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Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study

  • Original Article
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European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Introduction

Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, ‘real-world’ clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes.

Materials and methods

This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020–2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days.

Results

A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24–46] vs 38 [26–55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83–1.28 for trainee vs attending; IRR 1.13 95%CI 0.89–1.42 for supervised trainee vs attending) or hLOS.

Conclusion

The linkage of case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.

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Data availability

The ESTES SnapAppy Group welcomes the use of these de-identified pooled data for further research that benefits patients. Requests can be submitted to the ESTES Research Committee. Release is subject to their approval and the appropriate safeguarding as determined by applicable legislation (GDPR and HIPAA).

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Acknowledgements

ESTES SnapAppy Group: Gary Alan Bass, Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Sweden; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA. Shahin Mohseni, Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Sweden. Lewis J Kaplan, Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA. Rebecka Ahl Hulme, Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden. Alan Biloslavo, Department of General Surgery, Trieste University Hospital, Trieste, Italy. Yang Cao, Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Sweden. Maximilian P. Forssten, Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Sweden. Hayato Kurihara, Humanitas Clinical and Research Center, IRCCS, Milano, Italy. Isidro Martinez-Casas, Hospital Universitario Juan Ramón Jiménez de Huelva, Huelva, Spain. Jorge Pereira, Centro Hospitalar Tondela, Viseu, Portugal. Arvid Pourlotfi, Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Sweden. Éanna J Ryan, Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Sweden; Tallaght University Hospital, Dublin, Ireland. Matti Tolonen, Helsinki University Hospital HUS Meilahden Tornisairaala, Helsinki, Finland.

