Improving Outcomes in Laparoscopic Appendicectomy (LA)

1. Improving Outcomes in Laparoscopic Appendicectomy (LA) E Dinneen, T Tilmann, J Preston, MS Nair, R Navaratnam. North Middlesex University Hospital, Sterling Way, London, United Kingdom. • Results • No deaths • Insufficient power to detect significant differences in Endo–GIA vs. endoloop post-operative complication rates. • Endo-GIA vs. endoloop no significant difference in duration of surgical procedure. • Methods • Retrospective cohort study. • All LAs performed between March 2007 and January 2012 were identified through theatre log books and hospital electronic informatics system. • Information gathered from patient records: • Admission chronology and biochemistry, • Intra-operative subjective grade of appendiceal inflammation (no inflammation (0), inflammation (1), perforation (2)) • Post-operative complications and LOS. • Time spent intubated as a surrogate for duration of operation • Exclusion criteria: open appendicectomy, interval LA and incomplete data. • Primary outcome measures: mortality, post-operative complications • Secondary outcome data: post-op LOS, time spent intubated, duration of operation • Statistical Analysis performed with SPSS Statistics 20.0 package • Introduction • Appendicectomy is the most common surgical procedure in the world. Traditional open surgical techniques are steadily being replaced by laparoscopic approaches because of improved morbidity profiles. LA is increasingly performed in hospitals outside specialist centres. • Performance analysis to assess safety and identify areas for improvement is vital for a newly introduced technique in any hospital. • Controversial areas include whether operation length is shortened and real costs reduced by using the more expensive Endo-GIA stapling devise (€230.7 ) vs the cheaper Endo-loop ligature ( €28.85 )[1, 2, 3,4]. • Debate surrounds whether reduced time from admission to LA shortens post-operative inpatient hospital stay. [5, 6] • Results: Post-operative Length of Stay (LoS) • Mean Post-operative LoS; 76.7 h. (95% CI 66.0 h to 87.4 hrs) • When ‘inflamed appendix’ was identified by operator at operation, the use of Endo-GIA was associated with a reduction in Post-operative LoS from 59.7 hours to 35 hours. • Reduction of Post-operative LoS of 24.7 h (± 9.57 h). • Cost of 24 hours in a surgical bed in our hospital is £240. • No difference when ‘no appendicitis’ and ‘perforated appendicitis’ groups were included in Endo-GIA vs. Endo-loop Post-operative LoS analysis was performed. Endo-loop: n=36, Mean LoS = 59.7 h ±39.5 Endo-GIA: n=8, Mean LoS = 35.0 h ± 20.0 24.7 h r± 9.57 reduction in post-operative LoS. P < 0.05 (Mann-Whitney U Test) • Aims • To evaluate safety and outcomes during the ‘advent’ of LA in a London District General teaching hospital. • To identify pre & peri-operative variables which impact on LA outcomes and cost of inpatient stay. • To examine whether use of Endo-loop versus Endo-GIA techniques influenced length of operative procedure (time spent intubated). • To consider whether use of Endo-loop versus Endo-GIA techniques influenced Post-operative Length of Stay. • Discussion • Study limited in retrospective design. • Representative of the work load at a typical UK DGH. • Local perspectives on international LA issues. • Demonstrates largely successful increasing implementation of LA . • No evidence of decreased duration of operation nor decreased rates of complications using Endo-GIA. • However, use of Endo-GIA is supported in patients with confirmed uncomplicated appendicitis as is associated with shorter post-operative length of stay thereby improving patient experience and reducing hospital costs. *2012 to January 31st only. • LA • n = 107 • 15% of total number of Appendectomies • 63.6% female • Mean age 28.4 • Age Range 9-70yrs References Delibegovic S, Matovic E. Hem-o-lok clips in securing off the base of the appendix during laparoscopic appendectomy. SurgEndosc. 2009; 23(12): 2851-2854. Gomes CA, Nunes TA, Soares C Jr, Gomes CC. The appendiceal stump closure during laparoscopy: historical, surgical and future perspecitves. SurgLaparoscEndoscPercutan Tech. 2012; 22(1): 1-4. Ates M, Dirican A, Ince V, Ara C, Isik B, Yilmaz S. Comparison of intracorporeal knot-tying suture (polyglactin) and endoclips in laparoscopic appendiceal stump closure: a prospective randomized study. SurgLaparoscEndoscPercutan Tech. 2012; 22(3): 226-231. Delibegovic S. The use of a single Hem-o-lok clip in securing the base of the appendix during laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A. 2012 Jan; 22(1): 85-87. Nagpal K, Udqiri N, Sharma N, Curras E, Cosgrove JM, Farkas DT. Delaying an appendectomy: is it safe? Am Surg. 2012 Aug; 78(8): 897-900. Busch M, Gutzwiller FS, Aelig S, Kuettel R, Metzger U, Zingg U. In-hospital delay increases the risk of perforation in adults with appendicitis. World J Surg. 2011; 35(7): 1626-1633.