Appendectomy Procedure in

National Health Care Insurance Era

Dr. Dion Faisal, Sp.B
RSUD Tarakan
 INTRODUCTION
• Appendicitis is one of most common acute surgical conditions of the abdomen
and appendectomy is one of the most frequently performed operations in the
world.1
• Appendicitis  progressive disease that begins as acute inflammation
secondary to blockage of the appendiceal orifice, leading to necrosis and
possible perforation of the appendiceal wall.2
• Any factor that delays treatment may lead to higher rates of perforated
appendicitis.
• Compared with acute-onset appendicitis, perforated appendicitis is associated
with higher costs, longer hospitalizations, and higher hospital readmission and
complication rates.2
1. Noudeh YJ , Sadigh N , Ahmadnia AY. Epidemiologic features, seasonal variations and false positive rate of acute appendicitis in Shahr-e-Rey, Tehran . Int J Surg. 2007
2. Newman K, Ponsky T, Kittle K, et al. . Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg. 2003
 EPIDEMIOLOGY

• US: 11 cases per 10,000 population annually. ♂ >, perforated cases have no
gender predilection. In a lifetime, 8.6% of ♂ and 6.7% of ♀ can be expected to
develop acute appendicitis. Young age is a risk factor; nearly 70% < 30 years. The
highest incidence  ♂ 10-14yo vs ♀ 15-19yo. Perforation  19% of cases of
acute appendicitis, bimodal distribution  significantly >> among patients < 5
and > 65 years.1
• South Korea: overall incidences of appendicitis, total appendectomy, and
perforated appendectomy were 22.71, 13.56, and 2.91 per 10 000 population per
year, respectively. Appendectomy  59.70% of inpatients with appendicitis. The
incidence of appendicitis and appendectomy showed clear seasonality, with a
peak in summer. Lifetime risk of appendicitis  ♂ (16.33%) vs ♀ (16.34%), and
the lifetime risk of appendectomy  ♂ (9.89%) vs ♀ (9.61%).2
1. Addiss DG, Shaer N, Fowler BS, et al. e epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132:910–925.
2. Lee JH, Park YS, Choi JS. The Epidemiology of Appendicitis and Appendectomy in South Korea: National Registry Data. J Epidemiol. 2010; 20(2): 97–105.
 EPIDEMIOLOGY
DATA APPENDICITIS RSUD TARAKAN, KALTARA
Appendicitis Akut Appendicitis Kronik Appendicitis Perforasi
400
2020 sd
2015 2016 2017 2018 2019 Juni
Appendicitis Akut
350 356 215 246 217 257 85
Appendicitis Kronik 0 0 4 9 8 4
300
Appendicitis Perforasi 14 108 150 12 58 27
TOTAL
250 370 323 400 238 323 116

200

150

100

50

0
2015 2016 2017 2018 2019 2020 sd Juni
 HISTORY
• Claudius Amyand (December 6, 1735): St. George's Hospital
in London, perforated appendix within the inguinal hernial
sac of an 11-year-old boy  by a pin the boy had swallowed,
Hanvil Andersen recovery & discharged a month later.
• Lawson Tait (1880), London: transabdominal appendectomy
for gangrenous appendix.
• Charles McBurney (1889), New York City: presentation &
pathogenesis of appendicitis accurately  early
appendectomy was the best treatment to avoid perforation
& peritonitis.
• Autoappendectomies: Evan O'Neill Kane (1921), but the
operation was completed by his assistants. Leonid Rogozov
(1961), who had to perform the operation on himself as he
was the only doctor on a remote Antarctic base.
• Kurt Semm (September 13, 1980): the first laparoscopic
appendectomy.
 APPENDICITIS & COVID19

• Patients typically present with fever and respiratory

symptoms, also have gastrointestinal manifestations
(39,6%) diarrhea (12,9%), anorexia (12,2%), nausea
(17,3%), belching (5%), emesis (5%) and abdominal pain
(2,2-5,8%).
• Droplet transmission  main route of transmission, the
other transmission routes remain unclear
• Thorax CT is should be performed at the same time as
the abdominal CT. ground glass opacity & reticular
changes (crazy paving)