Bahrain: Bahrain Defence Force-Royal Medical Services: Nayef Louri (ORCID 0000-0001-9280-875X); Fatema Nedham (ORCID 0000-0002-5511-684X); Thomas Noel Walsh (ORCID 0000-0002-1600-8029); Jamal Hashem (ORCID 0000-0003-1544-8177). King Hamad University Hospital: Martin Corbally (ORCID 0000-0003-2599-6134); Abeer Farhan (ORCID 0000-0002-5121-6528); Hamad Al Hamad (ORCID 0000-0003-0568-3982); Rawan Elhennawy (ORCID 0000-0001-7076-6886). Salmaniya Medical Complex: Mariam AlKooheji (ORCID 0000-0002-3125-7939); Manar AlYusuf (ORCID 0000-0002-7206-8448); Wissal Aknouche (ORCID 0000-0001-9479-112X); Anas A. Zeidan (ORCID 0000-0002-9560-8187); Yusuf S. Alsaffar (ORCID 0000-0001-7492-4773). Estonia: North Estonia Medical Center: Edgar Lipping (ORCID 0000-0002-9593-5460); Peep Talving (ORCID 0000-0002-9741-2073); Sten Saar (ORCID 0000-0002-8958-5169); Katrina Graumann (ORCID 0000-0003-1429-4874); Liis Kibuspuu (ORCID 0000-0001-7321-3953); Eduard Harkov (ORCID 0000-0003-1194-2864). Finland: HUS Meilahden Tornisairaala: Gisele Aaltonen (ORCID 0000-0002-8265-6681); Iines S. Sillman (ORCID 0000-0001-7779-0432); Sami Haapanen (ORCID 0000-0001-8983-6733). HUS Jorvin sairaala: Hanna Lampela (ORCID 0000-0001-9619-1099); Henna Sammalkorpi (ORCID 0000-0001-8848-9346); Sofia Eskola (ORCID 0000-0001-8092-4550); Altti Laakso (ORCID 0000-0003-0417-9274). Hyvinkää Hospital Area: Johan Back (ORCID 0000-0002-9646-1914); Ulla Kettunen (ORCID 0000-0002-4107-8627); Antti M. Nummi (ORCID 0000-0002-4461-3373); Anika Szwedyc (ORCID 0000-0002-4399-1639); Taina Nykänen (ORCID 0000-0003-3160-2816); Rolle Rantala (ORCID 0000-0002-7689-1685). Oulun Yliopistollinen Sairaala: Elisa J. Mäkäräinen-Uhlbäck (ORCID 0000-0003-4408-2514); Sanna A. Meriläinen (ORCID 0000-0002-0789-9042); Heikki I. Huhta (ORCID 0000-0002-6273-198X); Jukka M. J. Rintala (ORCID 0000-0003-1865-8444); Kirsi E. M. Laitakari (ORCID 0000-0001-7837-7025). Turku University Hospital: Elina Lietzen (ORCID 0000-0002-7514-7176); Paulina Salminen (ORCID 0000-0001-6435-9264); Risto K. A. Rapola (ORCID 0000-0002-0204-7027). Iran: Namazi Hospital, Shiraz University of Medical Sciences: Vahid Zangouri; Mohammad Y. Karami; Sedigheh Tahmasebi; Majid Akrami; Alireza Golchini; Faranak Bahrami. Ireland: Tullamore General Hospital: Sean M. Johnston (ORCID 0000-0001-9445-9645); Sean T. Lim (ORCID 0000-0002-8448-7121); Irele Ifijeh Ahonkhai (ORCID 0000-0002-9572-1235); Eltahir Eltagani (ORCID 0000-0001-6627-8804); Odhran K. Ryan (ORCID 0000-0003-2750-4607). St Vincent's University Hospital: Ailbhe O’Driscoll-Collins (ORCID 0000-0002-8447-0944); Aine O'Neill (ORCID 0000-0001-9190-6008); Zakiya Penny (ORCID 0000-0002-0235-6671); Orlaith Kelly (ORCID 0000-0002-9123-7024); Carolyn Cullinane (ORCID 0000-0002-9320-1586); Ian Reynolds (ORCID 0000-0002-8790-2538); Helen Heneghan (ORCID 0000-0002-2009-3406); Sean Martin (ORCID 0000-0002-6351-8857); Des Winter. Galway University Hospitals: Matthew Davey; Maha Alkhattab; Aoife J. Lowery; Michael J. Kerin; Aisling M. Hogan; Martin S. Davey; Ke En Oh. Letterkenny University Hospital: Syed Mohammad Umar Kabir (ORCID 0000-0003-4801-042X); Huilun Huan (ORCID 0000-0002-3007-2342); Charlotte Aziz (ORCID 0000-0003-2384-0718). Michael Sugrue (ORCID 0000-0002-9337-8939). University Hospital Waterford: Jessica M. Ryan (ORCID 0000-0001-6161-9630); Tara M. Connelly (ORCID 0000-0002-3178-7091); Mohammad Alhazmi (ORCID 0000-0002-8226-328X); Youssef