Comparison of Climate Impact, Clinical Outcome, and Cost-Efficiency of Pediatric Transumbilical Laparoscopic Assisted Appendectomy vs Standard 3-Port Laparoscopic Appendectomy.

BACKGROUND: Healthcare is responsible for 8.5% of US greenhouse gas emissions. These impacts must be mitigated while maintaining clinical excellence. This study compares clinical outcomes, cost-efficiency, and climate impact of trans-umbilical laparoscopic assisted appendectomy (TULAA) versus 3-port laparoscopic appendectomy (LA).

STUDY DESIGN: Institutional Review Board approval was obtained. Appendectomies performed between Jan 1, 2020 and December 31, 2022 at a tertiary children's hospital were reviewed. Data abstracted included clinical characteristics, operative approach and findings, supplies and equipment utilized, and complications. For analysis TULAA was combined with cases converted to LA (TULAA+C). To determine a surgical site infection (SSI) increase of ≤ 2.5%, a minimum sample size of 479 patients per group was needed to achieve a power of 80%. A composite supply list for each approach was determined by averaging supplies from cases reviewed. The composite was used to calculate cost-efficiency and climate impact. Life cycle assessment was used to determine the carbon footprint (according to ISO 14067) of supplies and equipment.

RESULTS: Analysis was performed on 1,611 appendectomies: 497 LA and 1,114 TULAA+C (932 TULAA, 182 converted). Except for BMI, there were no clinically significant differences between groups. SSI did not increase with TULAA+C (n=15, 1.3%) versus LA (n=6, 1.2%), p=0.81. TULAA+C ($369.21/case) was more cost efficient than LA ($879.30/case) and TULAA+C (24.8 kg CO2e) produced fewer emissions than LA (27.4 kg CO2e).

CONCLUSIONS: While patient safety and excellent clinical outcomes must remain the top priority in healthcare, the current environmental crisis demands consideration of climate impacts. When clinical non-inferiority can be demonstrated, treatment options with a fewer greenhouse gas emissions should be chosen.