Title : Does senior surgical review prevent negative appendicectomy?
Abstract:
Background: Negative appendicectomy remains an important quality marker in emergency general surgery. Senior surgical review may improve diagnostic decision-making, although patients with greater diagnostic uncertainty may also be preferentially escalated. We evaluated whether consultant/equivalent review before the decision to operate was associated with a lower negative appendicectomy rate (NAR).
Methods: A retrospective clinical audit of 120 consecutive appendicectomy records from a single institutional dataset was performed. Negative appendicectomy was defined as a histologically normal appendix. Three cases without histopathology and one with parasitic pathology were excluded, leaving 116 evaluable cases. The primary exposure was the most senior surgeon reviewing the patient before the decision to operate: consultant/equivalent versus a doctor with at least three years’ experience but not consultant. Proportions, risk ratios, odds ratios and Fisher’s exact test were used. Exploratory logistic regression adjusted for age and sex.
Results: Overall, 22/116 appendicectomies were histologically normal, giving an NAR of 19.0%. Among patients reviewed by a consultant/equivalent, 15/70 (21.4%) had a negative appendicectomy compared with 7/46 (15.2%) reviewed by a non-consultant senior surgeon, an absolute difference of 6.2 percentage points. Consultant review was not associated with lower NAR (risk ratio 1.41, 95% CI 0.62–3.19; odds ratio 1.52; Fisher’s exact p=0.474). In exploratory adjustment, consultant review remained non-protective (adjusted OR 1.14, 95% CI 0.38–3.47; p=0.816), while increasing age was associated with lower odds of negative appendicectomy (adjusted OR per year 0.91, 95% CI 0.86–0.96; p<0.001). The observed comparison was underpowered, with wide confidence intervals.
Conclusion: In this cohort, consultant/equivalent review before the decision to operate did not reduce negative appendicectomy. The institutional NAR was 19.0%, meeting a commonly used UK audit benchmark of <20% but leaving scope for improvement. These findings should not be interpreted causally because of limited power and probable confounding by indication. Quality improvement should focus on a standardised diagnostic pathway integrating senior review with imaging, serial assessment and explicit documentation of diagnostic uncertainty, followed by prospective re-audit.
