Psychological Safety and Hierarchy in Operating Room Debriefing: Reflexive Thematic Analysis.

INTRODUCTION: Debriefing is a team discussion in a constructive, supportive environment. Barriers exist to consistent, effective team debriefing in the clinical setting, especially in operating theaters. The purpose of this study was to gain insights from frontline workers on how to set up an effective debriefing policy for our operating room. METHODS: This was a qualitative study in which we interviewed operating room workers in a tertiary children's hospital. Interviews were audio-recorded, transcribed, and coded. Data were analysed using the reflexive thematic analysis technique within a critical realism paradigm. RESULTS: Interviews were analysed from 40 operating room staff: 14 nurses, seven anesthetic technicians, seven anaesthetists, and 12 surgeons; 25 (65%) were female. The three key themes were (1) "commitment to learning"-healthcare workers are committed to teamwork and quality improvement; (2) "it is a safe space"-psychological safety is a prerequisite for, and is enhanced by, debriefing; and (3) "natural leader"-the value of leadership, but also constructs around leadership that maintain hierarchies. CONCLUSIONS: Psychological safety is both a prerequisite for and a product of debriefing. Leadership, if viewed as a collective responsibility, could help break down power structures. Given the results of this study and evidence in the literature, it is likely that routine debriefing, if well done, will improve psychological safety, facilitate team learning, reduce errors, and improve patient safety.

Reflexive thematic analysis of a coaching-based, holistic approach to child development.

BACKGROUND: The F-words Life Wheel (FWLW) approaches child development by hybridizing a holistic model in the F-words for Child Development, and a coaching model in Occupational Performance Coaching, along with a life-flow approach in the Kawa model. We report the impact of the FWLW as experienced by families. METHODS: This was a qualitative interview study of parents of children with developmental needs and experts in child development using reflexive thematic analysis. RESULTS: From 13 interviews, we developed three themes: 1) overwhelming, 2) power rebalance and 3) connectedness. The overwhelming theme addresses how life with developmental needs is challenging, engaging with the health and disability system is difficult and the focus on deficits can lead to a sense of being overwhelmed. The power rebalance theme addresses the transition from professionals calling the shots to giving agency to the child and family. Holistic goal setting empowers parents and children to direct and prioritize therapy, and helps shift from a deficit-focused to a 'can-do' attitude. The connectedness theme addresses the linkages between psychological health, physical health, the extended family and the planet as a whole. CONCLUSIONS: The FWLW approach appears to be empowering and motivating for children and families.

Energy-based scatter estimation in clinical PET.

BACKGROUND: Scatter correction (SC) is essential in PET for accurate quantitative imaging. The state-of-the-art SC method is single-scatter simulation (SSS). Although this method is usually robust and accurate, it can fail in some situations, for example when there is motion between the CT and PET scans in PET/CT. Therefore, it is of interest to consider other SC methods. PURPOSE: In this work, an energy-based scatter estimation (EBS) method is described in detail, tested in phantoms and patients, and compared to SSS. METHODS: This version of EBS was developed for list-mode data from Biograph Vision-600 PET/CT scanner. EBS is based on digitized 2D energy histograms in each bin of a coarsely sampled PET sinogram, either with or without time of flight (TOF). The histograms are modeled as a noisy realization of a linear combination of nine basis functions whose parameters were derived from a measurement of the 511-keV photopeak spectrum as well as Monte-Carlo simulations of the scattering process. EBS uses an iterative expectation maximization approach to determine the coefficients in the linear combination, and from this estimates the scatter. The investigation was restricted to 18 F-based PET data in which the acquired number of counts was similar to the levels seen in oncological whole-body PET/CT scans. To evaluate the performance, phantom scans were used that involved the NEMA NU2-2018 protocol, a slab phantom, an NU 2-1994 phantom, a cardiac phantom in an anthropomorphic chest phantom, and a uniformly-filled torso phantom with a bladder phantom slightly outside the axial field of view. Contrast recovery (CR) and other parameters were evaluated in images reconstructed with SSS and EBS. Furthermore, FDG PET scans of seven lung cancer patients were used in the evaluation. Standardized uptake values (SUV) based on SSS and EBS were compared in 27 lesions. RESULTS: EBS and SSS images were visually similar in all cases except the torso + bladder phantom, where the EBS was much closer to the expected uniform image. The NU2-2018 analysis indicated a 2% scatter residual in EBS images compared to 3% with SSS, and 10% higher background variability, which is a surrogate for image noise. The cardiac phantom scan showed that CR was 98.2% with EBS and 99.6% with SSS, and that the SSS sinogram had values greater than the net-true emission sinogram, indicating a slight overcorrection in the case of SSS. In the lesion SUV comparison in patient scans, EBS correlated strongly (R2  = 0.9973) with SSS, and SUV based on EBS were systematically 0.1 SUV lower. In the case of the torso + bladder phantom portion, the SSS image of the torso + bladder phantom was 299% times hotter than expected in one area, due to scatter estimation error, compared to 16% colder with EBS. CONCLUSIONS: In evaluating clinically relevant parameters such as SUV in focal lesions, EBS and SSS give almost the same results. In phantoms, some scatter figures of merit were slightly improved by use of EBS, though an image variability figure of merit was slightly degraded. In typical oncological whole-body PET/CT, EBS may be a suitable replacement for SSS, especially when SSS fails due to technical problems during the scan.

