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Background: Peritoneal drainage (PD) following laparoscopic appendectomy(LA) has long been considered beneficial for appendicitis patients, especially those with complicated appendicitis. However, recent research has raised doubts about the advantages of PD, as it not only fails to reduce postoperative complications but also prolongs the operative duration and hospital stay and incurs higher medical expenses. Given this controversy, we conducted a meta-analysis to determine whether drainage is necessary after LA for complicated appendicitis. This meta-analysis had registered in PROSPERO(ID: CRD42023472382)., Objective: This study assessed current evidence regarding the efficacy, safety, and potential benefits of drainage versus no drainage following LA for complicated appendicitis., Methods: We conducted a comprehensive search of PubMed, Springer, and the Cochrane Library using the search terms "appendicitis", "laparoscopic appendectomy", and "drain" or "drainage" for studies published between January 1, 2000, and December 31, 2022. We employed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria for study inclusion and exclusion. Primary outcomes included postoperative intra-abdominal abscess, postoperative intestinal obstruction, postoperative stump leakage, wound infection and postoperative visual analog scale(VAS) score, while secondary outcomes consisted of operative time, postoperative recovery time and total hospitalization duration. Studies with at least two outcomes were considered for meta-synthesis. Depending on I 2 values, fixed- or random effects models were used for data synthesis. Pooled odds ratios (OR) and weighted mean differences (WMD) were calculated for outcome comparisons between PD and no peritoneal drainage (NPD). Sensitivity analysis and meta-regression were performed to assess and investigate inter-study heterogeneity., Results: After conducting our literature search and screening, twelve studies were analyzed, comprising 3374 cases. During the comparison of primary outcomes between PD and NPD, the incidence of wound infection and postoperative VAS score were significantly higher in the PD group(P < 0.05). While during the comparison of secondary outcomes, the operative duration, postoperative recovery time and hospitalization duration were significantly longer in the PD group than in the NPD group(P < 0.05)., Conclusion: PD following LA for complicated appendicitis not only increases the incidence wound infection and aggravate patients' postoperative pain, but also prolongs the operative duration, postoperative recovery time and hospitalization duration. Therefore, routine PD after LA for acute complicated appendicitis is not recommended., Competing Interests: Declarations Ethics approval and consent to participate Ethics of the Approval Committee of the research institution names Ethics Committee of Huadu District People’s Hospital of Guangzhou. This is a meta-analysis and do not involve any human and/ or animal studies, ethical approval was not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Purpose: Practice patterns of same-day discharge for pediatric laparoscopic appendectomy for non-perforated appendicitis are not well-analyzed. Our aim is to evaluate current practice patterns and outcomes of same-day discharge for these patients., Methods: NSQIP-P retrospective registry identified patients (2017-2021) who underwent laparoscopic appendectomy for non-perforated appendicitis. Annual same-day discharge (SDD) rate was determined. SDD patients were compared to those discharged postoperative days 1-2 (non-SDD). Sub-group analysis was performed on ICD-10 code K35.30. Regression was performed., Results: Overall, 67,214 patients were identified. The SDD rate increased from 33.3% (2017) to 52.5% (2021) with decreased 30-day readmissions between SDD and non-SDD (1.3% vs 2.1%, p < 0.001). Sub-group analysis identified 7,330 patients with SDD rates from 50.7% (2019) to 60.4% (2021) with decreased 30-day readmissions (1.3% vs 2.1%, p < 0.001) for SDD versus non-SDD. No increase in adverse events for SDD occurred in either analysis. Regression identified esophageal/gastric/intestinal diseases increased odds of early readmission or reoperation (OR 1.85, p = 0.042)., Conclusion: Same-day discharge after pediatric laparoscopic appendectomy for non-perforated acute appendicitis continues to increase in frequency without a significant increase in adverse outcomes. SDD rates are 20-30% lower than previously published single-center studies, indicating there is a likely a larger percentage of patients that could discharge same-day., Level of Evidence (i-V): Level III., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Acute appendicitis is the most common cause of abdominal pain requiring surgery, usually managed with laparoscopic appendectomy. In Denmark, the standard postoperative treatment for complicated cases involves intravenous antibiotics. This study compares peroral versus intravenous antibiotics in the context of fast-track surgery and Enhanced Recovery After Surgery (ERAS) protocols. Our objective is to evaluate the impact of peroral versus intravenous antibiotics on patient-reported outcomes following laparoscopic appendectomy for complicated appendicitis., Methods: This was a sub-study within a broader Danish cluster-randomized non-inferiority trial conducted at Zealand University Hospital, focusing on adult patients undergoing laparoscopic appendectomy for complicated appendicitis. Participants were randomized into two groups: one receiving a three-day course of peroral antibiotics and the other intravenous antibiotics after surgery. Recovery quality was assessed on the third postoperative day using the Quality of Recovery-15 (QoR-15) questionnaire., Results: The study included 54 patients, 23 in the peroral and 31 in the intravenous groups. The peroral group reported significantly better recovery outcomes, with higher QoR-15 scores (mean difference of 12 points, p < 0.001). They also experienced shorter hospital stays, averaging 47 h less than the intravenous group (p < 0.001). No significant differences between the groups were observed in readmissions or severe postoperative complications., Conclusions: Peroral antibiotic administration after laparoscopic appendectomy for complicated appendicitis significantly improves patient recovery and reduces hospital stay compared to intravenous antibiotics. These results advocate a potential shift towards peroral antibiotic use in postoperative care, aligning with ERAS principles., Trial Registration Number: ClinicalTrials.gov NCT04803422., (© 2024. The Author(s).)

Purpose: Choosing the best stump closure method for laparoscopic appendectomy has been a debated issue, especially for patients with acute appendicitis. The lack of consensus in the literature and the diverse techniques available have prompted the need for a comprehensive evaluation to guide surgeons in selecting the most optimal appendiceal stump closure method., Methods: A comprehensive search was conducted on multiple databases from inception until December 2023 to find relevant studies according to eligibility criteria. The primary outcome was the incidence of total complications., Results: 25 studies with a total of 3308 patients were included in this study, overall complications did not reveal a significant advantage for any intervention (RR = 0.72, 95% CI: 0.53; 1.01), Superficial and deep infection risks were similar across all methods, Operative time was significantly longer with endoloop and Intracorporeal sutures (MD = 7.07, 95% CI: 3.28; 10.85) (MD = 26.1, 95% CI: 20.9; 31.29)., Conclusions: There are no significant differences in overall complications among closure methods. However, Intracorporeal sutures and endoloop techniques were associated with extended operative durations., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Modified endoscopic retrograde appendicitis therapy (mERAT) has been proposed as an alternative to laparoscopic appendectomy for the treatment of appendicitis. However, data from children in large samples are lacking. The aim of this article is to evaluate the efficacy between mERAT and laparoscopic appendectomy (LA) in children with uncomplicated appendicitis., Method: We retrospectively analyzed 594 patients with suspected uncomplicated appendicitis from October 2018 to May 2021. A pool of 294 consecutive patients who met the inclusion criteria were ultimately enrolled in this study (228 and 66 patients in mERAT and LA, respectively). Given the differences in baseline clinical data (gender, age), the regression equation including differences in clinical baseline, grouping factor, and white blood cell count was established to address the influence of potential confounding factors., Result: The initial success rate of mERAT management was 96.9%, and the recurrence rate was 6.9% in the mERAT group and 1.7% in the LA group within 1 year, which was no significant difference. But the mERAT group had a lower rate of adverse events. Finally, those results indicated that the treatment modalities, LA or mERAT, had no significant effect on initial success rate (P = 0.99) or recurrence rate (P = 0.17) within 1 year, but a significant effect on the adverse events rate during hospitalization (P = 0.01) in the multivariate regression analysis., Conclusion: Among children with uncomplicated appendicitis, an initial mERAT management strategy had a success rate of 96.9%, which was similar to the LA group at 1 year. This follow-up supports the feasibility of mERAT alone as an alternative to surgery for uncomplicated appendicitis., (© 2024 Japan Gastroenterological Endoscopy Society.)

