Laparoscopic Appendectomy Research Articles

SP1.14 - Advancing Surgical Education: A Pilot Study Evaluating the Impact of Augmented Reality in Post-Graduate Surgical Skill Training

Abstract Aim The landscape of post-graduate surgical education, influenced by the clinical pressures of the COVID-19 pandemic, has prompted a shift towards prioritizing patient safety and embracing simulated technology for skill development and assessment. This study aims to evaluate the influence of (LapAR™) simulation on the acquisition of surgical skills and the overall training experience for junior surgical trainees. Methods 15 trainees and 2 consultants were recruited across five training sites. Participants used (LapAR™) at home to perform ten appendicectomies, interspersed with LapPass tasks. Objective metrics, including completion time and distance, were quantified, followed by comprehensive interviews. Results Junior surgical trainees demonstrated improvements in completion time, distance travelled, smoothness, acceleration, and ambidexterity during repeated laparoscopic appendicectomies. It is of interest that trainees were meeting consultant benchmarks across all modalities. Qualitative analysis emphasized the relevance of Augmented Reality in early surgical training, advocating for its mandatory integration. Participants sought prolonged access to (LapAR™), acknowledging its value for list preparation, skill acquisition, and knowledge enhancement. Home-based training offered flexibility, contrast to the pressures of traditional surgical environments. Despite technical challenges, (LapAR™) delivered realistic educational benefits. Conclusion (LapAR™) presents a scalable and transformative approach to enhancing surgical skills while addressing common challenges faced by trainees. This study validates its efficacy through improved skills aligned with objective metrics, positive evaluations of educational content, and unanimous agreement on the realism of the simulation. Augmented Reality bridges the gap between surgical training and practice, offering a scalable solution to elevate the standards of surgical education.

Conversion Rates, Causes, and Preoperative Associated Factors in 3,411 Laparoscopic Appendectomies: Insights after Nearly Three Decades of Laparoscopy and an Analysis of the Learning Curve

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.

Beyond mere appendicitis: A case report on an unforeseen diagnosis of appendiceal schwannoma

IntroductionAppendiceal schwannomas are a rare diagnosis, with little evidence to guide management and follow-up. There are currently no case reports focusing on follow-up for appendiceal schwannomas after complete surgical resection. Presentation of caseA 64-year-old female presented to the emergency department, febrile, with migratory right iliac fossa pain and focal peritonism, consistent with acute appendicitis. The diagnosis was supported by a computed tomography scan and she underwent a laparoscopic appendicectomy. Histopathology was reported as acute appendicitis associated with a schwannoma at the appendiceal base. The patient underwent a colonoscopy six weeks after her initial surgery with no abnormal findings. Following multidisciplinary team discussion it was decided that no further follow up was required. DiscussionThere are only 15 case reports of appendiceal schwannomas in the literature. As a result, the management and follow up in this case was guided from evidence reported in studies of other schwannomas elsewhere in the gastrointestinal tract, standard management of benign appendiceal lesions and MDT discussion. One retrospective single-centre cohort study of histopathology records collected over a 20 year period showed that in 44 patients with GI schwannomas, there was no malignant transformation or recurrence during a mean follow up period of 5.0 ± 4.31 years (Singh et al., 2022). Based on this study there is a very low risk of malignant transformation associated with these lesions. ConclusionBased on limited published data resection remains the mainstay of management of appendiceal schwannomas. Colonoscopy is recommended to exclude any underlying lesion or synchronous pathology.