Al-Mukhaizeem (ORCID 0000-0003-3935-8619); Fiachra Cooke (ORCID 0000-0001-9289-4221); Peter M. Neary (ORCID 0000-0002-9319-286X); Beaumont Hospital: Arnold D. K. Hill (ORCID 0000-0001-9617-7983); Michael R. Boland (ORCID 0000-0001-9024-8189); Angus J. Lloyd (ORCID 0000-0002-3043-6900); Frances Fallon (ORCID 0000-0003-4481-0796); Eoin F. Cleere (ORCID 0000-0003-2750-3057); James Toale (ORCID 0000-0002-2026-7584); Mayo University Hospital: Patrick A. Boland; Michael Devine; Conor Keady; Sarah Hunter; M. Kevin Barry. Tallaght University Hospital:Michael E. Kelly (ORCID 0000-0002-0757-6411); Aidan T. O’Dowling (ORCID 0000-0003-0534-0568); Ben Creavin (ORCID 0000-0001-8209-4810); Dara O. Kavanagh (ORCID 0000-0001-9535-0844); Paul Neary (ORCID 0000-0002-7464-1287); Paul F. Ridgway (ORCID 0000-0002-8500-8532); Cathleen A. McCarrick (ORCID 0000-0002-9713-9038). St James' University Hospital: Jarlath Bolger; Barry Maguire; Cian Keogh; Surbhi Chawla. Mater Misericordiae University Hospital: John Conneely (ORCID 0000-0001-6352-9444); Emilie McCormack (ORCID 0000-0001-5217-1977); Ben Shanahan (ORCID 0000-0001-6890-5007); Nicola Raftery (ORCID 0000-0002-4684-5573); Darragh Rice (ORCID 0000-0001-7857-8273); Niall McInerney (ORCID 0000-0003-4051-3882); Aine Stakelum (ORCID 0000-0002-1593-758X); Jan Mares (ORCID 0000-0001-8217-647X); Jonavan Tan (ORCID 0000-0002-4202-804X); Mark Hanna (ORCID 0000-0002-2878-392X); Ishwarya Balasubramanian (ORCID 0000-0002-3864-5651); Christina Fleming (ORCID 0000-0003-2326-2655). Israel: Soroka University Medical Center: Guy Barsky (ORCID 0000-0001-6290-0619); Gad Shaked (ORCID 0000-0002-4992-252X). Italy: Emergency Surgery and Trauma Section, Humanitas Research Hospital: Rozzano Simone Giudici (ORCID 0000-0002-5721-2229); Martina Ceolin (ORCID 0000-0002-4689-480X); Simona Mei (ORCID 0000-0001-7952-0014); Francesca Mazzarella (ORCID 0000-0002-7132-3945). Trieste University Hospital: Annalisa Zucca (ORCID 0000-0002-7179-1191); Susanna Terranova (ORCID 0000-0003-1417-1903); Nicolo de Manzini (ORCID 0000-0002-8362-9044). Azienda Ospedaliero, Universitaria Città della Salute e della Scienza di Torino: Diego Visconti (ORCID 0000-0003-4041-1691); Emanuele Doria (ORCID 0000-0002-7941-1886); Mauro Santarelli (ORCID 0000-0017-9842-2240). San Maurizio Hospital, Bolzano: Giovanni Scotton (ORCID 0000-0003-2222-3822); Francesca Notte (ORCID 0000-0002-3559-1782); Giacomo Bertelli (ORCID 0000-0001-7681-1211); Anna Malpaga (ORCID 0000-0003-1171-6197); Giulia Armatura (ORCID 0000-0002-8536-7551); Antonio Frena (ORCID 0000-0001-9461-5345). Cisanello Hospital, University of Pisa: Dario Tartaglia (ORCID 0000-0003-1615-3370); Federico Coccolini (ORCID 0000-0001-6364-4186); Camilla Cremonini (ORCID 0000-0003-1503-7087); Enrico Cicuttin (ORCID 0000-0003-4584-9940); Alessio Mazzoni (ORCID 0000-0003-3325-2063); Massimo Chiarugi (ORCID 0000-0001-6905-2499). Portugal: Centro Hospitalar Universitário da Cova da Beira: Constança M. Azevedo (ORCID 0000-0002-9808-4083); Filipa D. Mendes (ORCID 0000-0002-7864-467X); Luis Q. Faria (ORCID 0000-0002-8089-9815); Carlos Nazario (ORCID 0000-0002-5751-5326); Daniela Machado (ORCID 0000-0002-3124-8952); Miguel Semiao (ORCID 0000-0002-1342-6081). Centro Hospitalar Tondela-Viseu: Jorge Pereira; Carlos Casimiro; Jose Pinto; Tiago Pavão; Raquel Pereira; Bruno Barbosa. Centro Hospitalar de Trás-os-Montes e Alto Douro: Nadia Tenreiro (ORCID 