Debriefing to improve interprofessional teamwork in the operating room: A systematic review.

PURPOSE: Debriefing has been pivotal in medical simulation training, but its application to the real-world operating room environment has been challenging. We reviewed the literature on routine surgical debriefing with special reference to its implementation, barriers, and effectiveness. DESIGN: Descriptive systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS: Inclusion criteria were papers pertaining to debriefing in routine surgical practice. Excluded were papers reporting simulation training. We searched Google Scholar, CINAHL, Web of Science Core Collection, PsychINFO, Medline, Embase, and ProQuest Theses & Dissertations Global. The last search was performed on March 14, 2022. Quality was assessed on a 21-point checklist adapted from a standard reporting guideline. Synthesis was descriptive. FINDINGS: The search process resulted in 19 papers. Publication dates ranged from 2007-2022. Study methods included surveys, interviews, and analysis of administrative data. Five papers involved a specific intervention. Quality scores ranged from 12-19 out of 21. On synthesis, we identified five topics: explanations of how debriefing had been implemented; the value of coaching and audit; the learning dimensions of debriefing, both team learning and quality improvement at the organizational level; the effect of debriefing on patient safety or the organization's culture; and barriers to debriefing. CONCLUSIONS: Successful implementation programs were characterized by strong commitment from management and support by frontline workers. Integration with administrative quality and safety processes, and information feedback to frontline workers are fundamental to successful debriefing programs. CLINICAL RELEVANCE: Debriefing can improve teamwork, learning, and psychological safety but is difficult to practice in the operating room environment. It is relevant to review the benefits and barriers to debriefing, and to learn from the experience of others, in order to run better debriefing models in our own hospitals.

Surgical smoke: how an issue in healthcare fits a planetary health framework.

AIM: The smoke generated from electrocautery machines may be harmful to health. Healthcare in general, and surgery in particular, has a large environmental footprint. The aims of this study were to discover what healthcare workers thought about the problem of electrocautery smoke, the idea of a surgical smoke-free policy, and to formulate ideas on how the matter could be approached in an environmentally and socially responsible way. METHOD: Operating room personnel in a tertiary referral hospital were invited to complete a survey about electrocautery smoke: perceived risks, current exposure, and measures to minimise exposure. Quantitative data were analysed in a generalised linear model, and qualitative data by reflexive thematic analysis within a constructivist theoretical framework. RESULTS: The survey response rate was 463/1234 (38%). Most supported a smoke-free policy (89%). Support for a policy was positively correlated with the perceived risk of electrocautery smoke (p<0.001. Support was lower amongst males (p<0.05). Themes from the qualitative analysis developed around nature, society and technology. A framework was developed consisting of earth and its ecosystems, human health, governance, economics, society, and the interconnected of these systems. CONCLUSION: Although smoke-free policies form part of the solution to electrocautery smoke, they are not the whole solution. Healthcare issues, in this case the issue of electrocautery smoke, could be tackled within a planetary health healthcare framework, promoting a systems approach. Applicability of the framework requires confirmation by further research.

Reproducibility of FDG PET/CT image-based cancer staging and standardized uptake values with simulated reduction of injected FDG dose or acquisition time.