Use of drainage after laparoscopic complicated appendectomy in children: a single-center experience

Use of drainage after laparoscopic complicated appendectomy in children: a single-center experience

Diagnostic Accuracy of C-Reactive Protein in Acute Appendicitis

Objective: To determine diagnostic accuracy of C-reactive protein in acute appendicitis. Study Design: Cross-sectional study. Place and Duration of Study: Surgical unit Combined Military Hospital Gujranwala Pakistan, from Apr 2019 to Jan 2021. Methodology: One hundred and twenty patients were included in the study following the inclusion criteria after their written permission and willingness. C-reactive protein levels were sent pre-operatively to the Pathology department of Combined Military Hospital Gujranwala. Patients were operated on by two classified surgeons. After open and laparoscopic appendectomies, specimens were sent to Histopathologists at Armed Forces Institute of Pathology Rawalpindi. Results were compared to determine the diagnostic accuracy of C-reactive protein. Results: Out of 120 patients, 72(60%) were males and 48(40%) were females. The diagnostic accuracy of C-reactive protein in acute appendicitis was calculated by keeping tissue diagnosis histopathology as the gold standard, where 82(68.33%) were true positive, 7(5.84%) were false positive, 13(10.83%) were true negative, and 18(15%) were false negative. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 89.13%, 67.86%, 90.11%, 65.52% and 84.17% respectively. Conclusion: The of C-reactive protein level test for the diagnosis of acute appendicitis was very sensitive but not very specific. C-reactive protein levels should be measured routinely in suspected cases of acute appendicitis, along with Total Leucocyte Count and ultrasound abdomen, as a useful marker for early diagnosis, thus reducing negative appendectomy rates.

Transumbilical laparoscopic-assisted appendectomy in children and adolescents: what have we learnt in more than 1200 cases?

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. 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. 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 33min. 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. 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.

Case report: a safe laparoscopic technique for complicated appendicitis

A case of complicated appendicitis is presented to illustrate a safe laparoscopic appendectomy technique. What makes extirpation so difficult in complicated appendicitis? Infection and tissue injury initiate the release of cytokines, which attract the omentum and cause contiguous loops of bowel to adhere, effectively isolating the inflammatory locus. Surgical dissection must reverse this process. Visualization is excellent in laparoscopy; however, operators lack tactile sensation; and when organs are fused together, touch is a valuable aid to accurate dissection. Injury to the adjacent organs (small bowel, colon, fallopian tubes, or ureter) may occur and require repair or resection (cecectomy or hemicolectomy). What is needed is an operative technique that is safe and effective in these challenging situations, especially when the appendix is adherent to adjacent structures and encased in a cocoon of (highly vascularized) fibrous tissue, a phlegmon. The technique presented is derived from open surgery. It is utilized to avoid injuring vulnerable structures in the pelvis, when performing a proctectomy for ulcerative colitis or Hirschsprung’s Disease. This goal is accomplished by maintaining a plane of dissection that abuts the rectal wall. The same technique is applied in complicated appendicitis to avoid injuring adjacent organs. This procedure is contrasted with an alternate (simpler) technique applicable to uncomplicated appendicitis.

Comparison of polymeric clip and endoloop in laparoscopic appendectomy: A systematic review and meta-analysis

BackgroundAppendicitis is a common surgical emergency with diverse clinical presentations, making its diagnosis challenging. Laparoscopic appendectomy has become the standard treatment, with various methods for appendiceal stump closure, including polymeric clips and endoloops. This study aims to compare the efficacy and safety of polymeric clips compared with endoloops in laparoscopic appendectomy. MethodsA systematic review and meta-analysis were conducted followingPreferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Medline, Scopus, and Embase were searched for studies up to March 25, 2024. ResultsIn total, 13 studies, including 6 randomized controlled trials, were analyzed. Polymeric clipping demonstrated significantly shorter surgical time compared with the endoloop (standardized mean difference 0.37, 95% confidence interval 0.22–0.53, P < .00001), with no difference in hospital stay or overall complications. However, the endoloop was associated with a greater incidence of intra-abdominal abscess (risk ratio 3.53, 95% confidence interval 1.56–8.00, P = .003). Other outcomes, including time from instrument application to appendiceal cutting, ileus, and surgical-site infection, showed no significant differences between the 2 techniques. ConclusionPolymeric clipping appears to be superior to endoloop in terms of shorter surgical time and lower risk of intra-abdominal abscess formation in laparoscopic appendectomy for uncomplicated appendicitis. However, both techniques have similar outcomes regarding hospital stay and overall complications. Further research addressing study limitations and exploring patient-centered outcomes is warranted to guide clinical practice.

