Acute appendicitis is one of the most common surgical conditions. Improvement in the treatment results in a shortened hospital length of stay. Currently, the basis of ambulatory surgery can be widely applied to patients treated with appendectomy [9–15]. However, the basis is reportedly successful only in patients who were treated with a laparoscopic approach. The success of this basis has never been reported yet in patients whose operation was an open appendectomy. As we have found in our preliminary report , a prolonged admission time before surgical consultation and a high percentage of patients presented their symptoms and come to the hospital at night largely impact the possibility of ambulatory surgery policy. In addition, with the nature of the disease, a certain appointment to the outpatient office like other elective surgical conditions is nearly impossible. To determine an appropriate policy to shorten the hospitalization duration of the disease, maybe the term "ambulatory surgery" does not work. As a result, at this time, we re-evaluate our increased data with a basis of immediate discharge rather than with the previously used one.
The outcomes demonstrated in the study might be a result of some factors that enhance our patients’ recovery. The no usage of electrocautery can reduce tissue damage, and the use of local anesthesia before abdominal wall closure can reduce postoperative pain. The particularly important factor that improves postoperative recovery is the author (P.S)’s small incision technique with which the overall tissue damage can be reduced. The small wound size that comparable to the size generated by the laparoscopic technique might be the explanation why these patients recovered rapidly. In this series, we have a new smallest incision length (Fig. 3). With the author’s experience, some obstacles will be presented to other surgeons should this technique is implemented into general practice. Like other surgical skills, a learning curve is required. Some difficult situations such as the retrocecal or subcecal position of the appendix are the conditions in which an author’s unique technique will help. Sequential traction sutures approximately 0.5-1 cm apart retrograde from base to appendiceal tip could deliver such type of appendix pass through the small opening (Fig. 4a and 4b).
At times, we might experience a situation in which the surgeon's digit is needed delving inside to find the appendix, or sometimes for breaking adhesions and freeing the appendix from surrounding structures. If too much effort is used, some cutaneous contusions will indispensably occur (Fig. 5a). Fortunately, this occurrence reduced over time. In addition, perforation which could be found at any time can cause a problematic event especially when accompanied by a fecalith. In at least 2 cases in our experience, while trying to remove the appendix from a small opening cause to break the fecalith which can leave a very small fraction of it, and results in chronic wound infection (Fig. 5b). However, this will be improved with prolonged recovery. Another obstacle would be the pressure from the co-workers surrounding the surgeon. When a difficult operation occurs, the surgeon might be asked to extend the skin incision from the personnel (e.g., assistants, scrub nurses, or anesthetic nurses). For this circumstance, the surgeon must be firm. After we retracted the incision with greater force, additional space of the opening will appear.
Approximately one-third of the patients in the study could meet our criteria. However, if we subgroup the time into the first and the second two-year period we will discover that over half of the patients in the latter period could be discharged immediately. The age, the patient with underlying disease, the WBC count, the wound length, the operative time, and the stage of the appendicitis were not the factors that impact the early discharge. This increased number could be explained by the change in the mind of the parents and the author’s team. Over the years, the team gradually accept this concept until they found that not only this will reduce their workload, but also the parents will save their expenses in the hospital. Up to date, all nurses at duty at our in-patient ward will help to clarify the concept of immediate discharge to the parents. The parents’ mindset is another difficulty to deal with. As shown in Table 3, the belief that admission is needed exists even in health personnel. There are two children in the study whose both mothers are physicians working at the same author’s hospital, a two-night stay is required in both cases.
There is a developed trick that significantly helps explain to parents before entering the operating room. With permission, we recorded a short video of a patient walking to the toilet shortly after the operation and used them as an adjunct tool when counseling with the parents. At present day, almost all patients with acute simple appendicitis who are without any surgical difficulty or problems due to anesthesia can successfully be discharged back to their homes for recovery. As we have discussed earlier, the only common hurdle for this concept is the night-time presentation or the time that results in the operation to be completed at night. Although there is a concept of delay and avoiding the operation at night so that the patient can be put into immediate discharge policy [16, 17], we think that the patient’s time of discharge will be delayed instead of discharging in the morning after the night operation.
Regarding the concern about the parents’ feelings or satisfaction. Although we did not construct a form to collect these data as conducted in other studies [18–20], at the time of follow-up, there was no negative feedback from any parent or caregiver. Interestingly, there was a notable case in our study. Since our in-patient ward does not allow for male persons to stay along the night with patients, so the patient and his lone father were quite happy to go back home for recovery following an hour after surgery.