Residents' Performance of Single-Incision Pediatric Endo-Surgery Appendectomy (SIPESA) Versus Conventional Laparoscopic Appendectomy (CLA) in Two Centers

Background: The outcome of SIPESA performed by surgical residents is explored once in the literature. To the best of our knowledge, there are no published studies comparing the outcome of SIPESA versus CLA performed by the surgical residents. Aim: To assess the outcome of SIPESA at King Fahd Armed Forces Hospital (KFAFH), Jeddah versus CLA at Prince Sultan Military Medical City (PSMMC), Riyadh performed by surgical residents. Material & Methods: A retrospective comparative study of the outcome of SIPESA versus CLA conducted in two centers from January 2011 to July 2018. The two groups were compared for age, seniority of operating surgeon, mean operative time (MOT), perioperative complications and length of hospital stay (LOS). Results: 136 appendectomies (83(61%) SIPESA & 53(39%) CLA) were performed by residents between January 2011 and July 2018 in both centers. Postoperative complications were reported in 3.8% of CLA and 3.6% of SIPESA. There was no signicant difference in postoperative complications between the two groups. The MOT of SIPESA and CLA was 92.25 minutes & 87.85 minutes respectively. Conclusion: SIPESA and CLA performed by residents are equally safe and feasible with no added morbidity. We believe that this good outcome is related to the adequate supervision of residents by experienced surgeons in conjunction with a properly structured training program. There was no signicant difference in the outcome of both groups.

groups. The MOT of SIPESA and CLA was 92.25 minutes & 87.85 minutes respectively.
Conclusion: SIPESA and CLA performed by residents are equally safe and feasible with no added morbidity. We believe that this good outcome is related to the adequate supervision of residents by experienced surgeons in conjunction with a properly structured training program. There was no signi cant difference in the outcome of both groups.

Background:
Most centers advocate laparoscopy for acute appendicitis to minimize the size and the number of skin incisions even for complicated appendicitis 1 . SIPESA, which was described for the rst time by Pelosi in 1992 2 ; and CLA are the most common procedures used in laparoscopic appendectomy. SIPESA gives easy and quick access for an incidental nding of intrabdominal anomalies, by removing the SIPESA port and performing the procedure extracorporeal.
Many comparative studies, a systematic review and pooled analysis demonstrated that single-incision laparoscopic appendectomy (SILA) is comparable to CLA in adults. These studies identi ed the need for randomized controlled trials to clarify the e cacy of SILA compared to CLA. RCTs comparing SIPSA to CLA showed that there is no difference except for the longer operative time 3 . SIPESA in pediatric patients has gained signi cant popularity because of its preferable cosmetic result which was not proved for SIPSA on long term follow up 4,5 . Previous studies have typically compared SIPESA & CLA appendectomy in children and have shown heterogeneous results 6 . There is no difference in the LOS or postoperative complications 5,7 . The longer MOT was the main concern of SIPESA 6 . One study has shown that SIPESA in children is safe and feasible when performed by residents versus fellows 8 . We have started SIPESA in 2011 and it became our standard approach for acute appendicitis. The residents have the priority in performing SIPESA in our institute. It is a challenging process for any center to balance between residency training curriculum and patient safety. To the best of our knowledge, this is the rst study to assess the outcome of SIPESA versus CLA undertaken by residents.

Aim
To assess the outcome of appendectomy performed by surgical residents. We compared the outcome of SIPESA at King Fahd Armed Forces Hospital (KFAFH), Jeddah versus CLA at Prince Sultan Military Medical City (PSMMC), Riyadh.

Material & Methods:
A retrospective comparative study conducted at KFAFH, Jeddah, and PSMMC, Riyadh, Saudi Arabia from January 2011 to July 2018. Medical students collected data from electronic records of all children below 14 years of age. Laparoscopic appendectomy was performed by residents in both centers. SIPESA is the preferred approach for acute appendicitis at KFAFH while CLA is preferred at PSMMC. All incidental appendectomies were excluded from the study. SIPESA was performed through a 1.5 cm umbilical incision using single-incision Medtronic SILS™ port. We applied endo-loops to the base of the appendix after controlling the meso-appendix mainly by hook diathermy with the aid of LigaSure TM device in complicated cases. The appendix was divided and retrieved through SIPESA port. All patients received IV Paracetamol (15 mg/kg q 8 h) and IM Tramadol (1 mg/kg q8h) postoperatively. All CLA patients were routinely catheterized before the operation to avoid urinary bladder injury as they routinely use Veress needle. CLA was undertaken using the standard approach with the rst 5 mm umbilical port and the other two ports were inserted in supra-pubic and left iliac fossa under vision. Ligation of the appendicular base was done with endoloops after division of the meso-appendix with diathermy hook. The appendix was extracted by endobag to avoid contaminating the wound. All patients received IV Paracetamol (15 mg/kg q8h) and IV Morphine infusion (10-20 mic/kg/hr) postoperatively. Pain was assessed by using the Facial Action Coding System (FACS) in both groups 8 .
The two groups were compared for seniority of operating surgeon, MOT, post-operative pain, duration of analgesia, postoperative complications, and LOS. A statistician analyzed the data by using Statistical Package for Social Science (SPSS) version 22. Descriptive statistics were used to summarize collected data. We reported frequency and percentages of categorical variables. We applied the reported descriptive statistics include mean, standard deviation (SD), median and inter-quartile range (IQR) for numerical variables. Distributions of continuous variables were examined to assess normality. We found the variables did not follow a normal distribution; therefore, non-parametric inferential tests were used.
Comparison between SIPESA and CLA was performed using inferential statistical analysis. Categorical variables were compared using chi-square tests or Fisher's Exact test where small frequencies were reported. Numerical variables were compared using the Mann-Whitney test or independent samples t-test depending on normality of data distribution.