Direct visualization endoscopic retrograde appendicitis therapy for treatment of acute uncomplicated appendicitis.

To investigate the diagnostic and therapeutic value of direct visualization (single-use eyeMax subscope) endoscopic management of acute uncomplicated appendicitis. Thirty-six patients diagnosed with acute uncomplicated appendicitis, confirmed by computed tomography or ultrasonography, from Jan 2023 to Feb 2024 were enrolled in this study. We collected demographics, colonoscopy findings, subscope findings, clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT), and adverse events associated with ERAT. Appendiceal intubation was successful for all 36 patients. Thirty-five patients (97.2%) were definitely confirmed as having acute uncomplicated appendicitis. One patient with negative appendicitis was diagnosed as having cecal diverticulitis with fecalith incarceration. The mean procedure time was 13.1 ± 13.6 min. One patient presented with worsening abdominal pain, and a computed tomography scan suggested a perforated appendix. The mean length of hospitalizations was 1.78 ± 2 days. The mean follow-up was 158 days; during this period, two patients (5.6%) experienced recurrent abdominal pain after 23 and 88 days and subsequently underwent laparoscopic appendectomy. Direct visualization ERAT may be effective for diagnosing and treating acute uncomplicated appendicitis and seems to have a low complication rate.

A Successful Laparoscopic Appendectomy for an Adult Male Patient with Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is a genetic connective tissue disease defined by the loss of bone mass and density, which makes the bones more brittle and more likely to fracture over time. Bone deformity and articular instability are the subsequent symptoms. This 25-year-old man had malformed lower limbs and trouble walking due to OI and dwarfism. He arrived complaining of fever, nausea, vomiting and diffuse peri-umbilical pain. During ultrasonography a blinded, oedematous lobe formation containing an appendicolith was discovered. Acute suppurative appendicitis was diagnosed, necessitating a laparoscopic appendectomy. Because the patient had previously undergone general anaesthesia, anaesthesia was thought to be attainable. Pneumoperitoneum and a 10 mm optical port inserted into the umbilicus were used in the surgical procedure. A diagnostic laparoscopy revealed faecolith obstruction and an acute suppurative appendicitis. After an hour, a laparoscopic appendectomy was performed effectively with little blood loss. Without experiencing any difficulties because of the surgery position, the patient was discharged. We present a case of an OI dwarf patient with acute suppurative appendicitis. It highlights the possibility of performing laparoscopic surgery in general and a laparoscopic appendectomy in particular on OI patients. In rare instances involving OI, laparoscopic surgery in general and laparoscopic appendectomy in particular are practical and efficient options.

A randomised, double blinded control study to compare the efficacy of intraperitoneal nebulization and instillation of ropivacaine for postoperative pain relief in patients undergoing laparoscopic appendicectomy

