Challenges to implement laparoscopic appendectomy as the first-line treatment for acute appendicitis: a fifteen-year experience in a tertiary hospital in Brazil

Abstract

Background: the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil.

Materials and methods: retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes.

Results: we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team's adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period.

Conclusion: the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

Figure 1. Analysis of the actions performed in an emergency department of a public hospital in Brazil during a 15-year period (2004 to 2018) for the implementation of laparoscopic access in appendectomies. 1 - Minimally invasive surgery training for residents (2007) → 16% laparoscopic appendectomies (2008); 2 - Laparoscopic stump closure using metal clips (2008) → 43% laparoscopic appendectomies (2009); 3 - Full-time availability of laparoscopic instruments for emergency surgeries (2011) → 26% laparoscopic appendectomies (2012); 4 - Third-party contract for maintenance of the laparoscopic instrument and implementation of polymeric clips for stump closure (2013) → 87% laparoscopic appendectomies (2014). Timeline comparisons were performed using the Chi-Square test for tendency, p<0.001.

Figure 2. Laparoscopic stump closure in an emergency department of a public hospital in Brazil during a 15-year period (2004 to 2018). Clip: LT 400 until 2012, hem-o-lok clips from 2013 onwards. Chi-Square for trend test, p=0.0020.

Figure 3. Laparoscopic stump closure in an emergency department of a public hospital in Brazil in the period from 2014 to 2018. Clip = hem-o-lok clips. Simple linear regression method.

Figure 4. Laparoscopic appendectomy operative time (in minutes) in an emergency department of a public hospital in Brazil from 2014 to 2018. Data are expressed as median. Nonlinear regression method, R square=0.7293.