Wednesday, September 15, 2010

NSQIP Appendicitis Data

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database has yielded some great ammunition to my preferred side in the ongoing open/laparoscopic appendectomy (OA/LA) debate. In this paper, over 17,000 cases of appendicitis were reviewed from 2008. Interestingly, over 14,000 of the appendectomies were performed laparoscopically, indicating a sea change in OR strategy on a wide scale. Pertinent findings:
*Shorter OR time for LA
*Lower incidence of superficial and deep surgical site infections with LA
*Shorter hospital stay for LA
*Significantly lower mortality in the LA group

Finally, the surgical literature is catching up with the facts on the ground. For the life of me, I just don't understand why any surgeon would want to make a McBurney incision anymore.

9 comments:

HudsonMD said...

Buckeye,
Great data. I don't think i have ever seen you write about the Color Trial. Any comments?

Boris Vinogradsky, MD said...

Jeff,

With all due respect, I disagree. I challenge you to replicate the data presented in the article. I did appy open since 1986, then, switched to lap and then - in 2004 - back to open. Why? Very simple. My incision is usually no longer than 1 inch (2.5 cm) It is smaller than all lap incisions combined. My skin-to-skin time is under 10 minutes (best is 6 minutes more than once). Given, some appys go for more, and some (rare) go for 1+ hour. I finish my average appy before you even place the ports. Ninety percent of my patients go home the next day, some go home the same day. I do not know how you can beat it. My infection rate is very low. The cost of an open appy is 1/3 of a lap case. Again, I like laparoscopy and would never do an open chole instead of a lap chole, but appy...? Sorry, I am not convinced, until you beat my numbers.

Paracelsus said...

I think it has a lot to do with proficiency in laparoscopic surgery. I've seen many specific complications after laparoscopic appendectomy (i.e., bowel injury, port site infection) after operations done by not-so-experienced laparoscopic surgeons, and even residual abscesses due to lack of proper cleanup (despite wonderful vision, due to lack of confidence in mobilizing the enteric loops). In my view, laparoscopic appendectomy is NOT an operation to be approached lightly (with the exception of very experienced laparoscopic surgeons). I think the patients that get the most benefit from the laparoscopic approach are young females with an uncertain diagnosis, and the obese. I also think the McBurney (or Lanz) still have their place.

Buckeye Surgeon said...

Boris-
Thanks for stopping. I have done close to 500 lap appy's in my nascent career. I have a ZERO percent infection rate (superficial wound or intra-abd abscess) for all cases of appendicitis (peforated and simple). My cases average about 12-15 min. It's a superior, elegant operation, in my opinion. The visualization laparoscopy affords allows me to drain all purulent fluid collections, mobilize the ascending colon for tough retrocecal appies, and identify any other unanticipated pathology.

I think an incision ought to be as long as it needs to be. MAking small cuts just for the cosmetic effect is not appropriate or wise. If you're struggling with an open case, then you lengthen the incision. Surely not all your Mcburney slices are 1 inch long. The laparosocpic incisions are ALWAYS the same, no matter how complex the pathology.

Again, the data presented suggest that I am not alone in my thinking.

Hudson-
I ought to write up the COLOR trial. For colorectal cancer, only recently has it become de rigeur to proceeed with laparoscopic resections.

Frank Drackman said...

Buckeye, Buckeye, Buckeye...
Know you can't wait for that big Michigan Game, must be nice to play in a Mid Major Conference...
Seriously, RON ZOOK?!?!?!? He got run out of the SEC faster than the "Bush Tax Cuts" became the "Obama Tax Cuts".
And since your not a Gas Passer, you don't know how to convert Boris Badinoff's claims to real world data..
Ya gotta move the decimal point to the right, so his "2.5cm incision" is really 25cm, multiply his claimed times by 5, and take everything with a jaundiced eye...

Frank "Woody Hayes was a Poof" Drackman

Anonymous said...

Thank you for a nice blog. Couldn't you please post a video recording (unedited preferably) of a typical 12-15 min laparoscopic appendectomy? You are certainly much faster than me, and way below the average operating time in the cited article (50.5 min). It would be great to see just how you do it.

Sergiu said...

@Anonymous 8:44 AM

Laparoscopic appendectomy: standard technique 04'54''

http://www.websurg.com/ref/search-vd01en1605.htm

Registration required.

Anonymous said...

@Sergiu

Now, that is a nice video. But what is shown are extracts from two operations using slightly different techniques. The video is edited (nothing wrong with that) and you can't really say anything abut the actual operating times ("skin to skin") of the respective procedures. I would love to learn how to complete all the steps of the operation in 15 minutes or less.

Erica said...

From the peanut gallery - I am a happy lapro appendectomy client.

I was home a day later, back at work in three days, no stitches to remove, and now four years later have no scars at all.

I wouldn't have minded if they had done the traditional surgery (I don't care about scars, etc.) but the LP seemed to be very low maintenance.