Techniques for mesoappendix transection and appendix resection: Insights from the ESTES SnapAppy study

Abstract text (incl. references and figure legends)

Introduction: Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection, and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications.

Material & Methods: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy. We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs).

Results: 3768 consecutive adult patients were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1,564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1,379(37.0%), with a stapler in 1,421(38.1%) and between clips in 929(24.9%). While no statistical difference in outcomes could be detected between different techniques for division of the appendix base, a decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices.

Conclusions: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intra-operative surgical technique towards advanced adjuncts.

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