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A tiered approach to optimize pediatric laparoscopic appendectomy outcomes. J Pediatr Surg 2019 Dec;54(12):2539-2545

Date

09/15/2019

Pubmed ID

31519359

DOI

10.1016/j.jpedsurg.2019.08.034

Scopus ID

2-s2.0-85071982482

Abstract

BACKGROUND/PURPOSE: Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost.

METHODS: Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes.

RESULTS: A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes.

CONCLUSIONS: SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year.

TYPE OF STUDY: Treatment Study.

LEVEL OF EVIDENCE: Level III.

Author List

Bence CM, Wu R, Somers KK, Szabo A, Arca MJ, Calkins CM, Gourlay DM, Oldham KT, Sato TT, Siddiqui SM, Densmore JC

Authors

Casey Matthew Calkins MD Professor in the Surgery department at Medical College of Wisconsin
John C. Densmore MD Professor in the Surgery department at Medical College of Wisconsin
David M. Gourlay MD Chief, Professor in the Surgery department at Medical College of Wisconsin
Keith T. Oldham MD Professor in the Surgery department at Medical College of Wisconsin
Thomas T. Sato MD Professor in the Surgery department at Medical College of Wisconsin
Sabina Mahvish Siddiqui MD Assistant Professor in the Surgery department at Medical College of Wisconsin
Kimberly K. Somers PAC Physician Assistant Surgical in the Surgery department at Medical College of Wisconsin
Aniko Szabo PhD Professor in the Institute for Health and Equity department at Medical College of Wisconsin




MESH terms used to index this publication - Major topics in bold

Acute Disease
Adolescent
Appendectomy
Appendicitis
Child
Child, Preschool
Direct Service Costs
Female
Humans
Infant
Laparoscopy
Male
Operative Time
Postoperative Period
Retrospective Studies
Severity of Illness Index
jenkins-FCD Prod-482 91ad8a360b6da540234915ea01ff80e38bfdb40a