Laparoscopic appendectomy by surgical trainees at a public teaching hospital in Cape Town, South Africa: A retrospective, observational study

Abstract

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Background: The uptake of laparoscopic appendectomy (LA) for acute appendicitis is variable in resource-limited settings despite an abundance of literature demonstrating associated improved patient outcomes. In South Africa, surgical trainees often perform most emergency operations unsupervised. This study’s objectives were to describe the uptake and trainee supervision of LA at a teaching hospital in a resource-limited setting.

Methods: A retrospective, observational study analysing data from 1 January 2013 through 31 December 2015 was conducted at New Somerset Hospital, a public teaching hospital in Cape Town, South Africa. The study cohort comprised patients who underwent appendectomy for acute appendicitis. Factors associated with the choice of LA over open appendectomy (OA) among surgical trainees and surgical outcomes were analysed.

Results: Two hundred seventy-six appendectomies (62%) were attempted laparoscopically, with 225 (84%) completed as LA and 51 (19%) converted to OA. The proportion of cases completed laparoscopically increased significantly from 29% in 2013 to 68% in 2015 (P<0.001). Trainees were involved in all appendectomies, unsupervised in 85% of cases. Factors significantly associated with choosing OA included male gender, generalized peritonitis, elevated heart rate, and unsupervised trainees (P<0.005). The absence of trainee supervision was not associated with an increased duration of hospitalization (P=0.352) or conversion to OA (P=0.506).

Conclusions: LA was the most commonly performed operation for acute appendicitis, and the majority were conducted by unsupervised trainees in this setting. The establishment of an LA policy that employs a change management approach with support from all stakeholders is essential for scaling up LA at teaching hospitals, which may serve as a benchmark for the initiation of minimally invasive surgery in resource-limited settings.