Trends and Indicators of Appendectomy in the Northern Region of Brazil: A Comparative Study between the Conventional and Videolaparoscopic TechniquesAbstract
Introduction The appendix is a structure of the large intestine, and its inflammation, termed appendicitis, is commonly caused by lumen obstruction. Treatment includes emergency surgical intervention (appendectomy) and antibiotics. The surgical approaches encompass conventional laparotomy and videolaparoscopy. In Brazil, both are performed within the Unified Health System (Sistema Único de Saúde, SUS, in Portuguese), but regional disparities are evident, particularly in the Northern Region. The current study aims to analyze appendectomy indicators in that region from 2020 to 2024, comparing the two appendectomy techniques.
Materials and Methods The present is a retrospective, observational, ecological study with a quantitative and descriptive approach. Data were collected from the database of the Department of Information and Computer Sciences of SUS (Departamento de Informação e Informática do SUS, DATASUS, in Portuguese), focusing on appendectomy procedures performed using the conventional and videolaparoscopic techniques between 2020 and 2024.
Results and Discussion A total of 61,943 appendectomies were recorded in the Northern Region. The conventional technique predominated (99.39%), and 95.87% of the procedures were performed in emergency settings. Videolaparoscopy procedures, although increasing annually, accounted for less than 1% of the cases, mostly concentrated in the states of Pará and Tocantins. Mortality was low, with 139 deaths overall, and only 1 associated with videolaparoscopy. The average length of hospital stay was longer for videolaparoscopy (of 4.2 days), possibly due to limited infrastructure. Hospital expenditure reached R$ 36.8 million, with 99.2% linked to conventional procedures. These findings underscore the need for investment in laparoscopic equipment and training.
Conclusion From 2020 to 2024, appendectomies in the Northern Region of Brazil were predominantly conventional and performed urgently. Despite being safe and increasingly adopted, videolaparoscopy remains underused, revealing structural and technological inequalities in Brazil's public healthcare system.
Keywords
appendectomy; Brazil; Unified Health System
Introduction
Appendicitis is one of the most frequent acute abdominal conditions worldwide, representing a major cause of emergency surgery. In Brazil, appendectomy is widely performed within the Unified Health System (Sistema Único de Saúde, SUS, in Portuguese),1–3 but disparities persist in the adoption of laparoscopic techniques across regions.
National epidemiological data reinforce its public health relevance. Between 2012 and 2021, more than 1.2 million hospitalizations for appendicitis were registered in Brazil,4,5 with an annual incidence ranging from 100 to 150 cases per 100 thousand inhabitants. These procedures generate significant hospital costs, exceeding R$ 200 million annually, and they contribute to work and school absenteeism, particularly among young adults—the population most frequently affected.
Despite the benefits of videolaparoscopy,6,7 including lower postoperative pain, shorter hospital stay, and faster recovery, its implementation remains uneven in the country. Regional inequalities are particularly evident in the Northern Region, where geographic distances and limited hospital infrastructure hinder the incorporation of minimally-invasive techniques.8,9
Therefore, analyzing the distribution and trends of appendectomy in this region is essential to identify disparities and to support strategies that expand access to modern surgical care. Comparative and evidence-based research plays a central role in guiding surgeons and health managers toward adopting safer and more effective methods.
Materials and Methods
The current is a retrospective, ecological, observational study with a quantitative and descriptive approach, based on secondary data extracted from the Department of Information and Computer Sciences of SUS – SUS Data Tabulator (Departamento de Informação e Informática do SUS [DATASUS] – Tabulador de Dados do SUS [TABNET], in Portuguese), specifically from the Hospital Information System (Sistema de Informações Hospitalares, SIH, in Portuguese).10 The database included records of conventional and videolaparoscopic appendectomy procedures performed between 2020 and 2024 in the states of Acre, Amapá, Amazonas, Pará, Rondônia, Roraima, and Tocantins.
To contextualize the surgical indicators, population data were obtained from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE, in Portuguese). According to the 2022 Brazilian Census, the Northern Region had approximately 18.6 million inhabitants, distributed across its states as follows: Pará – 8.1 million; Amazonas – 3.9 million; Rondônia – 1.6 million; Tocantins – 1.5 million; Acre – 830 thousand; Roraima – 710 thousand; and Amapá – 669 thousand. Information regarding the number of hospitals per state was retrieved from DATASUS, while data on the number of specialists (general surgeons, digestive surgeons, oncological surgeons, and colorectal surgeons) were collected from the Brazilian Medical Association (Associação Médica Brasileira, AMB, in Portuguese).
The variables analyzed included: region, state, nature of care (emergency or elective), procedure, year of processing, number of hospitalizations, total hospital costs, average length of hospital stay, and number of deaths. Data were extracted directly from the TABNET portal, which already provides tabulated results. No additional statistical software was employed. Only descriptive analyses were performed, including absolute and relative frequencies, and mean and average values.
As these are aggregated and publicly-available secondary data with no individual patient identification, submission to a Research Ethics Committee was not required, in accordance with Resolution no. 510/2016 of the Brazilian National Health Council (Conselho Nacional de Saúde, CNS, in Portuguese.
Results
Between 2020 and 2024, a total of 61,943 appendectomy procedures were performed in the Northern Region of Brazil. Of these, 99.39% (61,563) were conventional, and 0.61% (380), videolaparoscopic. Table 1 summarizes the annual distribution of procedures by surgical technique, while Figure 1 illustrates their temporal evolution. There was a progressive increase in videolaparoscopic surgeries, rising from 27 in 2020 to 174 in 2024.
