Factors influencing the difficulty and the need for external help during laparoscopic appendectomy: Analysis of 485 procedures from the resident-1 multicenter prospective resident-led trial

Abstract text (incl. references and figure legends)

Introduction: Laparoscopic Appendectomy (LA) is the gold standard for approaching acute appendicitis.LA is considered an index procedure for surgical trainees but can become a nightmare also for senior surgeons when dealing with complicated appendicitis (perforation, intrabdominal abscess, peritonitis). In this study we aimed to identify preoperative predictive factors for technically challenging laparoscopic appendectomy (LA), in which external help is needed to complete the procedure laparoscopically. Material & Methods: We retrieved the Resident-1 multicenter registry data, including pre-intra and postoperative clinical variables. The operator classified each procedure following a five-grade Likert scale to define technical difficulty. Grade 4-5 procedures identified challenging procedures needing external help, scrubbed in or not, to complete a LA. We performed a univariate analysis comparing Grade 1-3 versus 4-5 procedures and then built a logistic regression model to identify preoperative independent predictors of Grade 4-5 procedures. Results: Five hundred sixty-one patients were recruited from 2019 to 2021. Four hundred eighty-five patients were included in the final analysis. A BMI > 30 kg/m2, preoperative CT scan, and the AIR score were independent predictors of complex LA with the need for external help to be completed. Patients undergoing such procedures were more frequently affected by CA, had longer operative times and had the worst postoperative outcomes. Conclusion: The preoperative identification of technically demanding LA could be helpful to optimize the preoperative planning, maximize surgeons" preparedness, and include expert surgeons earlier in the procedure. A multi-institutional study to create and validate a scoring system for the technical difficulty of LA is desirable. Reference: Cioffi SPB et al. World J Emerg Surg. 2019;14:25. Published 2019 May 30. doi:10.1186/s13017-019-0243-4

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