Outcomes of selective case assignment for pediatric appendectomy in a teaching hospital

Background: Appendectomy remains the gold standard treatment for appendicitis in pediatric patients. In teaching hospitals facing workforce constraints, the integration of laparoscopic techniques presents unique challenges in balancing optimal patient outcomes with surgical education. This study evaluates the clinical outcomes of a selective case assignment system that evolved to address these dual objectives in pediatric appendectomy. Methods: We conducted a retrospective cohort study of 63 consecutive pediatric patients (≤18 years) who underwent appendectomy between January 2013 and December 2019 at a single tertiary teaching hospital. Complicated appendicitis was defined as perforated, gangrenous, or abscess-forming appendicitis based on operative findings and histopathology. Primary outcomes included length of hospital stay and complications. Case assignment patterns, surgeon experience levels, and temporal trends were analyzed to characterize institutional practices. Results: Of 63 patients, 37 (58.7 %) underwent open appendectomy and 26 (41.3 %) laparoscopic appendectomy. No significant differences were observed in baseline characteristics. Case assignment patterns revealed systematic selection: attending surgeons performed 78.4 % of open procedures, predominantly for complicated cases (89.7 % of attending-performed open cases), while supervised chief residents performed 69.2 % of laparoscopic procedures with selective inclusion of complicated cases (61.1 %). Length of hospital stay was comparable (median 4 vs 3 days, p = 0.245). No major complications occurred in either group. Laparoscopic utilization increased from 20 % (2013) to 60 % (2019), p = 0.021 for trend. Conclusions: Selective case assignment combined with structured supervision allowed safe integration of laparoscopic appendectomy into pediatric surgical training while maintaining acceptable clinical outcomes. These findings suggest that resident participation in minimally invasive pediatric emergency surgery is feasible when supported by appropriate case selection and oversight.