: Patients scheduled for laparoscopic appendicectomy encounter moderate to severe shoulder pain on the first postoperative day. Intraperitoneal nebulization of local anaesthetics is a new technique which provides uniform spread of local anaesthetic drug particles all through the peritoneum thus providing enhanced analgesic efficacy when compared to intraperitoneal instillation which provides non uniform distribution of the drug. : Fifty participants posted for laparoscopic appendicectomy under general anesthesia were randomized into Group A (Intraperitoneal nebulization of 8ml ropivacaine 0.75%) and Group B (intraperitoneal instillation of 8ml ropivacaine 0.75%). Our primary aim was to evaluate analgesic efficacy in both the groups postoperatively. Our secondary objectives were to compare the incidence of shoulder pain post operatively, total 48 hours fentanyl consumption and postoperative complications like nausea &amp; vomiting and paralytic ileus. : There was statistically significance in the pain scores at 24 hours (static pain p=0.003 and dynamic pain p=0.005) &amp; at 48 hours after surgery (static pain p=0.00 and dynamic pain p=0.015). Significant difference was seen in the incidence of shoulder pain. In Group A, no patients complained pain in shoulders while in Group B a maximum of 6 patients complained shoulder pain postoperatively (p=0.022). The total fentanyl consumption over 48 hours was 0.20 ± 0.005 in Group A and 0.80 ± 0.957 in Group B (p = 0.008). Occurrence of postoperative Nausea &amp; Vomiting were similar in both groups. None of the patients complained paralytic ileus in both groups as systemic absorption of the ropivacaine is also considerably less in comparison to other local anaesthetic drugs . : Intraperitoneal nebulized ropivacaine provides greater reduction in postop pain, lesser consumption of opioids, reduction in referred shoulder pain in laparoscopic appendicectomy patients.

Late intra-abdominal abscess after laparoscopic appendectomy in a child

Late intra-abdominal abscess after laparoscopic appendectomy in a child

Practice patterns and clinical outcomes in acute appendicitis differ in the elderly patient.

Appendicitis is the most frequent global abdominal surgical emergency. An ageing population, who often exhibit atypical symptoms and delayed presentations, challenge conventional diagnostic and treatment paradigms. This study aims to delineate disparities in presentation, management, and outcomes between elderly patients and younger adults suffering from acute appendicitis. This subgroup analysis forms part of ESTES SnapAppy, a time-bound multi-center prospective, observational cohort study. It includes patients aged 15years and above who underwent laparoscopic appendectomy during a defined 90-day observational period across multiple centers. Statistical comparisons were performed using appropriate tests with significance set at p < 0.05. The study cohort comprised 521 elderly patients (≥65years) and 4,092 younger adults (18-64years). Elderly patients presented later (mean duration of symptoms: 7.88 vs. 3.56days; p < 0.001) and frequently required computed tomography (CT) scans for diagnosis (86.1% vs. 54.0%; p < 0.001). The incidence of complicated appendicitis was higher in the elderly (46.7% vs. 20.7%; p < 0.001). Delays in surgical intervention were notable in the elderly (85.0% operated within 24h vs. 88.7%; p = 0.018), with longer operative times (71.1 vs. 60.3min; p < 0.001). Postoperative complications were significantly higher in the elderly (27.9% vs. 12.9%; p < 0.001), including severe complications (6.9% vs. 2.4%; p < 0.001) and prolonged hospital stays (7.9 vs. 3.6days; p < 0.001). Our findings highlight significant differences in the clinical course and outcomes of acute appendicitis in the elderly compared to younger patients, suggesting a need for age-adapted diagnostic pathways and treatment strategies to improve outcomes in this vulnerable population.

Risk factors for developing intra-abdominal abscess following appendicectomy for acute appendicitis: a retrospective cohort study

BackgroundLaparoscopic appendicectomy is commonly performed in Australia for treatment of acute appendicitis. Intra-abdominal abscess (IAA) is a potential complication following appendicectomy for acute appendicitis. Risk factors for developing post-operative IAA remain controversial and poorly defined. Laparoscopic washout may be performed for patients who develop complication(s) including IAA. The aim of this study was to define risk factors for both the development of IAA and identify patients who may require laparoscopic washout following appendicectomy.MethodsData were obtained from 423 patients who underwent laparoscopic appendicectomy over a five-year period (2012–2017). Clinical (fever, haemodynamics, examination findings), biochemical (white cell count, neutrophil count, C-reactive protein, bilirubin, albumin), radiological (CT free fluid), and operative factors (inflammation, suppuration, free-fluid, perforation, histopathology) collected in the pre-, peri-, and post-operative period(s) were analysed.Results23 (5.4%) patients developed post-operative IAA. Duration of intravenous antibiotics was significantly longer in patients who developed IAA and in those who required laparoscopic washout (p < 0.0001). C-reactive protein (CRP) on admission (p < 0.05) and appendiceal perforation (p = 0.0005) were significantly higher in patients who either developed IAA or needed laparoscopic washout. No clinical or radiological finding predicted either the development of IAA or need for laparoscopic washout.ConclusionElevated CRP on admission may predict the development of post-operative IAA formation or the need for laparoscopic washout post-appendicectomy. Prolonged post-operative antibiotic use appears independent of the development of IAA as well as the need for laparoscopic washout. These data highlight the need for clear guidelines on peri-operative antibiotic use following appendicectomy.