Background: Laparoscopic appendectomy is a common procedure and introduced early in general surgical training. How internal (i.e. surgeon's experience) or external (i.e. disease severity) may affect procedure performance is not well-studied. The aim of this study was to evaluate factors that may have an influence on the performance scores for surgical trainees., Methods: A prospective, observational cohort study of laparoscopic appendectomies performed by surgical trainees (experience < 4 years) operating under supervision. Trainers evaluated trainees' overall performance on a 6-point scale for proficiency. Perioperative data were recorded, including appendicitis severity, operating time and the overall difficulty of the procedure as assessed by the trainer. A "Challenging" procedure was defined as a combination of either/or "perforation" and "difficult". Trainees who had performed > 30 appendectomies were defined as "experienced". The trainees were asked if they had used simulation or web-based tools the week prior to surgery., Results: 142 procedure evaluation forms were included of which 19 (13%) were "perforated", 14 (10%) "difficult" and 24 (17%) "Challenging". Perforated appendicitis was strongly associated with procedure difficulty (OR 21.2, 95% CI 6.0-75.6). Experienced trainees performed "proficient" more often than non-experienced (OR 34.5, 95% CI 6.8-176.5). "Difficult" procedures were inversely associated with proficiency (OR 0.1, 95% CI 0.0-0.9). In "Challenging" procedures, identifying the appendix had lowest proficiency (OR 0.4, 95% CI 0.1-0.9). The procedures assessed as "difficult" had significantly longer operating time with a median (IQR) of 90 (75-100) min compared to 59 (25-120) min for the non-difficult (p < 0.001)., Conclusion: Both internal and external factors contribute to the performance score. Perforated appendicitis, technical difficult procedures and trainee experience all play a role, but a "difficult" procedure had most overall impact on proficiency evaluation., (© 2024. The Author(s).)

Background: Today, laparoscopy is frequently used in abdominal emergencies such as acute appendicitis. There are several techniques used to close the appendiceal stump during laparoscopic appendectomy. We aimed to compare the use of handmade loop and Hem-o-lok used to close the appendiceal stump in public hospitals where resources are limited, in terms of surgical outcomes and cost. Methods: Between January 2020 and December 2022, patients for whom handmade loops and Hem-o-loks were used to close the appendiceal stump during laparoscopic appendectomy in our clinic were included in the study. There were a total of 638 patients (mean age: 33 ± 13.5 years, 325 females and 313 males) in the patient cohort. Demographic and clinical data, duration of surgery, complications, hospital stay, pathology reports, mortality, and cost of supplies were compared between the two groups. Results: There were 308 patients in the handmade loop group (160 females, 148 males, mean age: 33.7 years, range: 18-85 years) and 330 patients in the Hem-o-lok group (166 females, 164 males, mean age: 32.5 years, range: 18-89 years). There was no significant difference between the two groups for American Society of Anesthesiologists score, duration of symptom, hospital stay, intensive care unit stay, preoperative laboratory values, histopathological results, mortality, and morbidity ( P > .05). The mean operation time was 48.76 ± 16.16 minutes in the handmade loop group and 40.53 ± 11.63 minutes in the Hem-o-lok group ( p = 0.001). In terms of cost, the cost per case of Hem-o-lok group was about 25.8 times as much as the group that used sutures ($31 versus $1.2). Conclusions: Both methods can be used safely in laparoscopic appendectomy. The use of Hem-o-lok has no advantage other than shortening the operation time. However, it is costlier. Especially in peripheral hospitals where resources are limited, closing the appendiceal stump using a handmade loop is an easy, safe, and cost-effective method.

Purpose: TULAA combines the laparoscopic and open technique and is considered to be a safe, fast and cost-effective procedure. On the other hand, preparation is limited due to the single instrument, especially in complicated appendicitis. In this study we analyze the outcome of our TULAA patients, focusing on conversion and complication rates., Methods: We performed a retrospective study including all patients treated with TULAA in our department between 2006 and 2016. We analyzed patient data, operative data, costs, complications, and conversion rate to standard laparoscopic or open appendectomy., Results: 1275 children and adolescents were enrolled. Mean age was 10.2 years. TULAA was completed in 88% of cases. The overall mean operative time was 33 min. The overall complication rate was 5.7%. The most common complications were wound infection (2.7%), seroma (1.7%) and wound abscess (1.4%). Both the conversion rate and the complication rate were significantly higher in complicated appendicitis. Furthermore, the conversion rate is higher in overweight or obese patients., Conclusion: TULAA is a safe, quick and cost-effective treatment option for acute appendicitis in children and adolescents. The complication rate and conversion rate are significantly correlated with the degree of appendiceal inflammation and comparable other surgical procedures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The aim of this study was to compare the clinic outcomes between new single-port laparoscopic appendectomy (NSLA) and conventional three-port laparoscopic appendectomy (CTLA) for patients with acute appendicitis. Patients who were diagnosed with acute appendicitis and underwent appendectomy were retrospectively collected from a single clinical center from September 2021 to June 2023. Baseline characteristics, surgical information, and postoperative information were compared between the NSLA group and the CTLA group. Univariate and multivariate logistic regression analyses were used to find out the predictors of overall complications. A total of 296 patients were enrolled from a single clinical medical center. There were 146 (49.3%) males and 150 (50.7%) females. There were 54 (18.2%) patients in the NSLA group and 242 (81.8%) patients in the CTLA group. After data analysis, we found the patients in the NSLA group had a shorter postoperative hospital stay (P < 0.01) than the CTLA group. The other outcomes including intraoperative blood loss (P = 0.167), operation time (P = 0.282), nature of the appendix (P = 0.971), and overall complications (P = 0.543) were not statistically different. After univariate and multivariate logistic regression analysis, we found that age (P = 0.018, OR = 1.039, 95% CI = 1.007-1.072), neutrophil percentage (P = 0.018, OR = 1.070, 95% CI = 1.011-1.132), and fever (P = 0.019, OR = 6.112, 95% CI = 1.340-27.886) were the predictors of overall complications. However, the surgical procedure (NSLA versus CTLA) was not a predictor of overall complications (P = 0.376, OR = 1.964, 95% CI = 0.440-8.768). Compared with CTLA, there was no significant increase in postoperative overall complications with NSLA, making it a safe and feasible new surgical procedure. More studies are needed to evaluate the long-term results., (© 2024. Italian Society of Surgery (SIC).)

Background: Perforated appendicitis is associated with postoperative development of intraperitoneal abscess. Intraperitoneal drain placement during appendectomy is thought to reduce the risk of developing postoperative intraperitoneal abscess. The aim of this study was to determine whether intraperitoneal drainage could reduce the incidence of intraperitoneal abscess formation after laparoscopic appendectomy for perforated appendicitis., Methods: This is a retrospective study of all patients (aged 7 and above) who were diagnosed with perforated appendicitis and subsequently underwent laparoscopic appendectomy between January 2018 and December 2022 at two government hospitals in the state of Kuwait. Demographic, clinical, and perioperative characteristics were compared between patients who underwent intraoperative intraperitoneal drain placement and those who did not. The primary outcome was the development of postoperative intraperitoneal abscess. Secondary outcomes included overall postoperative complications, superficial surgical site infection (SSI), length of stay (LOS), readmission and postoperative percutaneous drainage., Results: A total of 511 patients met the inclusion criteria between 2018 and 2022. Of these, 307 (60.1%) underwent intraoperative intraperitoneal drain placement. Patients with and without drains were similar regarding age, sex, and Charlson Comorbidity Index (CCI) (Table 1). The overall rate of postoperative intraperitoneal abscess was 6.1%. Postoperatively, there was no difference in postoperative intraperitoneal abscess formation between patients who underwent intraperitoneal drain placement and those who did not (6.5% vs. 5.4%, p = 0.707). Patients with intraperitoneal drains had a longer LOS (4 [4, 6] vs. 3 [2, 5] days, p < 0.001). There was no difference in the overall complication (18.6% vs. 12.3%, p = 0.065), superficial SSI (2.9% vs. 2.5%, p = 0.791) or readmission rate (4.9% vs. 4.4%, p = 0.835)., Conclusions: Following laparoscopic appendectomy for perforated appendicitis, intraperitoneal drain placement appears to confer no additional benefit and may prolong hospital stay., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Laparoscopic appendectomy is the current gold standard in treating acute appendicitis. Despite the low frequency of conversion to open surgery, it remains necessary in certain cases. Our primary outcome was to identify the conversion rate of laparoscopic appendectomy to open surgery and how this rate has changed over the learning curve. Second, we aim to determine the causes of conversion, their changes in frequency over time and to identify preoperative factors associated with conversion., Methods: A retrospective comparative study with prospective case registry was conducted. All patients who underwent laparoscopic appendectomy from January 2000 to December 2023 at a high-volume center were analyzed. The series was divided into six periods, each spanning 4 years. All patients who underwent totally laparoscopic appendectomy and those requiring conversion to open appendectomy were included., Results: A total of 3,411 appendectomies were performed during the study period, with an overall conversion rate of 0.96% (33/3,411). Our analysis showed that after the first three periods (12 years), the conversion rate decreased and reached a plateau of approximately 0.4%. The most common causes of conversion were perforation of the appendix base (9/33), abdominal cavity adhesions (8/33), and pneumoperitoneum intolerance (3/33). Age over 65, American Society of Anesthesiologists (ASA) score III/IV and symptom duration exceeding 24 h were preoperative factors significantly associated with conversion at univariate analysis. However, only age (p 0.0001) and symptoms exceeding 24 h (p 0.01) remained independently associated with conversion after multivariate analysis., Conclusion: In experienced centers, conversion from laparoscopic appendectomy to open appendectomy is uncommon, but remains necessary in certain cases. Despite identifying a population with higher association with conversion which should be advised preoperatively, due to the low incidence of conversions once the learning curve is overcome, an initial laparoscopic approach is the preferred choice., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Appendicitis is a most common abdominal condition worldwide, and appendectomy especially laparoscopic appendectomy is among the most commonly performed general surgeries. In this study, data were collected from patients who underwent laparoscopic appendectomy surgery at the Evangelical Hospital "Betania" in Naples, Italy. Linear multiple regression was used to obtain a simple predictor that can also assess which of the independent variables considered to be a risk factor. The model with R2 of 0.699 shows that comorbidities and complications during surgery are the main risk factors for prolonged LOS. This result is validated by other studies conducted in the same area.