0000-0002-6869-0795); Catia Ferreira (ORCID 0000-0002-5651-3791); Goncalo Guidi (ORCID 0000-0003-3564-1468); Daniela C. Martins (ORCID 0000-0003-3189-4599); Clara Leal (ORCID 0000-0003-2387-5144); Bruno B. Vieira (ORCID 0000-0001-9705-6489). North Lisbon University Hospital Center: Luís S. Castro (ORCID 0000-0002-4214-2539); Aldara Faria (ORCID 0000-0002-8621-7846). Alberto Figueira (ORCID 0000-0003-0737-4200); Mauro Sousa (ORCID 0000-0002-8872-1093); Pedro Rodrigues (ORCID 0000-0001-7536-5635); Rodrigo Roquette (ORCID 0000-0002-7885-3076). Centro Hospitalar Universitário do Algarve—Hospital de Faro: Ricardo Ribeiro (ORCID 0000-0001-7411-0577); Paulo Cardoso (ORCID 0000-0002-7204-0402); Joana Domingues (ORCID 0000-0001-8231-3040); Maria Isabel Manso (ORCID 0000-0003-4796-5857); Rute Pereira (ORCID 0000-0003-3989-565X); Tatiana Revez (ORCID 0000-0002-8751-2097). Romania: Ponderas Academic Hospital, Bucharest: Bogdan D. Dumbrava (ORCID 0000-0003-4587-8792); Florin Turcu; Ionut Hutopila; Bogdana Banescu; Gerald Filip; Catalin Copaescu (ORCID 0000-0002-7270-0706). Spain: Hospital Universitario Juan Ramón Jiménez: Marcos Alba Valmorisco (ORCID 0000-0002-4449-7042); Isabel Manzano Martín (ORCID 0000-0003-4952-1934); Rocio Martín García de Arboleya; José Ortega Seda (ORCID 0000-0002-8759-8206); Pablo Rodríguez González (ORCID 0000-0001-6887-60,740; Jose Antonio Becerra Toro (ORCID 0000-0003-4644-8903); Enrique Rodríguez Lara (ORCID 0000-0002-5121-9657); Jose Antonio González Minchón (ORCID 0000-0002-4059-6246). Hospital Universitario Son Espases: Juan José Segura-Sampedro (ORCID 0000-0003-0565-3791); Sebastián Jerí-McFarlane (ORCID 0000-0003-0319-2872); Alejandro Gil-Catalán (ORCID 0000-0001-8642-3925); Andrea Craus-Miguel (ORCID 0000-0002-2506-8621); Laura Fernández-Vega (ORCID 0000-0002-1998-5976); Xavier González-Argenté (ORCID 0000-0003-0003-9055). Hospital General Universitario de Ciudad Real: Mercedes Estaire-Gómez (ORCID 0000-0001-9153-9201); Borja Camacho Fernández-Pacheco (ORCID 0000-0003-3242-2892); Rebeca Vitón-Herrero (ORCID 0000-0003-4046-2691); Elisa Jimenez-Higuera (ORCID 0000-0003-2547-5814); Alejandro Barbero (ORCID 0000-0003-0818-0870); José M. Valverde (ORCID 0000--0001-6867-7710). Hospital Universitario Son Llàtzer: Enrique Colás-Ruiz (ORCID 0000-0001-8821-2531); Maria del Mar Escales-Oliver (ORCID 0000-0002-3991-071X); Olga Claramonte-Bellmunt (ORCID 0000-0002-0805-0710); Marta Castro-Suárez (ORCID 0000-0003-1837-8362); Naila Pagés-Valle (ORCID 0000-0003-0898-9303); José Andrés Cifuentes-Ródenas (ORCID 0000-0003-4886-0176). Hospital Universitario Central de Asturias: Marta Merayo Alvarez; Jose Luis Michi Campos; Luis Alejandro García González; Beatriz Carrasco Aguilera; Jaime Iturbe Menéndez; Jose Luis; Rodicio Miravalles. Infanta Sofía University Hospital: Carmen Rodríguez Haro (ORCID 0000-0002-2086-694X); Sara Núñez O'Sullivan (ORCID 0000-0001-8418-6145); Mariana García Virosta (ORCID 0000-0003-2021-4623); María Hernández O'Reilly (ORCID 0000-0003-0913-4446). Hospital Universitario de La Ribera: Izaskun Balciscueta-Coltell (ORCID 0000-0002-5787-5647); Javier Lorenzo-Perez (ORCID 0000-0003-0036-144X); Sonia Martinez-Alcaide (ORCID 0000-0002-8213-5616); Susana Martinez-Ramos (ORCID 0000-0001-5651-1246); Maria Sebastian-Fuertes (ORCID 0000-0003-2729-657X); Laura Gomez-Romer (ORCID 0000-0002-6061-8174). Hospital Universitario de Gran Canaria Dr Negrín: Maria M. Pelloni (ORCID 