18F-fluorodeoxyglucose (FDG) PET/CT is widely used for oncologic imaging. This study aimed to evaluate, using data simulation, if reduction of injected FDG dose or PET acquisition time could be technically feasible when utilizing a sensitive commercial PET/CT imaging system, without sacrificing image quality, image-based staging accuracy, or standardized uptake value (SUV) accuracy. De-identified, standard of care oncologic FDG PET/CT datasets from 83 adults with lymphoma, lung carcinoma or breast carcinoma were retrospectively analyzed. All images had been acquired using clinical standard dose and acquisition time on a single PET/CT system. The list mode datasets were retrospectively software reprocessed to achieve undersampling of counts, thus simulating the effect of shorter PET acquisition time or lower injected FDG dose. The simulated reduced-count images were reviewed and compared with full-count images to assess and compare qualitative (subjective image quality, stage stability) and semi-quantitative (image noise, SUVmax stability, signal-to-noise and contrast-to-noise ratios within index lesions driving cancer stage) parameters. While simulated reduced-count images had measurably greater noise, there appeared to be no significant loss of image-based staging accuracy nor SUVmax reproducibility down to simulated FDG dose of 0.05 mCi/kg at continuous bed motion rate of 1.1 mm/sec. This retrospective simulation study suggests that a modest reduction of either injected FDG dose or emission scan time might be feasible in this limited oncologic population scanned on a single PET/CT system. Verification of these results with prospectively acquired images using actual low injected FDG activity and/or short imaging time is recommended.

Identification of a Novel FUS/ETV4 Fusion and Comparative Analysis with Other Ewing Sarcoma Fusion Proteins.

Ewing sarcoma is a pediatric bone cancer defined by a chromosomal translocation fusing one of the FET family members to an ETS transcription factor. There have been seven reported chromosomal translocations, with the most recent reported over a decade ago. We now report a novel FET/ETS translocation involving FUS and ETV4 detected in a patient with Ewing sarcoma. Here, we characterized FUS/ETV4 by performing genomic localization and transcriptional regulatory studies on numerous FET/ETS fusions in a Ewing sarcoma cellular model. Through this comparative analysis, we demonstrate significant similarities across these fusions, and in doing so, validate FUS/ETV4 as a bona fide Ewing sarcoma translocation. This study presents the first genomic comparison of Ewing sarcoma-associated translocations and reveals that the FET/ETS fusions share highly similar, but not identical, genomic localization and transcriptional regulation patterns. These data strengthen the notion that FET/ETS fusions are key drivers of, and thus pathognomonic for, Ewing sarcoma. IMPLICATIONS: Identification and initial characterization of the novel Ewing sarcoma fusion, FUS/ETV4, expands the family of Ewing fusions and extends the diagnostic possibilities for this aggressive tumor of adolescents and young adults.

Tertiary survey by trauma nurse specialist at a paediatric trauma centre.

INTRODUCTION: Tertiary surveys aim to detect injuries missed in the initial assessment of trauma. We introduced a process by which the trauma nurse specialist performed a number of the tertiary surveys (NTSs) at our paediatric trauma centre. METHODS: Data from the first six months following introduction of the NTS were compared to retrospective data from the six months prior to NTS implementation (pre-NTS), when trauma surveys were completed by medical staff. RESULTS: Over the 12-month period, 130 children met the criteria for a tertiary survey. Pre-NTS, 57/62 eligible patients received a tertiary survey, compared to 61/68 during NTS (p=0.77). There were significantly more road traffic crash patients in the NTS group (p=0.008) but no significant differences by demographics, injury pattern, injury severity score or outcomes. New injuries were found in three patients pre-NTS compared to five patients during NTS (odds ratio 1.3 (95%CI 1.3-2.0, p=0.73)). CONCLUSION: This study conservatively supports the hypothesis that, with training and support, a trauma nurse specialist can perform tertiary surveys as effectively as doctors. A larger study is required to confirm these findings.

Is thoracoscopic esophageal atresia repair safe in the presence of cardiac anomalies?

BACKGROUND: Esophageal atresia (EA) is often associated with congenital heart disease (CHD). Repair of EA by the thoracoscopic approach places physiological stress on a newborn with CHD. This paper reviews the outcomes of infants with CHD who had undergone thoracoscopic EA repair, comparing their outcomes to those without CHD. METHODS: This was a review of infants who underwent thoracoscopic EA repair from 2009 to 2017 at one institution. Operative time and outcomes were analyzed in relation to CHD status. RESULTS: Twenty five infants underwent thoracoscopic EA repair during the study period. Seventeen (68%) had associated anomalies of whom 9 (36%) had cardiac anomalies. The mean operative time was 217 min. There was no difference in operative time between CHD and non-CHD cases (estimate 20 min longer operative time in the presence of a cardiac anomaly [95% CI -20 to 57]). Two cases were converted to open thoracotomy; both were non-CHD. There was no difference in the time to feeding, time in intensive care unit or time in hospital between CHD and non-CHD cases. Five patients developed an anastomotic leak (two CHD and three non-CHD) of which two were clinical; all were managed conservatively. There was no case of recurrent fistula. CONCLUSIONS: This pilot study did not find evidence that thoracoscopic EA repair compromised outcomes in children with congenital heart disease. A prospective multicenter study with long-term follow-up is recommended to confirm whether thoracoscopic repair in CHD is truly equivalent to the open operation. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: Level III.