Background and Objectives: Titanium DS clips are made to secure the appendiceal stump during laparoscopic appendectomy. The assumption is that they behave like stapler clips in the body, being made from titanium. However, the construction and weight of DS clips differs from staplers. Their biocompatibility may have implications for their clinical use., Methods: One hundred and twenty rats were randomized into four experimental groups: in the first group the appendiceal stump was secured by Vicryl® ligature, in the second by linear staplers, in the third by Hem-o-lok® plastic clips, and in the fourth by DS titanium clips. Ten animals from each group were sacrificed 7, 28, and 60 days post-surgery. Histopathological data and adhesion formation were assessed., Results: On postoperative day 7, a statistically significant difference was found in the occurrence of inflammation between the Hem-o-lok® and stapler groups. The adhesion score was significantly higher in the Vycril® and Hem-o-lok® in comparison to the DS and stapler groups. On postoperative day 28, a statistically significant difference was found in the occurrence of inflammation between the Vycril® and stapler groups. The adhesion score was significantly higher in the Vycril® than in the DS and stapler groups. On postoperative day 60, there were no statistical differences between any of the groups. The adhesion score was significantly higher in the Hem-o-lok® group in comparison to the DS and stapler groups., Conclusion: Staplers and DS clips have advantages over other methods of securing the appendiceal stump, because of their high biocompatibility and lower adhesion score., Competing Interests: Conflict of interests: none., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Aim of the Study: To compare the outcomes and hospital charges of patients who underwent laparoscopic appendectomy for non-perforated appendicitis and were discharged home either shortly after the operation after being admitted for overnight observation., Methods: Postoperative (30-day) emergency department (ED) visits, hospital readmissions, and reoperations were compared between patients who were discharged shortly after surgery (same-day discharge [SDD] group) and patients who were discharged after spending one night in the hospital (overnight observation group)., Study Period: July/2015 to June/2019. Patients with perforated appendicitis and/or who spent > 1 night in the hospital were excluded from the study., Results: We did 1957 laparoscopic appendectomies within the 4-year study period. After excluding all non-eligible cases, 930 patients were included in the overnight observation group, and 511 in the SDD group. Mean age and mean operative time were similar in both groups: 11.5 (SD 3.6)/11.8 (SD 3.5) years, and 35 (SD 13)/33 (SD 12) minutes, respectively. There were 24 (2.6%) ED visits within the overnight observation group. Sixteen patients (1.7%) were discharged from the ED, and 8 (0.9%) required a re-admission. There were 11 (2.1%; P = 0.61) ED visits within the SDD group. Six patients (1.1%; P = 0.41) were discharged from the ED, and 5 (1%; P = 0.82) required a readmission. Six of the 11 ED visits within the SDD group occurred on the 5th postoperative day or later, whereas five (1%) occurred within the first 3 days post appendectomy. These five patients would have likely benefited from an overnight admission and were erroneously discharged on the same day of the appendectomy. There were no reoperations in the overnight observation group, but there were 3 reoperations in the SDD group (0.6%, P = 0.01). The reasons for the reoperations (two bowel obstructions and one bowel perforation) were in no way related to the time of the original discharge. The mean hospital charges per patient in the SDD group and the overnight observation group were significantly different: $32,450 and $35,420, respectively (> 9% margin, P < 0.01)., Conclusion: Healthy children who undergo laparoscopic appendectomy for non-perforated appendicitis can be discharged home during the same day of the operation after a short period of observation. This approach is safe and does not result in more postoperative ED visits or hospital readmissions. In addition, there is a significant financial benefit when patients are discharged early., Level-Of-Evidence: Level III-retrospective comparative treatment study.

Introduction: We examined the safety and effectiveness of interval laparoscopic appendectomy (ILA) for adult appendiceal mass (AAM) and then used a novel white blood cell (WBC) parameter to identify the types of AAM cases for which nonsurgical treatment followed by ILA is effective., Methods: We reviewed the cases of 956 patients who had undergone appendectomy between April 2012 and March 2018 at our facility. Of these patients, 49 had AAM, including 34 who underwent ILA. We examined the safety and effectiveness of ILA by comparing it with laparoscopic appendectomy (LA); specifically, the 34 cases treated with ILA were compared with 477 cases of adult uncomplicated appendicitis treated with LA from the same patient cohort. We then examined the factors associated with not successfully completing the planned nonsurgical treatment and interval before ILA. Patient demographics and clinical variables were reviewed., Results: Patients who had undergone ILA had longer operative times than those who had undergone LA (P = .0059), but they also had shorter postoperative hospital stays (P < .001). There were no significant differences in other perioperative variables. Multivariate analysis showed that a ratio of WBC count on day 3 and day 0 from the start of nonsurgical treatment (WBC day3/day0) of 0.906 or higher was significantly associated with not completing the nonsurgical treatment and interval before ILA (P = .045)., Conclusion: A comparison of the procedures found that ILA for AAM was almost as safe and effective as LA for adult uncomplicated appendicitis. The WBC day3/day0 ratio can be an objective parameter to assess the effectiveness of the nonsurgical treatment before ILA earlier in the course of treatment., (© 2020 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Purpose: Acute appendicitis is one of the most common reasons for emergency medical consultation. While simple appendicitis can be treated with antibiotics or surgery, complex appendicitis including gangrene, abscess, and perforation requires appendectomy. During the COVID-19 pandemic in early 2020, an overall drop in emergency room consultations was observed. We therefore aimed to investigate the incidence and treatment strategies of acute appendicitis during that period., Methods: Data of insurance holders with the ICD code for "acute appendicitis" or OPS procedure of appendectomy of a major health insurance company in Germany were analyzed retrospectively. Groups were built, containing of the means of March-June of 2017, 2018, and 2019, defined as "pre-COVID group" with the "COVID group," defined as data from March to June of 2020. Data was analyzed by age, sex, comorbidities, length of hospital stay, diagnoses, and treatment. Data of the COVID group was analyzed for simultaneous COVID-19 infection., Results: During the COVID-19 pandemic of early 2020, an overall reduction by 12.9% of patients presenting with acute appendicitis was noticeable. These results were mainly due to decreased rates of uncomplicated appendicitis, while complicated appendicitis was scarcely affected. Especially in the group of females < 40 years, a drastic reduction was visible. Rates of extended surgery did not change. Likewise, the complication rate like appendix stump leakage or need for re-operation did not differ. In March 2020, 4.8% of acute appendicitis patients had concomitant COVID-19 infection., Conclusion: In line with the overall drop of emergency room visits during the COVID-19 pandemic of spring 2020 in Germany, a significantly lowered number of patients with uncomplicated appendicitis were noticeable, whereas complicated appendicitis did not differ. Also, treatment and complication rate of acute appendicitis did not change. These findings might be a hint that acute appendicitis is not a progressing disease but caused by different entities for uncomplicated and complicated appendicitis and therefore another clue that uncomplicated appendicitis can be treated with antibiotics or observation. Nevertheless provided data does not cover outpatient treatment; therefore, no statement observation or antibiotics in outpatients can be made.