Prognostic value of 24-hour cultivation of peritoneal fluid to distinguish complicated from uncomplicated acute appendicitis: a prospective cohort study

BackgroundThe distinction between complicated and uncomplicated acute appendicitis (AA) is important as it guides postoperative antibiotic treatment. A diagnosis based on intraoperative findings is imprecise and standard cultivation of peritoneal fluid is generally time-consuming with little clinical benefit. The aim of this study was to examine if cultivation of peritoneal fluid in acute appendicitis could reliably detect bacteria within 24 h.MethodsPatients older than 18 years undergoing laparoscopic appendectomy were prospectively enrolled at two surgical departments after informed consent was obtained. Periappendicular fluid was collected prior to appendectomy and sent for cultivation. Sensitivity, specificity and positive and negative predictive values were calculated with 95% confidence intervals (CIs) using 72-hour cultivation results as the gold standard. Patients with complicated AA as determined by the surgeon, received a three-day course of oral antibiotics. Postoperative infectious complications within 30 days after surgery were registered.ResultsFrom July 2020 to January 2021, 101 patients were included. The intraoperative diagnosis was complicated AA in 34 cases. Of these patients, six (17.6%) had bacteria cultured within 24 h after surgery, leading to a sensitivity of 60% and a specificity of 100%. The positive and negative predictive values were 1.00 and 0.96, respectively. Seven patients developed a postoperative infection (five superficial wound infections and two intra-abdominal abscess). In all cases with a positive cultivation result, the intraoperative diagnosis was complicated appendicitis and a postoperative course of antibiotics prescribed.ConclusionTwenty-four-hour cultivation of the peritoneal fluid in acute appendicitis is a valid indicator for peritoneal bacterial contamination. Randomized studies are necessary to determine if this approach is suitable for targeting postoperative antibiotic treatment as a means to prevent overtreatment without increasing the risk of infectious complications.

Analysis between open and laparoscopic appendectomy. A comparative study of the procedure in Brazil and worldwide

Introduction: The appendix is an organ in the human body that serves as a reservoir for natural bacteria in the gastrointestinal tract and also has an immunological function that is not so well understood. The acute inflammatory process that can occur in this organ is called acute appendicitis and is the most common surgical emergency worldwide. Objectives: To carry out a literature review on the analysis between open and laparoscopic appendectomy, and to compare how this surgery is performed in Brazil and worldwide. Material and Methods: The methodology used was a literature review. The research was carried out through an electronic search of scientific articles published on the Scielo (Scientific Electronic Library Online) and Lilacs (Latin American Health Sciences Literature) and Pubmed websites. The health terminologies consulted in the Health Sciences Descriptors (DeCS/BIREME) were used to analyze open and laparoscopic appendectomy. Discussion: Appendectomy has largely replaced open surgery as the treatment of choice for diseases of the appendix, especially acute inflammation, as it has effective results and some advantages. Video appendectomy did not gain absolute acceptance as quickly as cholecystectomy, for example, and it is only in the last 10 years that this type of minimally invasive approach has excelled the open approach worldwide. Conclusion: According to the literature, laparoscopy has recently become the most prevalent way of performing appendectomy. Despite this trend, the majority of appendectomies were performed by the open route. This can be explained by logistical, financial or medical team preparation issues. Some studies have shown that the rate of complications after surgery in the laparoscopic group was significantly lower than in the open appendectomy group.