0000-0002-5950-820X); Aida Cristina Rahy-Martín (ORCID 0000-0002-2791-529X); Andrés Felipe Yepes-Cano (ORCID 0000-0001-5827-8951). Hospital Universitario Virgen Macarena: Julio Reguera-Rosal (ORCID 0000-0003-4364-0908); Jose A. Lopez-Ruiz (ORCID 0000-0002-5905-7007); Beatriz Marenco (ORCID 0000-0002-0372-5707); Marina Retamar-Gentil (ORCID 0000-0002-0209-2047); Estela Romero-Vargas (ORCID 0000-0002-9012-6090); Angeles Gil-Olarte (ORCID 0000-0002-1324-9660). Urduliz Alfredo Espinosa Hospital: Aitor Landaluce-Olavarria (ORCID 0000-0002-8631-0151); Begoña Estraviz-Mateos (ORCID 0000-0002-5687-7667); Jose-Mario De Francisco-Rios (ORCID 0000-0001-6589-4250); Aitor Sainz-Lete (ORCID 0000-0003-2215-0870); Ane Emaldi-Abasolo (ORCID 0000-0001-5669-4441); Manolo Leon-Valarezo (ORCID 0000-0002-1755-5200). Donostia University Hospital: Claudia C. Lopes Moreira (ORCID 0000-0003-0404-736X); Aintzane Lizarazu Perez (ORCID 0000-0001-9091-4727); Araceli Rodriguez Gonzalez (ORCID 0000-0001-5249-6368); Iñigo Augusto Ponce (ORCID 0000-0003-0639-1834); Ignacio Maria Goena Iglesias (ORCID 0000-0002-7753-1606). Hospital Universitario de Burgos: Cristina González-Prado (ORCID 0000-0002-9548-505X); Guillermo Cabriada (ORCID 0000-0002-7161-7628); Beatriz López (ORCID 0000-0002-1541-8691); Michelle C. Otero (ORCID 0000-0002-3031-0953); Nerea Muñoz-Plaza (ORCID 0000-0001-8612-9849); Alberto Palomo (ORCID 0000-0002-7660-2134). Hospital Universitario Príncipe de Asturias: Fernando Mendoza-Moreno (ORCID 0000-0002-1046-6344); Manuel Díez-Alonso (ORCID 0000-0002-0993-8498); Francisca García-Moreno-Nisa (ORCID 0000-0001-5360-0577); Belén Matías-García (ORCID 0000-0001-9209-7724); Enrique Ovejero-Merino (ORCID 0000-0002-4254-3594); Ana Quiroga-Valcárcel (ORCID 0000-0001-5921-6920). Elche University General Hospital, Alicante: Luis Sánchez-Guillén (ORCID 0000-0003-0623-9074); Inmaculada Oller-Navarro (ORCID 0000-0003-0417-3489); Álvaro Soler-Silva (ORCID 0000-0002-5228-2746); Antonio Francisco Sanchís-López (ORCID 0000-0002-3421-1389). Complejo Asistencial Universitario de Salamanca: Francisco:Blanco-Antona (ORCID 0000-0001-5946-9944); Luis Muñoz-Bellvis (ORCID 0000-0002-7709-5201); Jaime López-Sánchez (ORCID 0000-0002-4506-4951); Sonsoles Garrosa-Muñoz (ORCID 0000-0002-3496-5068); Beatriz Barón-Salvador (ORCID 0000-0002-8591-0278); Juan Manuel Nieto-Arranz (ORCID 0000-0002-6545-9790). Hospital Universitari Parc Taulí: Andrea Campos-Serra (ORCID 0000-0001-6970-7141); Raquel Gràcia-Roman (ORCID 0000-0003-2861-9270); Anna Muñoz-Campaña (ORCID 0000-0003-4136-3046); Carla Zerpa-Martin (ORCID 0000-0002-5731-409X); Andrea Torrecilla-Portoles (ORCID 0000-0002-6585-1944); Tessa Landa (ORCID 0000-0001-5611-4486). Virgen del Rocío University Hospital: Virginia Durán Muñoz-Cruzado (ORCID 0000-0003-4499-0483); Felipe Pareja-Ciuró (ORCID 0000-0001-9192-3465); Daniel Aparicio-Sánchez (ORCID 0000-0001-7061-345X); Eduardo Perea del Pozo (ORCID 0000-0003-3219-2601); Sandra Dios-Barbeito (ORCID 0000-0002-5944-1826); Carlos García-Sánchez (ORCID 0000-0001-7573-295X); Antonio Jesús García-Moriana (ORCID 0000-0002-4866-3511). Hospital Clinic Barcelona: Victor Turrado-Rodriguez (ORCID 0000-0002-0573-7373); Roser Termes-Serra (ORCID 0000-0002-6982-3860); Paula Gonzalez-Atienza (ORCID 0000-0003-1957-6774); Xavier Morales-Sevillano (ORCID 0000-0002-4514-007X); Alba Torroella (ORCID 0000-0002-1911-2446); César Ginestà (ORCID 