Background: Postoperative intraabdominal abscess (IAA) is the most feared complication after laparoscopic appendectomy (LA). We aimed to evaluate the management of this complication in a large cohort of patients undergoing LA in order to design a treatment algorithm., Methods: We included a consecutive series of patients undergoing LA for acute appendicitis from January 2008 to December 2018. The cohort of patients with postoperative IAA was divided into three groups based on the implemented treatments: G1: antibiotics only, G2: CT-guided drainage, and G3: laparoscopic lavage. Characteristics of the fluid collections and outcomes were analyzed in the three groups., Results: A total of 1668 LA were performed; the rate of IAA was 2.2% (36 patients). There were 12 (33%) patients who received antibiotics only (G1), 8 (22%) underwent CT-guided percutaneous drainage (G2), and 16 (45%) underwent laparoscopic lavage (G3). The median size of the abscesses was 2.7 (1.2-4) cm in G1, 6.2 (4.5-8) cm in G2, and 9.6 (8-11.4) cm in G3 (p < 0.04). Patients with two or more fluid collections underwent a laparoscopic lavage in all cases. Treatment failure occurred in 16% (2/12), 12.5% (1/8) and 12.5% (2/16) of the patients in G1, G2, and G3, respectively. None of the patients in the entire cohort required open surgery to resolve the postoperative IAA., Conclusions: A minimally invasive step-up approach based on the size and number of fluid collections is associated with excellent outcomes. A treatment algorithm for post-appendectomy IAA is proposed.

Background: The purpose of this study was to evaluate the effect of 3D visualization applied to laparoscopic appendectomy (LA) performed by young surgeons (YS). We considered both operative features and clinical outcomes, aiming to highlight the benefits that this technology could bring to novice surgeons and their laparoscopic training., Methods: All the surgical procedures were performed by residents who had performed less than 20 appendectomies prior to the beginning of the study under the supervision of an expert surgeon. At the time of enrolment patients were randomized into two arms: Experimental arm (EA): laparoscopic appendectomy performed with laparoscopic 3D vision technology. Control arm (CA): laparoscopic appendectomy performed with the "standard" 2D technology. The primary endpoint was to find any statistically significant difference in operative time between the two arms. Differences in conversion rate, intra-operative complications, post-operative complications and surgeons' operative comfort were considered as secondary endpoints., Results: We randomized 135 patients into the two study arms. The two groups were homogeneous for demographic characteristics, BMI and ASA scores. The characteristics of clinical presentation and anatomical position showed no significant difference. The operative time was longer in the CA (57.5 vs. 49.6 min, p = 0.048, 95% CI). In the subgroup of complicated appendicitis, this trend toward inferior operative time was confirmed without reaching statistical significance (2D = 60 min, 3D = 49.5 min, p = 0.082 95% CI). No intra-operative complications were observed in either group. The conversion rate was 5.6% (4 patients) in the 2D group and 4.6% (3 patients) in 3D group., Conclusion: The utilization of 3D laparoscopy was associated with reduction in operative time without influencing other parameters, in particular without altering the safety profile of the procedure.

Surgical training is essential to maintain safety standards in healthcare. The aim of this study is to evaluate learning curves and short-term postoperative outcomes of laparoscopic appendectomy (LA) performed by trainees (TRN) and attendings (ATT). The present study included the medical records of patients with acute appendicitis who underwent a fully LA in our department between January 2013 and December 2018. Cases were divided into trainees (TRN and ATT groups based on the experience of the operating surgeon. The primary outcome measures were 30-day morbidity and mortality. Preoperative patients' clinical characteristics, intraoperative findings, operative times, and postoperative hospitalization were compared. Operative times were used to extrapolate learning curves and evaluate the effects of changes in faculty using CUSUM charts. A propensity score matching analysis was performed to reduce differences between cohorts regarding both preoperative characteristics and intraoperative findings. A total of 1173 patients undergoing LA for acute appendicitis were included, of whom 521 (45%) in the TRN group and 652 (55%) in the ATT group. No significant differences were found between the two groups in terms of complication rates, operative times and length of hospital stay. However, CUSUM chart analysis showed decreased operating times in the TRN group. Operative times improved more quickly for advanced cases. The results of this study indicate that LA can be performed by trainees without detrimental effects on clinical outcomes, procedural safety, and operative times. However, the learning curve is longer than previously acknowledged.

Background: After surgery and loss of anesthetic effect, postoperative pain can annoy the patient and affect patient satisfaction with treatment. This study was aimed at evaluating the effect of preoperative pentoxifylline (PTX) on postoperative pain and development of secondary hyperalgesia in patients undergoing laparoscopic appendectomy (LA)., Methods: This randomized, double-blind, placebo-controlled clinical trial study was conducted on 91 eligible subjects with acute appendicitis referred to Shahid Beheshti hospital of Sabzevar, Iran, in 2018. The intervention and control groups were administered with a single oral dose of PTX (10 mg/kg) and placebo an hour before surgery, respectively. Postoperative pain was measured within 24 hours after surgery using a VAS, and the area of secondary hyperalgesia was measured 24 hours after surgery using the Stubhaug et al. method., Results: The mean age of the subjects was 26.74 ± 9.99 years, and 57.14% were female. Pain intensity during rest was significantly greater in the control group as compared to the PTX group 24 hours after surgery (VAS scores 2.19 ± 0.49 and 3.13 ± 0.66, respectively; P < 0.001). Moreover, pain intensity during cough was substantially lower in the PTX group compared with the control group 24 hours after surgery (VAS scores 2.65 ± 1.90 and 4.10 ± 2.60, respectively; P = 0.003 in turn). The dynamic hyperalgesia was significantly greater in the control group as compared with the PTX group (3.80 ± 1.82 and 7.43 ± 2.38, respectively; P < 0.001)., Conclusions: Findings suggest that oral administration of PTX 1 hour before surgery in patients undergoing LA can reduce postoperative pain in patients and prevent secondary hyperalgesia at a surgical site., (© 2020 World Institute of Pain.)

Acute appendicitis is one of the main indications for urgent surgery representing a high-volume procedure worldwide. The current spending review in Italy (and not only in this country) affects the health service and warrants care regarding the use of different surgical devices. The aim of our study is to perform a cost evaluation, comparing the use of endoloops and staplers in complicated acute appendicitis (phlegmonous and gangrenous), taking into consideration the cost of the device in relation to the management of any associated postoperative complications. We retrospectively evaluated 996 laparoscopic appendectomies of adult patients performed in the Emergency General Surgery-St. Orsola University Hospital in Bologna (Italy). Surgical procedures together with the related choice of using endoloops or staplers were performed by attending surgeons or resident surgeons supervised by a tutor. A systematic review was performed to compare our outcomes with those reported in the literature. In our experience, the routine use of endoloop leads to a real estimated saving of 375€ for each performed laparoscopic appendectomy, even considering post-operative complications. Comparing endoloop and stapler groups, the total number of complications is significantly lower in the endoloop group. Our systematic review confirmed these findings even if the superiority of one technique has not been proved yet. Our analysis shows that the routine use of endoloop is safe in most patients affected by acute appendicitis, even when complicated, and it is a cost-effective device even when taking into consideration extra costs for potential post-operative complications.

Background: The rates of incidental appendiceal neoplasms after appendectomy performed for acute appendicitis is <2%. To date, no large studies have investigated the preoperative risk factors or imaging findings associated with incidental appendiceal tumors that present as appendicitis. Our study aims to identify preoperative factors that are associated with an increased risk of appendiceal tumors in patients who present with signs and symptoms of acute appendicitis. Materials and Methods: Using the targeted appendectomy American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent nonelective appendectomy for acute appendicitis in 2016. Patients with final pathology consistent with a tumor were compared with those with only appendicitis. A nonmatched case/control method was used to pull a random sample from the appendicitis cohort using a 1:4 ratio (tumor: acute appendicitis) to obtain adequate power for comparison. Preoperative patient variables and imaging findings were investigated using stepwise logistic regression to identify variables associated with appendiceal tumor. Results: Following multivariate analysis, preoperative imaging read of "indeterminate" and "not consistent with appendicitis," female gender, increased age, and lower preoperative white blood cell (WBC) count were significant predictors of tumor causing symptoms of appendicitis. The odds of having tumor pathology were significantly increased in patients with preoperative imaging of "indeterminate" and "not consistent with appendicitis." The odds of having tumor pathology were 82% higher for females than for males, increased by 2% for every 1-year increase in age, and increased by 3% for every one-unit decrease in WBC count. Conclusion: While incidental appendiceal tumors can present as acute appendicitis, 3 patient variables and one imaging finding were identified that may increase suspicion for appendiceal tumors. Consideration should be given to patients with these associated risk factors for additional preoperative consultation in addition to the potential for intraoperative pathology consultation.

