Comparison of Climate Impact, Clinical Outcomes, 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. This impact must be mitigated while maintaining clinical excellence. This study compares clinical outcomes, cost-efficiency, and climate impact of transumbilical laparoscopic-assisted appendectomy (TULAA) vs 3-port laparoscopic appendectomy (LA).STUDY DESIGN:IRB approval was obtained. Appendectomies performed between January 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 used, and complication. For analysis, TULAA was combined with cases converted to LA (TULAA+C). To determine a surgical site infection 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 International Organization for Standardization standard 14067) of supplies and equipment.RESULTS:Analysis was performed on 1,611 appendectomies: 497 LA and 1,114 TULAA+C (932 TULAA and 182 converted). Except for BMI, there were no clinically significant differences between groups. Surgical site infection did not increase with TULAA+C (15, 1.3%) vs LA (6, 1.2%), p = 0.81. TULAA+C ($369.21 per case) was more cost-efficient than LA ($879.30 per case) and TULAA+C (24.8 kilograms of carbon dioxide equivalents) produced fewer emissions than LA (27.4 kilograms of carbon dioxide equivalents).CONCLUSIONS:Although patient safety and excellent clinical outcomes must remain the top priority in healthcare, the current environmental crisis demands consideration of climate impact. When clinical noninferiority can be demonstrated, treatment options with fewer greenhouse gas emissions should be chosen.