Results:
One hundred thirty-six appendectomies performed by residents were included in the analysis. The majority (83, 61%) of the procedures was SIPESA at KFAFH, and the rest (53, 39%) were CLA at PSMMC.
As our study is retrospective and comparative between two training centers, the data collection was completed independently. There was a structured method for collecting the data by medical students. Results were analyzed by a statistician. Although SIPESA is considered as an accepted approach for appendectomy, its impact on the residency training program was not explored in detail. However, there is a general impression that surgery performed by a junior surgeon has worse outcome, but our results showed a good outcome with an acceptable complication rate. A major limitation of this study is that the comparison between SIPESA and CLA is effectively a comparison between KFAFH and PSMMC. The difference between surgical approaches and location in our study is statistically signi cant, Fisher's Exact test p < .001). The patient demographics were comparable between SIPESA and CLA groups, with similar patient ages and gender distribution (Table.1). The 30° cameras, energy source (electrocautery), mesoappendix dissection, and endoloop ligation of the appendicular stump were similar in both techniques. The postoperative analgesia protocol was different between CLA and SIPESA, but fortunately, there was a good postoperative pain control in both groups. The LOS was equal in both groups. The negative appendectomies were comparable in both groups.
It is known that the severity of appendiceal in ammation is one of the di cult factors that in uencing the appendectomy outcomes. There was no signi cant statistical difference in the rate of complicated appendicitis in both groups. In contrast to adults, we do not consider obesity or complicated appendicitis as contraindications to SIPESA 2 . We did not have any incisional hernia in either group (Table.2).
The MOT of SIPESA undertaken by our resident is not signi cantly longer than CLA as reported in other publications 16,17,18,19,20,21,22,23 . This may be explained by techniques we developed to overcome instrument collision such as changing the placement of instruments in the SILS port, rotating the port clockwise and anticlockwise depending on the direction of traction of the appendix. We also undertake continuous training in SILS (dry and wet laboratory workshops) for our residents. The use of exible articulating instead of straight instruments may overcome the technical di culty 12,13 . We prefer to use straight laparoscopic instruments and a long laparoscope (50 cm) as it makes the camera holder away from the operative eld and decreases the collision of instruments.
There was no signi cant difference in morbidity and mortality between the two groups in our study as previously reported 3 . Also there was no conversion to open in either technique.
We consider SIPESA as a good training model for surgical residents to build up their SIPES experience as it is the commonest surgical emergency. The good outcome is multifactorial including the basic laparoscopic background, supervision by the senior surgeon, and structured training workshops.

Conclusion:
This study suggests that SIPESA performed by residents is feasible and safe even for complicated appendicitis with no added morbidity. The technique can be imparted satisfactorily to residents with successful implementation in structured surgical training programs.

Declarations Funding Sources
This study was not funded by any company.

Con ict of Interest Statement
Author Enaam Raboe, declares that she has no con ict of interest.
Author Yazeed Owiwi, declares that he has no con ict of interest Author Alaa Ghalab, declares that he has no con ict of interest Author Ameen Alsaggaf, declares that he has no con ict of interest Author Mazen Zidan, declares that he has no con ict of interest Author Ahmed Alawi, declares that he has no con ict of interest Author Mohamed Fayez, declares that he has no con ict of interest Author Mohamed Al Onazi MD 2 , declares that he has no con ict of interest.
Author Mohammed Al-Mohaidly MD 2 , declares that he has no con ict of interest.
Author Mohammed Babiker MD 2 , declares that he has no con ict of interest.
Author M. Saleh Kamel MD 2 , declares that he has no con ict of interest.
Author A. Jawad Al-Hindi MD 2 , declares that he has no con ict of interest.
Author Khalil Al-Batniji MD 2 , declares that he has no con ict of interest.
Author Ihab Omer Ali MD 2 , declares that he has no con ict of interest.
Author Hanin Shalaby, declares that she has no con ict of interest Integrity of any part of the work are appropriately investigated and resolved Mazen Zidan MD 1 co-author Integrity of any part of the work are appropriately investigated and resolved Ahmed Alawi MD 1 co-author: Review, drafting, and nal approval of the manuscript.
Mohamed Nagem MD 1 co-author: Review, drafting, and nal approval of the manuscript.
Hanin Shalaby MSc HI 1 co-author : Analysis, or interpretation of data for the work Co-Author Mohamed Al Onazi MD 2 , In charge of PSMMCC team writing and interpreting the data and reviewing the last manuscript for approval Co-Author Mohammed Al-Mohaidly MD 2 , PSMMC team member In charge of PSMMCC team writing and interpreting the data and reviewing the last manuscript for approval Co-Author Mohammed Babiker MD 2 , PSMMC team member. In charge of PSMMCC team writing and interpreting the data and reviewing the last manuscript for approval Co-Author M. Saleh Kamel MD 2 , PSMMC team member. In charge of PSMMCC team writing and interpreting the data and reviewing the last manuscript for approval Co-Author A. Jawad Al-Hindi MD 2 , PSMMC team member. In charge of PSMMCC team writing and interpreting the data and reviewing the last manuscript for approval Co-Author Khalil Al-Batniji MD 2 , PSMMC team member. In charge of PSMMCC team writing and interpreting the data and reviewing the last manuscript for approval Co-Author Ihab Omer Ali MD 2 , PSMMC team member. In charge of PSMMCC team writing and interpreting the data and reviewing the last manuscript for approval