Background: Intra-abdominal abscesses (IAA) may develop after laparoscopic appendectomies (LA) for acute appendicitis. The identification of risk factors for postoperative IAA could lead to a decrease in the readmission rate and surgery redoes after LA for acute appendicitis., Materials and Methods: The present study retrospectively analyzed patients undergone LA for acute appendicitis during the period 2001-2017. Clinical, intraoperative, and postoperative outcomes were described. Comparison between groups was made via univariate and multivariate analyses., Results: The charts of 2076 patients undergone LA were reviewed. Thirty-seven patients (1.8%) developed a postoperative IAA. Male gender (p < 0.05), ASA score ≥ 2 (p < 0.05), a gangrenous or perforated appendicitis (p < 0.0001), abscess or pelvic peritonitis (p < 0.0001), clipping the mesoappendix (p < 0.0001), appendix division by mechanical stapler (p < 0.05), prolonged antibiotic therapy (p < 0.05), and piperacillin/tazocin regimen (p < 0.0001) were significantly more frequent in the group of patients with IAA. In terms of multivariate analysis, only pelvic peritonitis (p = 0.010), perforated appendicitis (p = 0.0002), and clipping the mesoappendix (p = 0.0002) were independent predictive factors for postoperative IAA., Conclusion: Patients with peritonitis or a perforated appendicitis, and those who had their mesoappendix clipped showed a higher likelihood of developing an IAA. At risk patients should be provided with careful follow-up for the early detection and management of this complication.

Background: The evidence regarding the safety and efficacy of nonoperative management is growing. However, the best treatment strategy for acute complicated appendicitis remains controversial. We aimed to evaluate the cost-effectiveness of treatment strategies for complicated appendicitis patients. This study sought to determine the most cost-effective strategy from the health care-payer's perspective., Methods: The primary outcome was an incremental cost effectiveness ratio (ICER) using nonoperative management with or without interval laparoscopic appendectomy (ILA) as the intervention compared with operative management with emergency laparoscopic appendectomy (ELA) alone as the control. Model variables were abstracted from a literature review, and from data obtained from the hospital records of Tochigi Medical Center. Cost-effectiveness was evaluated using an ICER. We constructed a Markov model to compare treatment strategies for complicated appendicitis in otherwise-healthy adults, over a time horizon of a single year. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization's criterion of $107,690., Results: Three meta-analysis were included in our analysis. Operative management cost $6075 per patient. Nonoperative management with interval laparoscopic appendectomy (ILA) cost $984 more than operative management and produced only 0.005 more QALYs, resulting in an ICER of $182,587. Nonoperative management without ILA cost $235 more than operative management, and also yielded only 0.005 additional QALYs resulting in an ICER of $45,123 per QALY. Probabilistic sensitivity analysis with 1000 draws resulted in average ICER of $172,992 in nonoperative management with ILA and $462,843 in Nonoperative management without ILA. The threshold analysis demonstrated that regardless of willingness-to-pay, nonoperative management without ILA would not be most cost-effective strategy., Conclusions: Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Based on our findings, operative management remains the standard of care and nonoperative management would be reconsidered as a treatment option in complicated appendicitis from economic perspective.

Background: The aims of this study were to compare the incidence of small bowel obstruction (SBO) requiring laparotomy after laparoscopic appendectomy (LA) and open appendectomy (OA) in children and to identify risk factors for SBO., Methods: Medical records of patients who underwent appendectomy from 2000 to 2014 at our department of Pediatric Surgery were reviewed. Risk factors were analyzed using Cox proportional hazard regression., Results: Totally 619 out of 840 patients were included. OA was performed in 474 (76.6%), LA in 130 patients (21%), and 15 (2.4%) were converted from LA to OA. Age, sex and proportion of perforated appendicitis were comparable in the LA and OA groups. Median follow-up time was 11.4 years (2.6-18.4). The incidence of SBO after LA was 1.5%, after OA 1.9% and in the converted group 6.7% (p = 0.3650). There were no significant differences in the incidence of postoperative intraabdominal abscess, wound infection or length of stay between LA and OA. Perforation and postoperative intra-abdominal abscess were identified as risk factors with 9.03 (p < 0.001) and 6.98 (p = 0.004) times higher risk of SBO, respectively., Conclusions: The risk for SBO after appendectomy in children was significantly related to perforated appendicitis and postoperative intra-abdominal abscess and not to the surgical approach., Level of Evidence: Level III., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Appendectomy is one of the most common operations. Laparoscopic appendectomy (LA) is considered first-line treatment, but the use of LA for treatment of complicated appendicitis remains controversial. Here, we performed a retrospective analysis to compare clinical outcomes between patients treated with LA and those who underwent open appendectomy (OA)., Methods: Data for 179 patients who underwent an operation for the treatment of complicated appendicitis at our hospital between 2011 and 2017 were retrospectively analyzed. The selection included 89 patients who underwent a conventional appendectomy and 90 patients who were treated laparoscopically. Outcome measures such as mean operative time, blood loss, time until oral intake duration of hospital stay, and postoperative complications were analyzed. Logistic regression analysis was performed to determine the concurrent effects of the examined factors on the rate of postoperative complications., Results: The mean ages of patients in the OA and LA groups were 50.17 ± 22.77 and 50.13 ± 25.84 year. Mean operative times were longer in the LA group than OA (10.2.56 ± 44.4 versus 85.4 ± 43.11 min; p = 0.009). The duration of hospital stay was shorter for the LA group (9.61 ± 5.57 versus 12.19 ± 8.4; p = 0.016). There were no significant differences in return to consumption of oral intake between the LA and OA groups (2.03 ± 1.66 versus 2.48 ± 2.17; p = 0.123). Multivariable analysis found that the rate of postoperative complications was significantly reduced for the LA group, in comparison with the postoperative-complication rate of the OA group (16.7% versus 27%; odds ratio 0.376; 95% CI 0.153-0.923; p = 0.0327)., Conclusions: These results suggest that LA is a safe and efficient operative procedure that provides clinically beneficial advantages in comparison with OA. Thus, when possible, appendectomy for complicated appendicitis should be attempted using a laparoscopic approach., Trial Registration: Retrospectively registered.

The aim of this study was to investigate the effects of laparoscopic and open surgery on the development of postoperative surgical wound infection and wound healing between complicated appendicitis patients. Patients with complicated appendicitis were divided into those underwent laparoscopic and open surgical procedures according to the surgical method. Patients were followed up with regard to development of any postoperative wound infection, and medical, radiological, and surgical treatment methods and results were recorded. A total of 363 patients who underwent appendectomy were examined, of which 103 (28.4%) had complicated appendicitis. Postoperative wound infection rate in patients who underwent open surgery was 15.9%, while it was 6.8% in the laparoscopic surgery group. There was no statistically significant difference between the two groups in terms of infection development rates (P > .05). The rate of surgical drainage use and rehospitalisation was significantly higher in the group with wound infection than in the group without wound infection. (P < .05). We suggest that in terms of wound infection and wound healing, laparoscopic surgery should be the method of choice for patients with complicated appendicitis. In order to reduce the frequency of wound infection, drains should not be kept for a long time in patients undergoing appendectomy., (© 2020 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

In contrast to classical appendectomy where the appendiceal stump is secured by a single or double ligature, in laparoscopic appendectomy various ways of securing the stump are mentioned. Each of these methods has advantages and disadvantages. Since different possibilities exist for closing the stump, it is very important to find the optimum method for closure of the appendiceal stump, bearing in mind their simplicity, biocompatibility and price. The aim of this review article has been to present the problem of securing the base of the appendix during laparoscopic appendectomy., (Copyright© by the Medical Assotiation of Zenica-Doboj Canton.)