Distribution of appendectomies by surgical technique and year, Northern Region of Brazil (2020–2024)
Evolution of appendectomy procedures by surgical technique, Northern Region of Brazil (2020–2024).
Regarding the nature of care, most procedures were performed under emergency conditions: conventional – 59,038 (95.9%); and laparoscopic – 345 (90.8%). Elective procedures only accounted for 4,1% (61,562) of the total (Table 2; Figure 2).
Mortality analysis revealed 139 deaths (0.22% of all cases), 138 (99.39%) of which occurred after conventional procedures, and only 1 (0.61%) following videolaparoscopy. Table 3 shows the annual distribution of deaths, while Figure 3 depicts mortality by surgical technique.
Annual distribution of deaths related to appendectomy by technique, Northern Region of Brazil (2020–2024)
The mean hospital stay was of 3.3 days for the conventional technique, and of 4.2 days for videolaparoscopy (Table 4; Figure 4). This difference was statistically significant (p < 0.05).
The total hospital costs associated with appendectomy were of R$ 36.8 million during the study period, with 99,2% (12,288) of the expenses related to conventional surgery. Although the proportion of laparoscopic procedures was small, their costs increased nearly tenfold between 2020 and 2024 (Table 5; Figure 5).
When comparing hospitals in capital cities and in other municipalities of the states (Table 6; Figure 6), videolaparoscopy was more frequently performed in capital cities (0.80% versus 0.27% respectively). Mortality rates were similar in both settings, although the average length of hospital stay was slightly higher in hospitals in other municipalities compared to the capital cities (3.6 versus 3.2 days respectively). The largest share of hospital costs was concentrated in capital cities, reflecting their greater surgical volume.
Comparison of appendectomy procedures performed in capital cities and in other municipalities within the states of the Northern Region of Brazil (2020–2024)
Comparison of surgical volume and laparoscopic adoption in capital cities versus other municipalities.
Discussion
The current study demonstrated the predominance of the conventional surgical approach for appendectomy in the Northern Region of Brazil, where emergency procedures accounted for more than 95% of hospitalizations. Despite a gradual increase in the use of videolaparoscopy, the technique represented only 0.6% of the cases, confirming the persistence of structural and technological disparities across the region.4,5
The new statistical analyses strengthen these findings by showing significant differences between surgical techniques. Videolaparoscopy yielded a longer mean hospital stay compared to the conventional approach (4.2 versus 3.3 days respectively; p < 0.05). Although the international literature typically associates laparoscopy with shorter hospital stays and faster recovery, the opposite result in the present study may reflect the low number of laparoscopic procedures, the possible selection of more complex cases for this technique, and logistical limitations of Northern hospitals. Similar discrepancies have been reported in other Brazilian studies10,15 that highlight barriers to the adoption of minimally-invasive methods in less-developed regions.
The overall mortality rate was low (0,22% - 70 deaths in total), with only 1 (0.11%) death related to videolaparoscopy during the study period. This reinforces the safety of minimally-invasive surgery, and it is consistent with meta-analyses9 that demonstrate comparable or even lower mortality rates when compared with open procedures. Most deaths were concentrated in emergency cases and in states with higher surgical volumes, such as Pará and Amazonas, which is expected, given the higher burden of severe cases in referral hospitals.
The cost analysis revealed that conventional procedures accounted for more than 99% (R$6.61 million - 2020 conventional, Table 5) of expenditures, although spending on videolaparoscopy grew almost tenfold between 2020 and 2024. This increase, even with a very small number of cases, reflects the higher unit cost of minimally-invasive procedures. However, studies indicate20,25 that, in the long term, videolaparoscopy may be cost-effective due to the shorter recovery time, lower complication rates, and reduced absenteeism. Thus, expanding its availability could optimize the balance between immediate costs and long-term social and health benefits.
The comparison between capital cities and other municipalities revealed that videolaparoscopy is highly concentrated in capital cities (0.80% versus 0.27%). This disparity highlights the unequal distribution of infrastructure, human resources, and training programs. Capital cities concentrate larger hospitals and specialized teams, while towns face difficulties in maintaining equipment and trained professionals. This finding is consistent with national evidence of inequalities in the distribution of surgical technologies across Brazilian regions.
Taken together, the results emphasize the need for investments in hospital infrastructure, professional training, and regional policies aimed at expanding access to minimally-invasive surgery in the Northern Region of Brazil. The incorporation of videolaparoscopy into the routine practice could contribute to better clinical outcomes and to greater equity within the Brazilian Unified Health System.
The limitations of the currnet study include its ecological and retrospective design, based on secondary data, which prevents the evaluation of individual clinical variables. Furthermore, the low absolute number of videolaparoscopic procedures limits the statistical power of certain comparisons. Nevertheless, the robustness of the dataset and the consistency of the trends observed reinforce the relevance of the findings.
Conclusion
Between 2020 and 2024, appendectomy in the Northern Region of Brazil was predominantly performed using the conventional technique and under emergency conditions. Videolaparoscopy, although safe and progressively increasing, remained underused and concentrated in a few states and capital cities, reflecting structural and regional disparities within the Brazilian Unified Health System.
These findings highlight the need for investments in infrastructure, training, and equitable policies to expand access to minimally-invasive techniques and modernize surgical care in the region.
Funding
Data Availability
Data will be available upon request to the corresponding author.
References:
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