Zhang JJ, Dong X, Cao YY, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy. 2020.
 APPENDICITIS & COVID19
• Basal pneumonia with pleural effusion may explain pain and
discomfort in the upper abdomen
• SARS-CoV-2 have proteins that readily bind to the cell receptor
angiotensin-converting enzyme 2 (ACE2)
• GI epithelial cells  ↑ ACE2 receptors (30 %, vs 1 % in the lungs)
• Identified the SARS-CoV-2 RNA in anal/rectal swabs and stool
specimens of Covid-19 patients, even after the clearance of the
virus in the upper respiratory tract
• Possible transmission route through the faecal contents???
• Hospitalisation >>> patients with GI symptoms & poorer
prognosis
Pan L, Mu M, Ren HG et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional,
multicenter study. Am J Gastroenterol 20.3.2020.
 APPENDECTOMY PROCEDURE
OPEN VS LAPAROSCOPIC

McCall JL, Sharples K, Jadallah F. Systemic review of randomized controlled trials comparing laparoscopic with open appendicectomy: a
metaanalysis. J Am Coll Surg . 1998; 186:545–553; and Sauerland S, Lefering R, Neugebaur EA. Laparoscopic versus open surgery for suspected
appendicitis. Cochrane Database Syst Rev . 2004;4:CD001546.
 OPEN APPENDECTOMY
• Preoperative Preparation
• IV fluids, VS  closely monitored. Dehydration  Foley catheter (urine output
monitoring).
• Severe electrolyte abnormalities (>> in cases of perforation)  corrected prior
to the induction of anesthesia.
• Prophylaxis: a single dose of antibiotics, typically a 2nd gen cephalosporin.
• Incision: 1. McBurney's incision (grid iron), 2. Lanz incision, 3. Rutherford
Morison incision, 4. Paramedian incision
• Reexamined after the induction of anesthesia  deep palpation: a mass +
representing the infamed appendix  incision can be centered at that
location. Mass -  incision should be centered over McBurney’s point
• Important not to make the incision too medial (opens into the anterior rectus
sheath) or too lateral (lateral to the abdominal cavity).
 OPEN APPENDECTOMY

• Antegrade

Zinner MJ, Ashley SW, Hines OJ. Maingot’s Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery : pathophysiology and management. Springer. 2003
OPEN APPENDECTOMY

• Mesoappendix
clamped, ligated with
3-0 silk suture, and
divided.
SOFSILK

Zinner MJ, Ashley SW, Hines OJ. Maingot’s Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery : pathophysiology and management. Springer. 2003
 OPEN APPENDECTOMY

• Two heavy, absorbable

sutures such as 0
chromic gut  doubly
ligate the appendix

Zinner MJ, Ashley SW, Hines OJ. Maingot’s Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery : pathophysiology and management. Springer. 2003 CHROMIC GUT
 OPEN APPENDECTOMY

• If stump inversion is
chosen  seromuscular
purse-string 3-0 silk
suture is placed in the
cecum around the
appendiceal base
SOFSILK

Zinner MJ, Ashley SW, Hines OJ. Maingot’s Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery : pathophysiology and management. Springer. 2003
 OPEN APPENDECTOMY

• Peritoneum: continuous 0
absorbable suture.
• Internal & external oblique
muscles: continuous 0
absorbable suture.
• Scarpa’s fascia: interrupted
absorbable sutures
• Skin: subcuticular
absorbable suture.
POLYSORB

Zinner MJ, Ashley SW, Hines OJ. Maingot’s Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery : pathophysiology and management. Springer. 2003
 OPEN APPENDECTOMY

• Retrograde

Zinner MJ, Ashley SW, Hines OJ. Maingot’s

Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery :
pathophysiology and management. Springer.
2003
ABDOMINAL CLOSURE
ABDOMINAL CLOSURE