Purpose: Intraabdominal abscess (IAA) is a feared complication after laparoscopic appendectomy (LA) for complicated appendicitis. Benefits of obtaining intraoperative culture swabs (ICS) still remain controversial. We aimed to determine whether ICS modify the rate and management of IAA after LA for complicated appendicitis., Methods: A consecutive series of patients who underwent LA for complicated appendicitis from 2008 to 2018 were included. The cohort was divided into two groups: group 1 (G1), with ICS, and group 2 (G2), without ICS. Demographics, operative variables, pathogen isolation, antibiotic sensitivity, and postoperative outcomes were analyzed., Results: A total of 1639 LA were performed in the study period. Of these, 270 (16.5%) were complicated appendicitis; 90 (33%) belonged to G1 and 180 (67%) to G2. In G1, a higher proportion of patients had generalized peritonitis (G1, 63.3%; G2, 35%; p < 0.01). Seventy-two (80%) patients had positive cultures in G1. The most frequently isolated bacteria were E. coli (66.7%), Bacteroides spp. (34.7%), and Streptococcus spp. (19.4%). In 26 (36%) patients, the initial empiric antibiotic course was modified due to bacterial resistance. The rate of IAA was higher in patients with ICS (G1, 21.1%; G2, 9.4%; p = 0.01). IAA was treated similarly in both groups. A different type of bacteria was isolated in 7 (53.8%) patients with new culture swabs., Conclusions: Obtaining ICS in LA for complicated appendicitis with further antibiotic adjustment to the initial pathogen did not lower the incidence of postoperative IAA and did not modify the treatment needed for this complication.

Laparoscopic appendectomy for perforated appendicitis in children has the advantages of quick recovery, little influence of inflammatory and oxidative stress and low infection rate. Altogether 115 children with perforated appendicitis treated in our hospital from June 2018 to August 2019 were selected and divided into two groups according to different treatment methods. Laparoscopic appendectomy was used as the research group (RG) (67 cases) and open appendectomy (48 cases) as the control group (CG). The clinical indexes (operation time, intraoperative blood loss, ambulation time, incision length, postoperative exhaust time and length of stay) of the two groups were observed. The levels of C- reactive protein (CRP), procalcitonin (PCT), interleukin -6 (IL-6) and tumor necrosis factor-α (TNF-α) before and after treatment were detected by enzyme-linked immunosorbent assay (ELISA). The levels of oxidative stress factors (superoxide dismutase (SOD), malondialdehyde (MDA)) and the incidence of postoperative incision infection were observed in the two groups. A visual analogue scale (VAS) score was used to evaluate the postoperative pain in children. Logistic regression analysis was used to analyze the risk factors of postoperative incision infection in children. The improvement degree of clinical indicators in RG was significantly better than that in CG. The expression levels of CRP, PCT, IL-6 and TNF-α in RG were significantly lower than those in CG. The expression levels of SOD and MDA in RG were significantly better than those in CG. The postoperative incision infection rate in RG was significantly lower than that in CG. The postoperative VAS score in RG was significantly lower than that in CG. Logistic regression analysis results showed that the risk of incision infection was increased in children with operation time over 1h, incision length &gt;3cm, high CRP, high PCT, high IL-6, high TNF-α, high SOD and low MDA. Laparoscopic appendectomy for perforated appendicitis in children can effectively reduce intraoperative hemorrhage, postoperative pain, and the damage to the body of children, and can also reduce oxidative stress and inflammatory reaction in children.

Background: Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost., Methods: We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes., Results: In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001)., Conclusions: The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.

Introduction: Laparoscopic appendectomy is a commonly performed procedure. The base of appendix is secured by various techniques (suture, LigaSure, endoloop, or hamlock clip). Harmonic scalpel (HS) may be used to seal the base of the appendix. The study was conducted to assess the efficacy of HS in laparoscopic appendectomy for sealing the base of the appendix. Materials and Methods: The patients were divided into two groups: group 1 in which base was secured by endoloop and group 2 in which base of the appendix was sealed by HS in a stepwise manner. We made a record of patients' age and gender, and operative time. The patients were followed for a period of 3 months from the time of discharge. Results: During the study period of 4.5 years, 102 patients were in group 1 and 108 patients in group 2. Both groups were age and gender matched. Mean operating time for group 1 was 43.34 ± 6.7 minutes and that for group 2 was 28.46 ± 7.19 minutes ( P  < .0001). Complications included postoperative ileus (group 1 = 8, group 2 = 10) and surgical site infection (group 1 = 4, group 2 = 4, P  > .05). Conclusion: It appears that use of HS for laparoscopic appendectomy is feasible and safe. Its results appear to be comparable with other methods of laparoscopic appendectomy. Complications are minimal. Further studies at other centers may substantiate our efforts.

Background: In general, the three main options for stump closure in laparoscopic appendectomy are clips, endoscopic staplers and endoloops. However, there is no gold standard, especially regarding complicated acute appendicitis which is generally associated with worse outcomes. Objectives: We aimed to assess the outcomes of different stump closure techniques during laparoscopic appendectomies for complicated appendicitis Methods: Our multicenter observational study of 18 surgical units assessed the outcomes of 1269 laparoscopic appendectomies for complicated appendicitis that used the three main stump closure techniques: clips, staplers and endoloops. Groups were compared in terms of peri- and postoperative outcomes. Results: Staplers were superior in terms of overall morbidity (9.79 vs. 3.29% vs. 7.41%, p  = .017) and length of stay (4 vs. 3 vs. 4 days, p  < .001) respectively for clips, staplers and endoloops. However, no differences in major complication rates, postoperative intraabdominal abscess formation, reintervention rates and readmission rates were found. Conclusion: Although our results show some clinical benefits of staplers for appendix stump closure, they are based on a non-randomized group of patients and are therefore prone to selection bias. Further well-designed trials taking into consideration not only the clinical benefits, but also, the economic aspects of the surgical treatment of complicated acute appendicitis are needed to confirm our results.

Intraperitoneal local anesthetics have been increasingly used nowadays. However, they are not routinely given in laparoscopic appendectomy and a lot of controversies are found about their administration in this procedure. The goal of this study is to review effectiveness and safety of intraperitoneal local anesthetics in laparoscopic appendectomy. We conducted a computer search of four authentic databases. We included randomized controlled trials (RCTs) which compared intraperitoneal local anesthetics versus control group in laparoscopic appendectomy. Data were extracted from eligible studies and pooled in a meta-analysis model using RevMan software. We evaluated post-operative pain in different periods and safety outcomes including postoperative nausea and vomiting (PONV) and shoulder pain. Furthermore, we assessed the length of hospital stay and postoperative opioid consumption within 24 hours. Seven RCTs were included with a total of 579 patients in this review. Our analysis indicated a significant difference in postoperative pain at different durations preferring intraperitoneal local anesthetics compared to control. Moreover, intraperitoneal local anesthetics were significantly linked to fewer patients experienced PONV and shoulder pain respectively (RR= 0.28, 95% CI [0.16, 0.50], p < 0.0001), (RR= 0.32, 95% CI [0.17, 0.58], p = 0.0002). We found less hospital stay duration in intraperitoneal local anesthetics group after removal of the heterogeneity (MD= -0.39, 95% CI [-0.63, -0.16], p = 0.001). Intraperitoneal local anesthetics were significantly linked to less postoperative opioid consumption (SMD = -0.60, 95% CI [-0.96, -0.24], p = 0.001). Intraperitoneal local anesthetics can be routinely used in laparoscopic appendectomy as it is associated with less postoperative pain and reduction in different adverse events postoperatively.

Purpose: We are presenting a new very minimally invasive technique for laparoscopic appendectomy (needlescopic appendectomy [NAP]) in children and adolescents using suture grasper device, epidural needle, and homemade isolated long diathermy probe without any conventional laparoscopic instruments. Patients and Methods: NAP was attempted in 48 patients with uncomplicated acute appendicitis at Al-Azhar, Tanta University Hospitals and other allied hospitals during the period from May 2017 to November 2018. The study included patients with acute appendicitis and patients scheduled for interval appendectomy. Exclusion criteria were patients with concealed appendix, patients with appendicular abscess or appendicular mass, patients with acute appendicitis complicated with generalized peritonitis, and patients unfit for laparoscopy. The appendix was brought outside through the umbilical port and the operation was completed extracorporeally. In cases of appendicitis with tethered cecum, the whole procedure was completed intracorporeally. Results: Forty-eight patients with acute uncomplicated appendicitis were treated by NAP. They were 36 males and 12 females with a mean age 9 ± 3.7 years (range = 4-15 years). Two cases with concealed appendix and one case with appendicular mass were diagnosed during initial laparoscopy and excluded from the study. Thirty-two cases (71.11%) were completed intracorporeally and 13 cases (28.89%) were completed by extracorporeal NAP. Mean operative time was 33.29 ± 3.95 minutes (range = 27-40 minutes) for intracorporeal NAP and 20.9 ± 7.01 minutes (range = 14-40 minutes) for extracorporeal NAP. Degrees of cosmetic satisfaction of the patients and parents were excellent in 93.33% ( N  = 42/45 patients), and very good in 6.67% ( N  = 3/45 patients) of patients. Conclusion: NAP using needles only is a new technique that is very minimally invasive, very cheap, safe, reproducible, and easy to be done with outstanding cosmetic results.

