Under the supervision of: J. P Slavin Laparoscopic vs. Open appendicectomy: A prospective audit Marina Yiasemidou Under the supervision of: J. P Slavin

Purpose of Audit Examine if patient selection is done correctly for open/lap appendicectomy Assess whether complication preventive measures are taken when laparoscopic appendicectomy is performed Importance of audit Ensuring that patients get the optimum treatment Ensuring that appropriate measures are taken in order to prevent post-op complications

Guidelines NHS Evidence - National Library of Guidelines SAGES guideline for laparoscopic appendectomy

Points of interest (SAGES guidelines) A. Patient selection Uncomplicated Appendicitis Laparoscopic approach: Multiple randomized controlled studies Shorter hospital stay Possibly more rapid return to work Recent update from authors of meta-analysis of 28 trials Less post-operative pain Wound infections were slightly lower

Points of interest A. Patient selection Perforated Appendicitis GUIDELINE: Laparoscopic appendectomy may be performed safely in patients with perforated appendicitis (Level II, grade B) 8, 17 and is possibly the preferred approach (level III, grade C) Women of Childbearing Age GUIDELINE: Laparoscopic approach for fertile women with presumed appendicitis should be the preferred method of treatment. (Level 1, grade A)   Elderly Patients GUIDELINE: Laparoscopic approach may be the preferred method of treatment. (Level II, Grade B) Obesity GUIDELINE: Laparoscopic appendectomy is safe and effective in obese patients.(level II, Grade B) and may be the preferred approach (level III, grade C)

Points of interest B. Laparoscopic appendicectomy-Technical aspects GUIDELINE: Developing a consistent operative method decreases costs, OR time, and complications. (level II, Grade B) peritoneal lavage Positioning: Supine position with Trendelenburg, left arm tucked with both surgeon and camera operator on patient’s left side. Foley placement, or voiding preoperatively in uncomplicated appendicitis, provides decompression of bladder which may help with exposure and avoid injury.

Points of interest Trocar placement: Basic principles of triangulation in trocar placement apply. All studies describe placement of the initial (usually a 10mm camera) port at the umbilicus. One study 31 found that using all 5 mm ports wasfeasible although 35% needed conversion to a 10mm trocar due to a fatty mesoappendix. Secondary port placements: LLQ and RLQ directly above appendix for retraction. This location provides a means for “fingeroscopy” 18 to break up adhesions. One study found that fingerscopy may allow more efficient and full lysis of inflammatory adhesions and loculations and prevent incomplete appendectomy. Having two working ports in adjacent quadrants (i.e. LLQ and suprapubic positions) allows the surgeon to work two-handed, rather than relying on an assistant to provide retraction while the surgeon dissects. Surgeons should consider the experience level of their assistant as well as the goals of a training program if they work in one.

Methods An audit proforma was developed from SAGES guidelines for lap appendectomy Theatre staff was informed about audit and kindly agreed to place proforma in patient’s notes Medical staff was informed via e-mail about the audit Proformas were filled out right after surgery and were collected in recovery room Prospective data for 22 appendicectomies was collected No of open 19-86% No of lap 3-14%

Proforma

Results Standard Standard met (% of patients) Lap app for: Perforated Appendicitis 0% Women of Childbearing Age 50% Obese Lap appendicectomy technical aspects Peritoneal lavage (Should be done) 67% Surgeon on L side 100% Camera holder on L side

Results Standard Standard met (% of patients) Supine with Trendelenburg (position suggested by guidelines) 0% Bladder voiding pre-op 100% Primary port at umbilicus Port placement according to assistant experience Size of ports (all 5mm) 67%

Reasons for not undertaking lap appendicectomy (derived from answers given on audit proforma) Not familiar with patient selection guidelines After hours- Junior registrars do not feel confident to undertake lap appendicectomies after hours No lap instruments for children

Conclusions Laparoscopic appendicectomy is rarely performed in our hospital When performed though the vast majority of complication preventive measures are undertaken Surgeons not familiar with guidelines Registrars do not feel confident undertaking lap chole after hours without consultant support. Paediatric laparoscopic instruments are not supplied by our hospital

Changes to be implemented Increase awareness of Laparoscopic appendicectomy guidelines Formal induction lecture on Laparoscopic appendicectomy guidelines In association with trust authorities create and circulate (through ISPC etc) list with recommended laparoscopic skills courses Make proper authorities aware of lack of paediatric laparoscopic instruments and of lap approach benefits. Re-audit after recommendations have been implemented

Thank you