Improved Alignment of PET and CT Images in Whole-Body PET/CT in Cases of Respiratory Motion During CT.

Respiratory motion during the CT and PET parts of a PET/CT scan leads to imperfect alignment of anatomic features seen by the 2 modalities. In this work, we concentrate on the effects of motion during CT. We propose a novel approach for improving the alignment. Methods: Respiratory waveform data were gathered during the CT and PET parts of 28 PET/CT scans of cancer patients with 40 lesions up to 3 cm in size in the lung or upper abdomen. PET list-mode data were reconstructed by 3 reconstruction methods: PET/static (the standard method with no motion correction); PET/ex (a method that calculates a range of expiratory amplitudes from the lowest one to the highest one); and PET/matched (a novel method that uses both waveforms). The 3 methods were compared. The distance between tumor positions in PET and CT were characterized in visual interpretation by physicians as well as quantitatively. Tumor SUVs (SUVmax and SUVpeak) were determined relative to SUV based on the static method. Image noise was evaluated in the liver and compared with PET/static. Results: In visual interpretation, the rate of good alignment was 13 of 21, 13 of 23, and 18 of 21 for the PET/static, PET/ex, and PET/matched methods, respectively, and the mean PET/CT distances were 3.5, 5.1, and 2.8 mm. In visual comparison with PET/ex, the rate of good alignment was increased in 1 of 10 and 7 of 10 cases for PET/static and PET/matched, respectively. SUVmax was on average 21% higher than PET/static when either PET/ex or PET/matched was used. SUVpeak was 12% higher. Image noise in the liver was 15% higher than PET/static for the PET/ex method, and 40% higher for PET/matched; that is, noise was much lower than in gated PET. Conclusion: Acquiring respiratory waveforms both in PET (as in the current state of the art) and in CT (an unusual key step in this approach) has the potential to improve the alignment of PET and CT images. A proposed method for using this information was tested. Improved alignment was demonstrated.

Car seat survey at a children's hospital: need a booster?

AIM: Child restraint practices among New Zealand children have fallen short of best practice recommendations. In 2013, New Zealand child restraint legislation was amended. The aim of the present study was to determine the child restraint practices of a cohort of children admitted to hospital and how practices have changed since the amendment in child restraint legislation. METHODS: We conducted interviews with the parents of 300 paediatric inpatients aged 0-13 years. Data were recorded on their child's usual child restraint use, the restraint used during their trip to hospital, and parental knowledge of child restraint law and best practice recommendations. We compared their responses with those of our survey published in 2013, which was performed before the amendment in child restraint legislation. RESULTS: The median age of the 300 children was three years: 181 (60%) were aged 0-4 years, 65 (22%) 5-9 years and 54 (18%) 10-13 years. One hundred and thirty-six (45%) were girls. Of children <5 years of age, 97% always used a child restraint. Of children 5-9 years of age, 60% always used a child restraint, 12% sometimes and 28% never. A significantly greater proportion of 5-9 year-old children used a child restraint at least some of the time in the present study compared to the 2013 study (47/65 versus 27/53, OR 2.49 [95%CI 1.09-5.81]). Child restraint use declined in children <6 years of age. On their journey to hospital, five children used no restraint, four of whom were held in the arms of a caregiver. Parental knowledge of child restraint recommendations correlated inversely with their compliance with the recommendations (OR 0.33 [95%CI 0.11-0.91]). CONCLUSIONS: Consideration should be given to extending child restraint legislation to children older than seven years of age. Further studies could explore the barriers parents face to the use of child restraints and the potential effect of extending child restraint laws to older children.

Radiation burden of pediatric ultrasound-guided percutaneous central venous access devices: A prospective cohort study.

