Single incision transumbilical laparoscopic-assisted appendectomy performed by surgical residents is safe and feasible

Kazuhiro Endo, MD1, Dai Kujirai, MD2, HIroharu Shinozaki, MD1, Hinako Maeda, MD1, Hiroki Ozawa, MD1, Yuriko Kiriya, MD1, Tadashi Matsuoka, MD1, Ryo Nakanishi, MD1, Yuko Kumagai, MD1, Takashi Ishida, MD1, Toshiaki Terauchi, MD1, Masaru Kimata, MD1, Kenji Kobayashi, MD1, Naohiro Sata, MD3. 1Saiseikai Utsunomiya Hospital, Department of Surgery, 2Keio University, Department of Emergency medicine, 3Jichi Medical University, Department of Surgery

Introduction: The aim of this study is to compare the clinical outcomes of single incision transumbilical laparoscopic-assisted appendectomy performed by surgical residents and staff surgeons.

Patients and methods: We examined clinical factors and outcomes of 131 laparoscopic appendectomy procedures performed from January 2011 to June 2014 retrospectively. During the study period, 13 residents and six board-certified staff surgeons performed the procedures. All operations performed by residents were supervised by staff surgeons. Appendicitis was diagnosed by physical findings, blood tests, and computed tomography scan. The following characteristics were compared for operations performed by residents and by staff surgeons: gender, age, body mass index, ASA score, temperature, white blood cell count, CRP level, and presence of fecal stones and abscesses. Clinical outcomes including operative time, estimated blood loss, need for additional ports, conversion to open surgery, intraoperative complications, postoperative complications, and postoperative hospital stay were compared by the two groups. Results were compared using the chi-squared test and statistical significance was set at p<0.05.

Surgical procedure: Three 5mm ports were inserted through a 2cm umbilical incision. After pneumoperitoneum was induced, the appendix was identified, and the ileocecum was mobilized. The appendix was removed through the umbilical incision and the mesoappendix was ligated and dissected under direct visualization. The appendiceal root was ligated and dissected, and the stump inverted.

Results: Preoperative white blood cell counts in the resident-operated group is significantly higher than patients operated by staff surgeons. (14.0 vs 10.8 (x103 /mm3 ), p=0.007) There is no other significant difference in clinical variables between the two groups. Patient outcomes show that estimated blood loss is significantly higher and operative time tended to be longer in the resident group. No other significant difference is observed.

Resident (n=103)Staff (n=28)p-value
Operative time (min)8672.030.056
Estimated blood loss (ml)23.449.750.031
Additional port insertion14 (13.6%)3 (10.7%)0.691
Conversion to open surgery2 (1.9%)1 (3.6%)0.612
Intraoperative complications1 (1%)0 (0%)0.604
Postoperative hospital stay(days)4.344.670.515
Postoperative complications5 (4.9%)1 (3.6%)0.775

Conclusion: Single incision laparoscopic appendectomy performed by residents is associated with slightly increased estimated blood loss and longer operative times. There are no significant differences in the rate of operative complications or postoperative course between the two groups. Single incision laparoscopic appendectomy performed by residents is safe and feasible and is recommended as part of surgical training.

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