The "all-in-one" appendectomy: quick, scarless, and less costly.

BACKGROUND: A technique for laparoscopic appendectomy (LAP APPY) that involves brief surgeon and operating room times, results in no appreciable scar, and requires few disposable supplies would be desirable. METHODS: During 2009, 508 children underwent LAP APPY at our institution including 398 (78%) for acute, non-perforated appendicitis. Our "all-in-one" operative procedure involves use of a single instrument through a side-arm viewing operative laparoscope which is inserted through a single, trans-umbilical port. Successful procedure completion rates and operative times ("cut-to-close") were determined. Our data for surgeon-directed, disposable supply costs per procedure were collated by Child Health Corporation of America and compared with 2009 LAP APPY data (n = 5692) from 17 other children's hospitals in the United States. RESULTS: We successfully completed 359 (90.2%) LAP APPY procedures using the all-in-one technique resulting in no appreciable scar. Additional ports were used in 9.8% and there were no conversions to open procedures. Median operative time for the all-in-one technique was 24 minutes (5-66 min). Our median surgeon-directed, disposable supply cost was the lowest in the study group and significantly less than the other 17 children's hospitals ($166 vs $748, P < .001). Median variation of supply costs among surgeons within each institution was $448 ($3-$870). Aggregate savings of nearly $1.3 million are predicted if all study surgeons were to reduce their disposable costs per procedure to the 25th percentile ($551). CONCLUSIONS: We conclude that the all-in-one laparoscopic appendectomy technique is quick, scarless, and less costly than conventional multi-port techniques. Wider application of the all-in-one technique seems indicated.

Advance directives use in acute care hospitals.

It is a federal requirement for health care organizations to provide and obtain information from admitted patients about their rights to self-determination and executing an advance directive. But how compliant are acute care organizations with this law? This article explores the extent to which hospitalized patients in one Southeastern United States organization had advance directive documentation; its correlation with socioeconomic factors, and the success of educating patients and providing care that is consistent with patient's wishes.