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

2. 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

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

4. 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

5. 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)

6. 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.

7. 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.

8. 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 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%

9. Proforma

10. 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

11. 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%

12. 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

13. 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

14. 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

15. Thank you