in management of appendicitis in a regional setting during service reorganization and compares infective complication rates for each procedure. METHODS Data were retrieved from the Lothian Surgical Audit database on 1824 patients treated for appendicitis by OA or LA during equal 31-month periods before and after service reorganization in August 2002. Outcome measures were duration of admission, recovery time from operation to discharge and reintervention for infective complications. Analysis was by intention to treat. RESULTS The rate of LA in Lothian increased from 29.9 to 39.4 per cent (P < 0.001) after subspecialist service reorganization. Recovery time from operation to discharge was significantly shorter after LA than OA when results were stratified with respect to sex (mean 2.5 versus 4.4 days respectively in women, P < 0.001; 2.7 and 3.1 days in men, P = 0.023), timing of surgery (2.7 versus 3.3 days before subspecialization, P = 0.007; 2.5 versus 3.6 days after subspecialization, P < 0.001) and whether appendicitis was associated with peritoneal contamination (2.2 versus 3.0 days for uncontaminated surgery, P < 0.001; 4.3 versus 5.1 days for contaminated surgery, P = 0.060). Peritoneal contamination at primary operation was the only independent risk factor that predicted reintervention for infective complications. CONCLUSION LA is associated with a shorter hospital stay from operation to discharge than OA, with no evidence of an increased rate of intra-abdominal infective complications.
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Affiliation(s)
- H M Paterson
- Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK
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