Permanent central venous access is essential for the management of many pediatric patients. Knowing the amount of ionizing radiation used during the insertion of these devices is important. Our aim was to identify the radiation used in percutaneous insertion of central venous access devices, and to correlate radiation exposure to patient weight. METHODS: Data was prospectively collected during a 12-month period from August 2015 to August 2016 on all ultrasound-guided percutaneous central venous access device insertions. An image intensifier was used in all insertions with data on radiation dose and screening time extracted, when available. The total radiation dose was measured in mGym2 and the total radiation time in seconds. A p-value <0.05 was used to denote statistical significance. RESULTS: A total of 145 central venous access devices were inserted (82 portacaths, 43 double lumen lines, 16 single lumen lines and 4 hemocaths) in 127 patients (Median Age: 5.5years (Range 0-17); Median Weight 21kg (Range 1.9-100)) with 15 patients requiring multiple insertions over the course of the study. Of these, 88 had data captured for total radiation dose and time used and a further 23 had screening time only recorded. Median radiation dose was 0.00599 mGym2 (range 0.000543-0.148) with a median fluoroscopic screening time of 18s (range 2-479). Median dose was higher for children <10kg compared to larger children, 0.00661 mGym2 (range 0.00202-0.0468) versus 0.005715 mGym2 (range 0.000543-0.148) respectively. Left-sided internal jugular vein (IJV) insertions also had a higher median radiation dose of 0.0091 mGym2 (range 0.00142-0.148 mGym2) versus 0.005245 mGym2 (range 0.000543-0.0285 mGym2) for right-sided IJV insertions. CONCLUSION: The radiation burden to children from percutaneous ultrasound-guided central venous access device insertions is small, in the order of that received during a chest radiograph. Weight<10kg and access of the left IJV are associated with receiving higher doses. STUDY TYPE: Cohort Study (Level of Evidence: II).

Metal Artifact Reduction of CT Scans to Improve PET/CT.

In recent years, different metal artifact reduction methods have been developed for CT. These methods have only recently been introduced for PET/CT even though they could be beneficial for interpretation, segmentation, and quantification of the PET/CT images. In this study, phantom and patient scans were analyzed visually and quantitatively to measure the effect on PET images of iterative metal artifact reduction (iMAR) of CT data. Methods: The phantom consisted of 2 types of hip prostheses in a solution of 18F-FDG and water. 18F-FDG PET/CT scans of 14 patients with metal implants (either dental implants, hip prostheses, shoulder prostheses, or pedicle screws) and 68Ga-labeled prostate-specific membrane antigen (68Ga-PSMA) PET/CT scans of 7 patients with hip prostheses were scored by 2 experienced nuclear medicine physicians to analyze clinical relevance. For all patients, a lesion was located in the field of view of the metal implant. Phantom and patients were scanned in a PET/CT scanner. The standard low-dose CT scans were processed with the iMAR algorithm. The PET data were reconstructed using attenuation correction provided by both standard CT and iMAR-processed CT. Results: For the phantom scans, cold artifacts were visible on the PET image. There was a 30% deficit in 18F-FDG concentration, which was restored by iMAR processing, indicating that metal artifacts on CT images induce quantification errors in PET data. The iMAR algorithm was useful for most patients. When iMAR was used, the confidence in interpretation increased or stayed the same, with an average improvement of 28% ± 20% (scored on a scale of 0%-100% confidence). The SUV increase or decrease depended on the type of metal artifact. The mean difference in absolute values of SUVmean of the lesions was 3.5% ± 3.3%. Conclusion: The iMAR algorithm increases the confidence of the interpretation of the PET/CT scan and influences the SUV. The added value of iMAR depends on the indication for the PET/CT scan, location and size/type of the prosthesis, and location and extent of the disease.

Analgesic effect of intraperitoneal local anesthetic in surgery: an overview of systematic reviews.

BACKGROUND: Intraperitoneal local anesthetic (IPLA) reduces postoperative pain as shown by previous systematic reviews. The purpose of this review was to compare the efficacy of IPLA between different types of procedure and to formulate GRADE recommendations for the use of IPLA. MATERIALS AND METHODS: A systematic search for systematic reviews of the effect of IPLA, versus no IPLA or placebo, on pain after any surgical procedure. Databases included in the study were MEDLINE, EMBASE, CDSR, and DARE. Two reviewers independently undertook searches, selected studies, extracted data, and assessed the risk of bias. Meta-analysis was by random effects. Recommendation was by GRADE. The main outcome measure was self-reported early postoperative pain scores. RESULTS: Searches uncovered nine systematic reviews. This study included randomized trials numbered 76, representing 4000 participants, 2022 in IPLA and 1978 in control groups. Six reviews scored at low risk of bias and three at high risk. Meta-analysis demonstrated that IPLA reduced the mean pain score (0-10 scale) by 0.95 point (95% confidence interval: 0.73-1.17). Excluding laparoscopic cholecystectomy, the effect size increased to 1.52 (95% confidence interval: 1.15-1.88). Heterogeneity was high overall at I2 = 91.7% but on excluding laparoscopic cholecystectomy trials reduced to I2 = 31.3%. CONCLUSIONS: IPLA could be considered a viable option for early postoperative analgesia in certain laparoscopic operations. Further research on the effect of IPLA on procedures other than laparoscopic cholecystectomy would help clarify its place in a postoperative analgesia protocol.