Assessing the impact of appendicectomy in daily activities/social life of children

Background: Appendicectomy is a common surgical procedure for children presenting with appendicitis. Understanding the impact of appendicectomy on daily activities and social life is crucial for optimizing patient outcomes. Aims and Objectives: This study aimed to assess the impact of appendicectomy on children’s daily activities and social lives. Materials and Methods: A retrospective analysis was conducted of patients aged ≥5 years who underwent appendicectomy at our center between April 2022 and April 2023. Data on demographics, surgical approach (open or laparoscopic), post-operative outcomes, and return to daily activities were collected using a standardized questionnaire. Results: Among the 70 identified cases, there was a male predominance (63%), with most presenting with acute appendicitis (85%). Laparoscopic appendectomy was the predominant surgical approach used (80%). Post-operative symptoms included pain (n=12), vomiting (n=3), fever (n=2), and wound infection (n=6). Appendicular abscesses were found in 9% of laparoscopic surgeries and 14% of open surgeries. The average duration of hospital stay was shorter in laparoscopic cases. Return to school and normal diet varied between surgical approaches, with laparoscopic cases generally showing a quicker recovery. Conclusion: Although appendicectomy is commonly performed, it has implications for children’s daily routines and social interactions. Parental anxiety plays a crucial role in post-operative recovery. Future studies should focus on addressing these social determinants to optimize patient outcomes.

Management of acute appendicitis in pediatric patients with acute leukemia: Insights from a single-center study.

Acute appendicitis (AA) in pediatric patients with acute leukemia mandates prompt treatment. Diagnosis presents challenges, relying on clinical and radiological assessments, often leading to treatment delays that may disrupt leukemia management. Our study on 14 such cases underscores the pivotal role of swift intervention. While conservative AA treatment may pose no risk to healthy children, our findings mandate the performance of laparoscopic appendectomy within 24hours of diagnosis. This strategy yielded successful surgical outcomes while ensuring uninterrupted leukemia care. Our experience contributes important insights to the limited understanding of navigating this complex clinical scenario.

Non-Operative Management of Uncomplicated Appendicitis in Children: Can Patients Be Discharged From the Emergency Department?

IntroductionNon-operative management of uncomplicated appendicitis in children is a safe alternative to laparoscopic appendectomy. The purpose of this study is to determine the feasibility of nonoperative outpatient management of uncomplicated appendicitis in pediatric patients. MethodsA standardized pathway for non-operative outpatient management of uncomplicated appendicitis in children (NOMA-C) was implemented in a university pediatric surgery practice starting October 2021. Those who met criteria would be considered for discharge from the emergency department (ED) with oral antibiotics and close followup over the following year. A quality improvement project started concurrently to monitor patients for recurrent symptoms of appendicitis. ResultsA total of 121 patients were diagnosed with acute appendicitis during the study period (October 2021 to April 2023). Forty-five children (38%) met criteria for the NOMA-C protocol, and 11 patients/families chose appendectomy. Of the 34 patients who pursued nonoperative management, 14 patients were admitted to the hospital and 20 patients were discharged from the ED. Total time in the ED/hospital was significantly shorter for patients discharged from the ED (7 hours versus 23 hours; p<0.001). At one year follow up only 4 (12%) had undergone appendectomy. There were no adverse events for patients who underwent nonoperative management. ConclusionA protocol offering non-operative management of appendicitis with an option for outpatient management was feasible and safe. Outpatient management was associated with shorter ED/hospital stays than those admitted. Future studies should evaluate whether this protocol can be adopted by EDs without pediatric surgery services to avoid the need for transfer.

Evaluation of Laparoscopic Appendectomy in Response to Anatomical Variation of Appendix

Evaluation of Laparoscopic Appendectomy in Response to Anatomical Variation of Appendix