How Can Laparoscopic Appendectomy Become the First-Line Treatment for Acute Appendicitis in Lower-Income Countries: A 15-Year Experience

Abstract

Introduction: The barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource cost and availability. The present study evaluates the impact of actions took over 15 years in a single academic center aiming to implement the routine use of laparoscopy for acute appendicitis. Methods: Retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared with 4 major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. Results: We identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p < 0.001). Since 2016 the standard of care in our institution is appendiceal stump closure with polymeric clips, even in complicated acute appendicitis. Conclusion: The development of a feasible, reproducible, and safe technical standardization is one of the cornerstones for a consistent and viable change in the current practice for appendectomies in lower-income countries.