Reliability and refinement of a pain location tool for children's abdominal surgery.

AIM: To determine the 'inter-rater' and test-retest reliability of a pain location tool for children. MATERIALS & METHODS: In children aged 5-14 years who had undergone a laparoscopic operation, pain scores at each of seven abdominal locations, and at the shoulder tip, were recorded at baseline and after a 5- and 30-min interval. RESULTS: Intraclass correlation coefficients were predominantly in the 'moderate' to 'substantial' range for both 'inter-rater' and test-retest reliability. Three quarters of children would prefer an electronic version of the tool. Thematic analysis showed accuracy, usability, utility and usefulness were areas for future development. CONCLUSION: Children can reliably indicate where they hurt after laparoscopic surgery. An electronic version could increase acceptability to children and usability by professionals.

Intraperitoneal Local Anesthetic for Laparoscopic Appendectomy in Children: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to investigate the efficacy of intraperitoneal local anesthetic (IPLA) on pain after acute laparoscopic appendectomy in children. SUMMARY OF BACKGROUND: IPLA reduces pain in adult elective surgery. It has not been well studied in acute peritoneal inflammatory conditions. We hypothesized that IPLA would improve recovery in pediatric acute laparoscopic appendectomy. METHODS: This randomized controlled trial in acute laparoscopic appendectomy recruited children aged 8 to 14 years to receive 20 mL 0.25% or 0.125% bupivacaine (according to weight) atomized onto the peritoneum of the right iliac fossa and pelvis, or 20 mL 0.9% NaCl control. Unrestricted computer-generated randomization was implemented by surgical nurses. Participants, caregivers, and outcome assessors were blinded. The primary outcome was pain score. Analysis was by a linear mixed-effects model. RESULTS: Of 184 randomized participants (92 to each group), the final analysis included 88 IPLA and 87 control participants. There was no statistically significant difference in overall pain scores (effect estimate 0.004, standard error 0.028, 95% confidence interval -0.052, 0.061), and no difference in right iliac fossa or suprapubic site-specific pain scores, opioid use, recovery parameters, or complications. No child experienced a complication related to the intervention. CONCLUSION: IPLA imparted no clinical benefit to children undergoing acute laparoscopic appendectomy and cannot be recommended in this setting.

Interventions to optimize recovery after laparoscopic appendectomy: a scoping review.

BACKGROUND: No enhanced recovery after surgery protocol has been published for laparoscopic appendectomy. This was a review of evidence-based interventions that could optimize recovery after appendectomy. METHODS: Interventions for the review Clinical pathway, fast-track or enhanced recovery protocols; needlescopic approach; single incision laparoscopic (SIL) approach; natural orifice transluminal endoscopic surgery (NOTES); regional nerve blocks; intraperitoneal local anaesthetic (IPLA); drains. Data sources MEDLINE, EMBASE, the Cochrane Library, and the Web of Science Core Collection. Study eligibility criteria Randomized controlled trial (RCT); prospective evaluation with historical controls for studies assessing clinical pathways/protocols. Participants People undergoing laparoscopic appendectomy for acute appendicitis. Study appraisal and synthesis methods Meta-analysis, random effects model. RESULTS: Clinical pathways for laparoscopic appendectomy were safe in selected patients, but may be associated with a higher readmission rate. Needlescopic surgery offered no recovery advantage over traditional laparoscopic appendectomy. SIL afforded no recovery advantage over conventional laparoscopic surgery, but may increase operative time in children. The search found no RCT on NOTES appendectomy. Transversus abdominis plane blocks did not significantly reduce pain after laparoscopic appendectomy. IPLA should be considered in laparoscopic appendectomy; studies in paediatric surgery are needed. The search found no RCT on the use of drains in appendectomy. CONCLUSIONS: This review identified gaps in the literature on optimizing recovery after laparoscopic appendectomy and found the need for more randomized controlled trials on regional anaesthesia and intraperitoneal local anaesthesia in children.