Abstract
Abstract
Introduction:
Appendectomy is the most common pediatric surgical procedure. To decrease the cost and environmental impact of single incision pediatric endosurgery (SIPES) appendectomy, we switched from using endoscopic staplers to polymeric clips placed with nondisposable laparoscopic appliers. The aim of this study was to compare the resulting reduction in cost and amount of waste generated per case, as well as to compare the perioperative variables and outcomes in patients in whom clips were used, with those of historical patients in whom staplers were used.
Materials and Methods:
Retrospective chart review of SIPES appendectomies was performed and patients in whom clips were used were compared with patients in whom staplers were used. Demographic, operative, and clinical data were collected. t-Test, Mann-Whitney test, and chi squared test were used to analyze the data as appropriate. The cost to the hospital of the clips and staplers was compared. The disposable waste generated from clips and the staplers was weighed.
Results:
A total of 246 patients were included: 111 in stapler group and 135 in clip group. There were no statistically significant differences between the groups in operative time, estimated blood loss, length of stay, and complications. There were no complications related to use of clips. In the clip group, staplers were used in 10% because base of appendix was too large, gangrenous, or perforated and could not be clipped. Use of polymeric clips was less expensive and generated less waste.
Conclusions:
Use of polymeric clips for appendectomy is safe and effective, and results are comparable with those of stapling. Based on our data, in 90% of appendectomies, the base of appendix is amenable to clipping. This study supports use of clips over staplers to decrease cost and environmental impact.
Introduction
A
Before 2013, we used the endoscopic stapler because of its ease and speed. We then transitioned to using nonabsorbable polymeric clips to lower cost and decrease environmental impact. Use of polymeric clips for appendectomy was previously demonstrated in the literature and was found to be safe and effective in a small series of adult patients.7,8
In this single-surgeon retrospective review, the staplers and polymeric clips in single incision pediatric endosurgery (SIPES) appendectomy were compared in terms of patient outcomes. We hypothesized that there would be no difference between the two methods in operative time, estimated blood loss (EBL), length of stay (LOS), and complications.
Materials and Methods
Operative technique
All appendectomies were performed with single incision laparoscopy using a commercial multichannel trocar. Early in the series, Olympus TriPort™ (Olympus, Tokyo, Japan) was used, which was transitioned to GelPoint Mini™ (Applied Medical, Rancho Santa Margarita, CA) in second part of the series. Traditional nonarticulating 5 mm laparoscopic instruments were used. L-hook monopolar cautery was used to take the mesoappendix in all cases. In the stapler group, 35 mm endoscopic staplers of hospital-preferred manufacturer were used to transect the appendiceal base. In the clip group, two nonabsorbable polymer clips (Hem-o-lok™, Teleflex, Wayne, PA) were used to ligate appendiceal base and appendix was transected with endoscopic scissors between clips. All cases were performed by general surgery residents with help of attending pediatric surgeon.
Data collection
After study protocol was approved by the Institutional Review Board, single-surgeon appendectomy cases were identified from August 2011 to March 2017 from the American College of Surgeons case log. Polymer clip technique was introduced in October 2013. Charts were retrospectively reviewed and the following variables were recorded: age, gender, weight, diagnosis, operative time, EBL, postgraduate year of operating resident, LOS, and complications. The cost to the hospital of the clips and staplers was compared. The disposable waste generated from clips and the staplers was weighed.
Statistical analyses
All statistical analyses were done in IBM SPSS 24. For testing the differences between the clip and the stapler groups, we used Student's t-tests and Mann-Whitney tests for continuous variables, and Pearson's chi-squared tests for categorical variables. A P-value of <.05 was used as a criterion for statistical significance. To assess the practical significance of the results, we used the following effect size measures: Cohen's d (t-tests), Pearson's r (Mann-Whitney tests), and Cramer's V (chi-squared tests). Intention to treat based analysis was employed: cases in clip group wherein the stapler had to be used because the appendiceal base was not amenable to clipping were analyzed with the rest of the clip group.
Results
A total of 246 patients were included, 111 in stapler group and 135 in clip group. Demographics of study patients are summarized in Table 1. There were no statistically significant differences.
Interpretation of effect size: small (0.10–0.30), medium (0.30–0.50), and large (>0.50).
M, arithmetic mean; SD, standard deviation.
Percentage of perforated appendicitis as defined by St. Peter et al. 9 was 23%, which includes interval appendectomies. Most procedures were performed by 4th year general surgery residents (50%), followed by 2nd year residents (41%), and interns (7%).
Perioperative variables are summarized in Table 2.
EBL, estimated blood loss; LOS, length of stay; M, arithmetic mean; SD, standard deviation.
Complications
There were no intra- or postoperative complications related to use of clips. There were no conversions to open or to multiport laparoscopy.
The most common postoperative complication was intraabdominal abscess formation that required drainage, which was similar between groups and occurred in 12% in complicated and 1% in simple appendicitis.
Two complications required repeat operations: 1 patient in the stapler group had a laparotomy and wash-out for multiple abscesses, and 1 patient in the clip group had laparoscopic lysis of adhesions for small bowel obstruction.
Two patients in the stapler group and 1 patient in clip group had a superficial wound infection that required opening of incision and packing.
Other complications did not require procedural intervention. They included returns to the emergency room for constipation or pain, Clostridium difficile colitis, and pneumonia.
Depending on the number of staple loads used to ligate the appendiceal base, the hospital spent between $286 and $333 less per case when using the polymeric clips. The polymeric clips come in packs of six clips and two to three clips are used in each case. The weight of the disposable waste from polymeric clips per case was 9.8 g plastic and 0.4 g paper. The weight of the disposable waste from endoscopic staplers per case was 582 g metal, 381 g plastic, and 12.1 g paper.
Discussion
In this single-surgeon retrospective review of 246 SIPES appendectomies, we found no statistical difference in the operative time, EBL, LOS, and complication rate between stump closure with endoscopic staplers and polymeric clips. These results are consistent with the existing literature demonstrating that polymeric clips are safe and effective.
Although this study confirms the safety and efficiency of polymeric clips for appendiceal stump closure, it also demonstrates cost savings and waste reduction of a single procedural change in a common operation. Even in a small children's hospital performing ∼300 appendectomies per year, this can lead to a $90,000 annual savings and 289 kg less waste generated annually or a 52-fold reduction in waste per case.
This retrospective review has some limitations. First, only one surgeon at one institution was analyzed. In addition it has a narrow focus, analyzing the differences between only two methods of stump closure. Most patients followed up 2 weeks postoperatively, and this short follow-up may miss some complications such as adhesive disease or clip migration that may take longer to present.
Further studies could include analysis of larger data sets from multiple surgeons and multiple institutions. Including multiple closure methods in the analysis would also be helpful.
In summary, appendiceal stump closure with polymeric clips is comparable with that with endoscopic stapler with regard to operative time, EBL, LOS, and complication rate for pediatric patients undergoing SIPES appendectomy at our institution.
Footnotes
Disclosure Statement
No competing financial interests exist.