Purpose: The aim of this study was to compare the outcomes of laparoscopic appendectomy (LA) using purse string invaginating sutures (PS) with those using intracorporeal knotting (IK) or Hem-o-lock polymeric clips (HL)., Methods: A total of 882 patients who underwent laparoscopic appendectomy from January 2015 to December 2017 were studied retrospectively. Of these, 538 patients used PS, 229 patients used IK and 115 patients used HL to close the appendiceal stump. Their demographic characteristics, intraoperative findings and postoperative complications were analysed retrospectively., Results: There were similar percentages of complicated cases in all the groups (21.7% in PS vs. 21.4% in IK vs. 24.3% in HL, p = 0.803). The mean length of hospital stay was shorter in PS group when compared to IK or HL group (3.72 + 2.35 in PS vs. 4.41 + 2.40 in IK, 4.43 + 2.66 in HL, p < 0.05) as well as lower ASA scores (1.7 + 0.6 in PS vs. 1.8 + 0.6 in IK vs. 1.7 + 0.6 in HL, p < 0.05). The overall complication rates for the PS, the HL and the IK groups were 12.1, 8.7 and 9.2%, respectively. The rate of wound infection was higher in PS group for uncomplicated appendicitis (5.0% in PS vs. 2.8% in IK and 1.1% in HL, p = 0.129). Furthermore, there were no differences in the rate of intra-abdominal infection among the groups in both uncomplicated and complicated cases., Conclusions: Based on our results, purse string suture failed to demonstrate better postoperative outcome in laparoscopic appendectomy and is no longer recommended by our institution as initial approach.

Background: Despite emerging evidences on the feasibility and efficacy of single-incision laparoscopic appendectomy (SILA) for managing simple appendicitis, advancing its use for treating complicated appendicitis remains unwarranted. This study aimed to evaluate the surgical outcome of SILA compared with that of standard multiport laparoscopic appendectomy (MPLA) in the management of complicated appendicitis., Methods: Between July 2013 and September 2017, 40 patients who underwent SILA and 150 patients who underwent MPLA for the treatment of complicated appendicitis, defined as AAST grades II-V, were recruited for this study. The demographic characteristics, intraoperative and recovery parameters were retrospectively recorded. No routine drainage was placed in the SILA group., Results: SILA was smoothly performed without requiring conversion to MPLA. No significant difference was observed between the 2 groups in demography and preoperative severity. The operation duration was approximately 8 min shorter in the SILA group than in the MPLA group, without a statistical difference (60.03 ± 21.01 vs. 68.04 ± 32.03 min, p = 0.222). The recovery parameters, including soft diet intake and postoperative hospitalization, were more favorable in the SILA group (p < 0.001). Despite the absence of routine drainage in the SILA group, only 1 patient developed an intra-abdominal hematoma necessitating further computed tomography-guided drainage., Conclusion: SILA is safe and feasible for the management of complicated appendicitis. SILA had non-inferior results to MPLA in terms of time to resume oral intake and postoperative hospital stay. Furthermore, this study posted a question on the concept of routine postoperative drainage in complicated appendicitis., (Copyright © 2019. Published by Elsevier Taiwan LLC.)

Background/purpose: Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost., Methods: Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes., Results: A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes., Conclusions: SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year., Type of Study: Treatment Study., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Acute appendicitis is a common condition in the pediatric population. In patients with uncomplicated appendicitis, laparoscopic appendectomy (LA) is preferred as compared to open appendectomy (OA). However, in patients with complicated appendicitis (CA), as defined as suppurative, gangrenous or perforated appendicitis, or appendicitis with periappendicular abscess formation, the decision to perform OA or LA remains unclear., Methods: The PRISMA guidelines were adhered to. An electronic database search from 1997 to 2017 was performed using the Cochrane, Medline, PubMed, Scopus, Ovid, Embase, and Web of Knowledge databases. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Assessment of methodological and statistical heterogeneity, as well as publication bias of the included studies, was performed., Results: Six randomized-control trials (296 LA versus 373 OA) and 33 case-control trials (3106 LA versus 4149 OA) were analyzed. Compared to OA, LA has a shorter length of stay (WMD = - 0.96, 95% CI - 1.47 to - 0.45) and a lower rate of surgical site infection (OR 0.37, 95% CI 0.25-0.54), although the rates of intraabdominal abscess formation were similar (OR 1.01, 95% CI 0.71-1.43). LA was also shown to have lower readmission rates, lower incidences of postoperative ileus or intestinal obstruction, lower incidence of reoperation, as well as a shorter time taken to oral intake. Operative time for OA was shorter than LA (WMD = 12.44, 95% CI 2.00-22.87)., Conclusion: While studies in the past have associated LA with higher rates of intraabdominal abscess in patients with CA, our meta-analysis has shown that they were similar. Considering this, together with other improved postoperative outcomes, LA should be the procedure of choice in pediatric patients presenting with CA.

Background: Acute appendicitis represents one of the main causes of surgical emergencies. It can be approached as open appendectomy or laparoscopic appendectomy (LA). LA uses different modalities, such as conventional laparoscopic appendectomy (CLA) or single-port laparoscopic appendectomy (SPLA). The aim of this work is to compare the results of CLA versus SPLA in patients diagnosed with Acute Appendicitis. Materials and Methods: A comparative multicenter prospective study of patients undergoing LA with a clinical diagnosis of acute appendicitis was presented. They were divided into two groups (CLA group and SPLA group). Results: A total of n  = 147 patients were included (72 CLA and 75 SPLA). Preoperative and intraoperative times were shorter for patients undergoing CLA ( P  = .002; P  = .068). Postoperative and reinsertion time was lower for SPLA ( P  = .000; P  = .0004). There were no differences in postoperative complications. The type of approach showed statistically significant differences with respect to pain within the first 12 hours of the postoperative period, as well as at discharge, while no differences were observed in relation to cosmetic satisfaction when the two approaches were compared. Conclusion: SPLA technique presented less intraoperative time, shorter time of labor reinsertion, and less postoperative pain. There were no statistically significant differences in postoperative complications.

Introduction: Recent meta-analyses revealed that laparoscopic appendectomy (LA) is a feasible procedure even for patients with complicated appendicitis. More than a few patients with acute appendicitis arrive at the hospital during night shifts and have their operation postponed for various reasons. However, the feasibility and disadvantages of this so-called "postponed laparoscopic appendectomy" (PLA) remain controversial., Methods: We included 149 patients who underwent LA for acute appendicitis within 48 h of diagnosis between January 2013 and May 2018. Patients were divided into an immediate LA group (patients who underwent LA within 4 h of diagnosis, n = 84) and a PLA group (patients who underwent LA 4-48 h after diagnosis, n = 65). Comparisons were made between these groups., Results: The preoperative characteristics of the patients in the immediate LA and PLA groups were not significantly different. Operative time was significantly longer in the PLA group than in the LA group (92.5 ± 40.8 vs 78.1 ± 29.7 min, P = 0.012). The incidence of postoperative complications (grade II or higher) was significantly greater in the PLA group than in the LA group (32.3% vs 17.8%, P = 0.041). Multivariate analysis revealed that a preoperative CT finding of periappendiceal fluid (P = 0.005, odds ratio = 4.71) and surgery 4-48 h after diagnosis (P = 0.005, odds ratio = 4.425) were independent risk factors of postoperative complications (grade II or higher)., Conclusions: For patients with acute appendicitis, surgeons should perform immediate LA, if that is the patient's preferred surgical treatment, as long as there is no special reason to postpone surgery., (© 2018 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Surgery may lead to poor blood flow and hypercoagulation. Few studies have investigated the incidence of venous thromboembolism (VTE) in Asian patients following appendectomy. We conducted a nationwide cohort study to investigate the risk of VTE in patients who underwent appendectomy compared with those who did not in Taiwan. We studied the entire hospitalized population in Taiwan from 2000 to 2012, with a follow-up period extending to the end of 2013. We identified patients who underwent appendectomy in Taiwan's National Health Insurance Research Database as the appendectomy cohort, and selected a nonappendectomy cohort from the general population that was 4:1 frequency-matched by age (5-year interval), sex, and index year for each appendectomy case. We used Cox models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for symptomatic VTE in the appendectomy cohort for comparison with the nonappendectomy cohort. The appendectomy cohort exhibited a higher incidence of symptomatic VTE than the nonappendectomy cohort (5.90 vs. 3.29 per 10,000 person-years). After adjustment for covariates, a 1.68-fold HR for symptomatic VTE was observed in the appendectomy cohort (95% CI 1.56-1.81). Compared with the nonappendectomy cohort, the patients who underwent open appendectomy had a 1.73-fold increased adjusted HR for symptomatic VTE (95% CI 1.61-1.87). Laparoscopic appendectomy was not significantly associated with symptomatic VTE. An 8.15-fold higher adjusted HR for VTE was observed in patients who underwent appendectomy within the first month after surgery compared with the nonappendectomy cohort. Open appendectomy carried an increased risk of symptomatic VTE. Laparoscopic appendectomy was not significantly associated with symptomatic VTE.