0000-0002-5867-7503). Hospital Universitario Arnau de Vilanova: Alfredo Escartín (ORCID 0000-0002-5234-2366); Ferney Gomez (ORCID 0000-0002-0022-1327); Ana Pinillos (ORCID 0000-0003-2507-1318); Jaume Ortega (ORCID 0000-0001-9196-4689); Guillermo Lopez (ORCID 0000-0002-6368-5591); Eric Gutierrez (ORCID 0000-0001-9005-6523). Hospital Del Mar de Barcelona: Estela Membrilla-Fernandez; Francisco Ocho-Segarra; Ana María González-Castillo; Amalia Pelegrina-Manzano; Juan Guzmán-Ahumada; Juan Jose Sancho-Insenser. Complejo Hospitalario Universitario de A Coruña: María Lourdes García-Jiménez; Laura Castro-Diez; Manuel González-Bermúdez; Mónica Torres-Díaz; Carla Madarro Pena; Angélica Blanco Rodríguez. Sweden: Örebro University Hospital: Dhanisha Trivedi (ORCID 0000-0003-3875-5831); Souheil Reda (ORCID 0000-0001-6145-1233). Capio S:t Göran Hospital: Hans Edvardsson (ORCID 0000-0001-9511-9730); Lovisa Strömmer (ORCID 0000-0001-5424-7111). Sahlgrenska University Hospital: Eva-Corina Caragounis (ORCID 0000-0001-5637-2637); Karin Sillén (ORCID 0000-0003-2942-0810); Sofia Warfvinge. Sahlgrenska University Östra Hospital: Fredrik Bergstedt; Philip Enström; Harald Olsson; Anders Rosemar. Karolinska University Hospital: Nathalie Young (ORCID 0000-0002-4675-7581); Agnieszka Popowicz (ORCID 0000-0001-7960-0962); Johanna Lerström; Johanna Jäderbo (ORCID 0000-0002-0115-4242); Folke Hammarqvist (ORCID 0000-0001-9175-4534). Danderyds Hospital: Hanna Zacharias (ORCID 0000-0003-1180-0970). Karlstad Hospital: Maria B. Wikström (ORCID 0000-0001-8864-7068); Anna Stene Hurtsén (ORCID 0000-0003-0646-2508). Östersund County Hospital: Haytham Bayadsi (ORCID 0000-0002-4877-5150); Emma Jansson (ORCID 0000-0002-9944-5733); Nils Brunstrom (ORCID 0000-0002-0398-7328); Ellen B. Malers (ORCID 0000-0002-7148-3252). Linköping University Hospital: Per I. Loftås (ORCID 0000-0002-8289-3054); Anders Möller (ORCID 0000-0001-9608-3864); Elena Atanasova. Switzerland: Bern University Hospital: Simone N. Zwicky (ORCID 0000-0003-4465-6813); Beat Schnüriger (ORCID 0000-0002-1672-2775). United Kingdom: Aintree University Hospital: Olga Rutka (ORCID 0000-0002-8791-1987); Arjun T. Kattakayam (ORCID 0000-0002-7664-609X); Mushfique Alam (ORCID 0000-0001-9924-8791); John V. Taylor (ORCID 0000-0003-3059-9766). Tameside and Glossop Integrated Care NHSFT: Andrei Mihailescu (ORCID 0000-0002-4364-6042); Eszter T. Karip (ORCID 0000-0002-7610-1604); Ehtisham Zeb (ORCID 0000-0002-2947-2082); Adam O’Connor (ORCID 0000-0001-5267-2819); Goran Pokusevski (ORCID 0000-0003-3585-1860). Brighton and Sussex University Hospitals, Brighton: Mansoor Khan (ORCID 0000-0002-0496-7652); Charlotte Florance; Christie Swaminathan; Shameen Jaunoo; Mohammed Sajid. United States of America: University of Pennsylvania Hospital System, Philadelphia: Caoimhe C. Duffy (ORCID 0000-0001-6302-1683); John Rees (ORCID 0000-0003-4343-395X); Mark J. Seamon (ORCID 0000-0001-7536-5467); Niels D. Martin (ORCID 0000-0002-2157-0825); Ian J. McCurry (ORCID 0000-0002-9701-338X); Emily A. Vail (ORCID 0000-0002-1849-5780); Bradford C. Bormann (ORCID 0000-0001-7746-0249). Maine Medical Center: Daniel C. Cullinane (ORCID 0000-0002-0414-1949); Jaswin S. Sawhney (ORCID 0000-0003-3693-0229); Jonathan Dreifus; Forest R. Sheppard (ORCID 0000-0001-5461-2297). Riverside University Health System Medical Center: Raul Coimbra (ORCID 0000-0002-3759-6851); Paul Albini (ORCID 0000-0002-1115-2419); Sara Edwards.

