ABSTRACT Background: the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil. Materials and Methods: retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. Results: we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team’s adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period. Conclusion: the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries. Background 1 Brazil Methods 200 2018 service 2007, , (2007) 2008, 2008 (2008) 247 24 7 24/ 2010, 2010 (2010) thirdparty third party 2013. 2013 . (2013) Results 116 69 59%, 59 59% (59%) 46 40%, 40 40% (40%) 1% (1% open converted respectively 11 80 2016 p<0.001. p0001 p p<0.001 0 001 (p<0.001) hemolok hem o lok feasible teams team s adherence 85 201 rd physicians reported 30day day 30 Conclusion reproducible optimization lowerincome lower income countries 20 (2007 (2008 2 (2010 (2013 6 5 (59% 4 (40% (1 8 p000 p<0.00 00 (p<0.001 3 (200 (201 (59 (40 ( p00 p<0.0 (p<0.00 (20 (5 (4 p0 p<0. (p<0.0 (2 p<0 (p<0. p< (p<0 (p< (p
RESUMO Introdução: o presente estudo tem como objetivo avaliar as medidas que permitiram a implementação de cirurgias laparoscópicas de urgência em hospital de ensino médico ao longo de 15 anos. Método: foi realizado estudo clínico retrospectivo de pacientes submetidos a Apendicectomia aberta ou Laparoscópica no período de 15 anos (2004 a 2018). Os dados clínicos foram confrontados com as ações implementadas: 1) Treinamento dos médicos residentes em cirurgia minimamente invasiva (2007); 2) Uso do endoclip para tratamento do coto apendicular (2008); 3) Disponibilidade do set de laparoscopia em tempo integral para o Pronto Socorro (2010); e, 4) Terceirização do serviço de manutenção do set e materiais de vídeo e uso do endoclip Hem-o-lok® para tratamento do coto apendicular (2013). Resultados: foram realizadas 1.168 cirurgias, das quais 691 abertas (59%), 465 laparoscopias (40%) e 12 convertidas (1%). O treinamento da equipe levou à realização de 11% de laparoscopia (2007) e o uso do endoclip para tratamento do coto apendicular para 16% (2008). Com a disponibilização do set de vídeo em tempo integral para o Pronto Socorro a partir de 2011, houve aumento de laparoscopias para 26% (2012). A padronização do endoclip Hem-o-lok® no tratamento do coto apendicular aumentou para 85% e a partir de 2016 foi realizado em todos os casos, sem complicação relacionada ao seu uso, mesmo em apendicites complicadas. Conclusão: o emprego da laparoscopia no serviço de urgência envolve além do treinamento da equipe cirúrgica, investimento tecnológico contínuo e uso de técnicas que sejam factíveis, viáveis e seguras. Introdução 1 Método 2004 (200 2018. 2018 . 2018) implementadas 2007 2 2008 (2008) 3 2010 (2010) 4 Hemolok® Hemolok Hem lok® lok Hem-o-lok 2013. 2013 (2013) Resultados 1168 168 1.16 69 59%, 59 59% , (59%) 46 40% 40 (40% 1%. 1% (1%) 11 (2007 16 2008. 2011 26 2012. 2012 (2012) 85 201 casos complicadas Conclusão cirúrgica factíveis seguras 200 (20 (2008 (2010 (2013 116 1.1 6 5 (59% (40 (1% (2012 8 20 (2 (201 1. (59 (4 (1 ( (5