Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis

Single-incision laparoscopic surgery (SILS) is a novel area of minimally invasive surgery that uses a single incision to minimize all ports to one site. The end result is an incision that can be strategically placed in the umbilicus for a perceived scarless abdomen. The authors rationalized that a randomized controlled trial was important given the rapid popularization of this approach. An institutional review board-approved prospective randomized trial compared patients undergoing SILS (SILS-A) and conventional laparoscopic (LAP-A) appendectomy at a free-standing children's hospital during a median follow-up period of 2.2 years. A total of 50 patients (50 % boys and 67 % Hispanics) were randomized equally to SILS-A and LAP-A. The patients ranged in age from 3 to 15 years without a difference between the two groups. Half (50 %) of these patients were younger than 8 years. The technique for SILS-A involved a single supraumbilical curvilinear skin incision with three fascial incisions. Ports were inserted to varying depths to minimize restriction of instrument movement. Coaxial visualization was improved by the use of a 30° scope. To achieve technical comparability with the LAP-A, a stapler device was used, which required upsizing a 5 mm port to a 12 mm port. The mean duration of the operation was 46.8 ± 3.7 min (range, 22-120 min) compared with 34.8 ± 2.5 min (range, 18-77 min) for standard LAP-A (p = 0.010). No conversions occurred, and the two groups did not differ in hospital length of stay. The postoperative complications consisted of one wound seroma in the SILS-A group (nonsignificant difference), and no hernias were seen. No difference in readmissions, diet tolerance, fever, or postoperative pain was noted between the two groups. The findings show the SILS approach to be feasible in the pediatric population despite the limited abdominal domain in younger children. Although SILS operating room times currently are longer than for LAP-A, they are comparable, and no other outcomes differed appreciably between the two techniques at the time of hospitalization or during the follow-up period

An Evolutionary Change in First Case on Time Starts Using Perioperative Process Improvement, Communication and Enhanced Data Integrity

Background: First Case on Time Starts (FOTS) are an important Operating Room performance metric. The study aim is to show how implementation of process improvement (PI) solutions and an electronic health record (EHR) led to a progressive, significant, and sustainable improvement in FOTS. Methods: FOTS were tracked in the Main OR Suite (MOR) at Children’s Medical Center Dallas, from January 2007 through March 2014. Approximately 17,000 scheduled first cases were evaluated. Significance was set at p&lt;0.05. Results: FOTS were 12% in 2006. An OR Collaborative Redesign, implementation of a preoperative clinic and a change the preoperative phone call increased FOTS to 32% by early 2009. In 2009, an EHR was implemented. The EHR, its ability to identify specific accountability for delay (surgeon, anesthesiologist, and nurse, patient, other) and improved data integrity, increased FOTS to 60% by 2012. Using enhanced communication methods such as real time communication to staff, and data socialization, OTS further improved to 80% by 2014.</p