Funding

This work was unfunded. This manuscript was presented, in part, as a peer-reviewed podium presentation, at International Surgery Week ISW 2022, 15–18th August 2022, Vienna, Austria.

Author information

Authors and Affiliations

  1. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University, Solna, Sweden

    Nathalie Young, Rebecka Ahl Hulme, Isidro Martinez-Casas, Jorge Pereira, Arvid Pourlotfi, Éanna J. Ryan & Matti Tolonen

  2. Division of Trauma and Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Örebro, Sweden

    Rebecka Ahl Hulme, Maximilian Peter Forssten, Shahin Mohseni & Gary Alan Bass

  3. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA

    Lewis Jay Kaplan & Gary Alan Bass

  4. Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA

    Lewis Jay Kaplan

  5. Royal College of Surgeons in Ireland Medical University, Busaiteen, Bahrain

    Thomas Noel Walsh

  6. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Örebro, Sweden

    Yang Cao

  7. Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA

    Gary Alan Bass

  8. Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA

    Gary Alan Bass

Authors
  1. Nathalie Young
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  2. Rebecka Ahl Hulme
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  3. Maximilian Peter Forssten
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  4. Lewis Jay Kaplan
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  5. Thomas Noel Walsh
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  6. Yang Cao
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  7. Shahin Mohseni
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  8. Gary Alan Bass
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  • , Charlotte Florance
  • , Christie Swaminathan
  • , Shameen Jaunoo
  • , Mohammed Sajid
  • , Caoimhe C. Duffy
  • , John Rees
  • , Mark J. Seamon
  • , Niels D. Martin
  • , Ian J. McCurry
  • , Emily A. Vail
  • , Bradford C. Bormann
  • , Daniel C. Cullinane
  • , Jaswin S. Sawhney
  • , Jonathan Dreifus
  • , Forest R. Sheppard
  • , Raul Coimbra
  • , Paul Albini
  •  & Sara Edward

Contributions

All collaborators will be listed on PubMed as authors; see end of manuscript for list of Manuscript Writing Group, SnapAppy Steering Committee and Study Collaborators, their affiliations, and their contributions, per the Contributor Roles Taxonomy (CRediT).

Corresponding author

Correspondence to Gary Alan Bass.

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The authors have no conflicts of interest to disclose.

Additional information

The members of ESTES SnapAppy Group are listed in Acknowledgements section.

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Young, N., Ahl Hulme, R., Forssten, M.P. et al. Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study. Eur J Trauma Emerg Surg 49, 33–44 (2023). https://doi.org/10.1007/s00068-022-02142-3

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