POLYSORB
IDEAL SUTURE:
MORE FILAMENTS
FINER FILAMENTS
EXCELLENCE COATING

MULTIFILAMENT
ABSORBABLE SUTURES
 OPEN APPENDECTOMY

• Postoperative Care
• Similar after laparoscopic and open approaches  patients with
nonperforated appendicitis typically require a 24- to 48-hour hospital stay.
• Patients can be started on a clear liquid diet immediately, which can be
advanced to their preoperative baseline diet as tolerated.
• No postoperative antibiotics are required for nonperforated appendicitis.
• Patients can be discharged when they tolerate a regular diet and pain is
controlled on oral agents.
LAPAROSCOPIC APPENDECTOMY

Zinner MJ, Ashley SW, Hines OJ. Maingot’s Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery : pathophysiology and management. Springer. 2003
 LAPAROSCOPIC APPENDECTOMY

Lasso Technique
Zinner MJ, Ashley SW, Hines OJ. Maingot’s Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery : pathophysiology and management. Springer. 2003
 LAPAROSCOPIC APPENDECTOMY

Endobag

Zinner MJ, Ashley SW, Hines OJ. Maingot’s Abdominal Operation. Mc Graw Hill 13 ed. 2019
Haile T. Debas. Gastrointestinal surgery : pathophysiology and management. Springer. 2003
 LAPAROSCOPIC APPENDECTOMY

V-LOCTM KNOTLESS SUTURES

 APPENDEKTOMI DI ERA JKN

• PROSEDUR BEDAH ABDOMEN TERBANYAK  POTENSIAL FRAUD???

• POTENSIAL DISPUTE CLAIM (PENDING):
1. Resume medik dan laporan operasi tidak lengkap dan tidak jelas
terbaca
2. Pemeriksaan penunjang tidak dilakukan
3. Klaim yang berbiaya mahal
• POTENSIAL KERUGIAN RS DAN OPERATOR BEDAH
 TANTANGAN DI ERA JKN

• Sistem pembayaran di era JKN  INA CBGs, diagnosa dan tindakan di

input berdasarkan ICD
• Evaluasi tahun 2014-2019, tindakan Appendektomi merupakan salah
satu tindakan yang menjadi dispute klaim (pending) di ranking 10
besar (Laporan Tahunan Tim JKN RSUD Tarakan).
• BPJS Kesehatan selaku verifikator, dengan mengacu pada SE
HK/03.03/MENKES/516/2018 menyatakan bahwa tindakan yang satu
kesatuan dengan tindakan utama  omit code  penurunan tarif
• BPJS kesehatan mengacu prinsip efisiensi dan kehati-hatian dalam
pembayaran sedangkan RS mengutamakan optimalisasi pelayanan
kesehatan dengan kendali mutu dan biaya
 SIMULASI KLAIM BPJS RS TIPE B

K35.8 47.01

K35.2 54.11

47.09
K35.8
 SIMULASI KLAIM BPJS RS TIPE B

• Dx: Appendicitis Perforasi +

Peritonitis General
• Tindakan: laparotomi
eksplorasi + Appendektomi
• LOS: 4 hari
 TIPS & TRICK
(RESUME REKAM MEDIK)
• Elektronik rekam medik, jika masih tulis tangan maka konsekuensinya tulisan harus jelas dan terbaca
• Tutup celah konfirmasi klaim verifikator dengan membuat resume medik yang sinkron antara anamnesa,
pemeriksaan fisik, pemeriksaan penunjang dan tatalaksana
 TIPS & TRICK
(LAPORAN OPERASI)
• Laporan operasi:
semua tindakan
penting harus
tercantum lengkap
sesuai dengan
resume medik
• Verifikator internal
RS harus memiliki
kompetensi medik
yang baik (minimal
dokter umum) dan
DPJP harus bersedia
jika dilakukan
konfirmasi
 TAKE HOME MESSAGE

• Appendektomi merupakan operasi emergency terbanyak, di era

pandemic covid19  WASPADA PASIEN COVID dengan GI symptom
• Appendektomi di era JKN  “kendali mutu & kendali biaya”:
METICULOUS TECH, HEMAT RESOURCES (ALKES & BHP, LOS), HINDARI
DISPUTE CLAIM