Background: Presently, there is equipoise regarding the surgical technique used to manage the appendiceal stump during laparoscopic appendectomy. The purpose of this research was to determine whether the routine use of loop ligature, compared to stapling, is cost effective from a hospital payer perspective., Methods: A retrospective cohort study was conducted amongst patients undergoing emergency laparoscopic surgery for acute appendicitis at two major academic hospitals. In order to eliminate possible systematic bias arising from one technique being preferentially employed with more complex presentations, patients were divided into study groups based on the technique routinely employed by their surgeon, loop ligature (LLA) versus stapler (LSA). Pediatric patients and open appendectomies were excluded. Costs were determined using a previously published model derived from publicly available data from the Ontario Case Costing Initiative, in conjunction with local cost data for disposable procurement. Secondary outcomes included operating room time, length of stay, and complication rates., Results: Between Jan 1, 2014 and Dec 31, 2015, 567 adult patients had an emergency laparoscopic appendectomy for acute appendicitis. In comparing surgeons who routinely employed LLA to LSA, there was a significant decrease in total mean hospital cost with LLA ($1988 ± $143 vs. $2253 ± $99, p = 0.002). In addition, mean disposable cost was reduced for surgeons using LLA ($310 ± $27 vs. $668 ± $26, p < 0.001). This reduction in cost was not associated with a difference in length of stay (1.5 vs. 1.4 days, p = 0.28) or complication rates (8% vs. 10%, p = 0.43)., Conclusions: These findings suggest that surgeons who routinely use loop ligature to secure the appendiceal base during emergency laparoscopic appendectomy offer more cost-effective care compared to stapler users, saving their institution more than $200 per case with no clear disadvantages. A shift from routine use of staplers to loop ligature should result in significant overall cost savings to the hospital.

Purpose: The aim of this long-term study was the comparison of appendiceal stump closure with polymeric clips or staplers with respect to perioperative costs and surgical outcome under routine conditions in a university centre., Methods: For this retrospective chart review, a total of 618 patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2010 and 2017 were reviewed: 410 patients in the stapler group and 208 patients in the clip group. The database contained demographic data, operation time, inflammation parameters, closure method of the stump, surgeon status, length of hospital stay, and complications as well as histology reports. The costs were also compared., Results: Clip application was more likely among younger patients (mean age 33.6 years vs. 41.7 years). Histopathological evidence for appendiceal pathology was found in 96.6% of patients in the clip group and 99.5% of patients in the stapler group. Laparoscopic appendectomy in the clip group was more frequently performed by resident physicians (69.2%) than in the stapler group (57.8%). The mean postoperative stay was 2.9 days in the clip group and 3.7 days in the stapler group. The use of the polymeric clip resulted in considerable cost savings (19.94€ vs. 348.70€)., Conclusions: The use of polymeric clips for appendiceal stump closure during appendectomy is safe and effective. The base of the appendix is amenable to clipping in 32% of appendectomies in adult patients. This study supports the use of polymeric clips over staplers to decrease cost and environmental impact.

Background: Appendectomy is amongst the most common general surgical procedures and the laparoscopic approach is recognized and recommended by international guidelines as a valid option. The different closure techniques of the appendicular stump constitute a matter of debate since their possible implication in determining postoperative infectious complications. The aim of the present meta-analysis is to compare endostapler versus endoscopic loop ties for stump closure during laparoscopic appendectomy., Methods: This is a systematic review with meta-analysis of randomized trials and cohort studies comparing endostapler with endoscopic loop ties for the closure of appendicular sump in laparoscopy appendectomy. Subgroup analysis of pediatric patients and patients with complicated appendicitis were performed when data were available. Complicated acute appendicitis was defined as in case of gangrenous/necrotic appendix or perforated appendix. Main outcomes were wound infection rate, intra-abdominal infection rate, length of stay, readmission and reoperation rates., Results: a total of 5934 patients from 14 studies were included in the analysis. Endostapler was associated with a similar intra-abdominal abscess rate (RR 0.88, 95%C.I. 0.54-1.43) but a lower incidence of wound infection (RR 0.54, 95%C.I. 0.22-0.97) Length of stay, readmission and reoperation rates were similar. In subgroups analysis endostapler reduces significantly the wound infection rate in pediatric patients; no differences in main outcomes were observed in patients with complicated acute appendicitis., Conclusion: In complicated acute appendicitis the stump closure technique did not affect outcomes; the use of endostapler seems to be associated to a reduction of wound infection rate in pediatric patients with non-complicated acute appendicitis., (Copyright © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: Ambulatory laparoscopic appendectomy has gained popularity due to the improved understanding of patient selection criteria, the application of enhanced recovery pathways, and the potential for improving healthcare resource utilization. The aim of the review was to compare the morbidity and readmission rates between ambulatory and conventional laparoscopic appendectomy (LA)., Methods: A systematic search was undertaken using PubMed, Embase, Cochrane, and Web of Science. Studies from 2014 to 2018, on adult patients undergoing ambulatory LA, were considered. Meta-analyses were conducted to pool the total number of complications and readmission events in the ambulatory and conventional groups., Results: A total of 5 studies met our inclusion criteria accounting for 7079 total of patients with acute appendicitis treated by ambulatory LA and 6370 patients treated by conventional LA. We included four observational studies (two prospective and two retrospective) and one randomized controlled trial. Length of stay was significantly lower in the ambulatory group (mean difference = - 15.63 h, 95% CI = - 21.78 to - 9.49, P = < 0.00001). The relative risk (RR) of reoperation was 0.49 (95% CI = 0.12-1.95, P = 0.31). The results demonstrated a pooled RR of overall morbidity of 0.79 (95% CI = 0.65-0.97, P = 0.02) and a pooled RR of readmission of 0.72 (95% CI = 0.59-0.88, P = 0.002), both results favoring the ambulatory LA group., Conclusion: There is a lack of high-quality comparative studies making conclusive recommendations not possible at this time. Based on current data, ambulatory LA may be safe and feasible as compared with conventional LA.

Background: Previous studies regarding same-day discharge (SDD) after laparoscopic appendectomy for pediatric patients have been limited by the cohort size and lack of specificity regarding the definition of SDD. Our study evaluates the safety of appendectomy performed with SDD in pediatric patients when compared to appendectomy followed by an overnight stay, using a large nationwide database and a strict definition of SDD by using hospital length of stay (LOS). Methods: Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) registry, we identified patients younger than 18 years of age who underwent outpatient laparoscopic appendectomy, with SDD ( n  = 2647) or overnight stay ( n  = 5045). One-to-one propensity score matching was performed to compare 30-day readmission rates and postsurgical complications. Results: Non-Hispanic black race was associated with a higher likelihood of overnight stay after laparoscopic appendectomy. In the propensity score-matched analysis ( N  = 2443 pairs), SDD was not associated with an increased risk of 30-day unplanned readmission (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.6-1.4; P  = .667) or any 30-day complication (OR = 0.8, 95% CI: 0.6-1.1; P  = .258). Conclusion: SDD after laparoscopic appendectomy in pediatric patients was not associated with an increased risk of 30-day hospital admission or complication rate. Protocols to expedite perioperative care, including standardization of intraoperative care, may facilitate same-day hospital discharge, resulting in a decrease in health care costs.