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ISSN:

2754-8880

Published

00

11

0000

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ACCESS

Edited

by

A.Hussain

Submitted

2

Oct.

2026

Accepted

10

Oct.

2026

Citation

A

Lumsden

and

M

Stephens.Group

And

Save

Sampling

In

Emergency

Appendicectomy:

A

Multi-Centre

Audit.Editorial

article:BJOSS::2026:(6);210-

213

Group

And

Save

Sampling

In

Emergency

Appendicectomy:

A

Multi-Centre

Audit

A

Lumsden

1*

and

M

Stephens

2

1

Consultant

Paediatric

Anaesthetist,

Department

of

Anaesthesia,

Royal

Hospital

for

Children

Glasgow,

UK.

ORCID:

0009-0006-9136-0838

2

Consultant

Anaesthetist,

Department

of

Anaesthesia,

University

Hospital

Wishaw,

UK

*

Correspondence

author:

Andrew

Lumsden,

Department

of

Anaesthesia

Royal

Hospital

for

Children,

Glasgow

1345

Govan

Road,Glasgow,G51

4TF.

ORIGINAL

Abstract

Background

Emergency

appendicectomy

is

one

of

the

most

common

emergency

surgical

procedures

performed

in

Scotland.

Despite

low

reported

perioperative

transfusion

rates,

no

national

guidelines

exist

for

pre-operative

group

and

save

(G&S)

sampling.

This

multi-centre

audit

examined

current

G&S

sampling

practice,

transfusion

rates,

and

the

associated

ﬁnancial

and

environmental

impact

across

Scotland.

Methods

Data

were

collected

retrospectively

from

16

hospitals

across

8

Scottish

health

boards,

serving

approximately

3.6

million

people.

Adult

patients

undergoing

emergency

appendicectomy

during

a

consecutive

12-month

period

were

included.

Results

A

total

of

1546

patients

underwent

appendicectomy,

of

whom

91.2%

had

a

laparoscopic

proce-

dure.

A

total

of

2029

G&S

samples

were

taken.

Six

patients

received

a

blood

transfusion

within

7

days

of

surgery,

with

a

transfusion

rate

of

0.4%,

while

12

out

of

16

hospitals

recorded

no

transfusions.

The

estimated

cost

of

G&S

sampling

was

£28,000-£77,000

with

carbon

emissions

of

872kg

CO2e.

Conclusion

Emergency

appendicectomy

in

Scotland

is

associated

with

a

very

low

perioperative

transfusion

rate

despite

widespread

use

of

G&S

sampling.

These

ﬁndings

support

further

evaluation

of

risk-stratiﬁed

approaches

to

pre-operative

blood

testing.

Keywords

Blood

transfusion,

preoperative

testing,

sustainability,

appendicectomy

Introduction

Acute

appendicitis

is

the

most

common

abdominal

surgical

emergency

in

the

world

(

1

?

),

with

laparoscopic

appendicectomy

being

the

most

common

general

surgical

emergency

operation

performed

in

Scotland,

with

over

2600

procedures

(

2

)

and

over

50,000

annually

in

England

(

3

;

4

).

There

are

currently

no

national

guidelines

on

the

use

of

group

and

save

(G&S)

samples

in

emergency

laparoscopic

appendicectomy

cases

(

5

).

There

is

wide

international

variation

in

the

ﬁnancial

cost

of

G&S

sampling,

with

a

median

cost

of

£19.80

internationally

and

£13.80

in

the

UK

(

6

).

Local

laboratories

estimate

the

cost

of

a

G&S

to

be

£37.82

(comprising

reagent

cost

of

£1.97,

staﬀ

costs

of

£27.12

and

laboratory

overhead

costs

of

£8.73).

Two

chronologically

distinct

samples

(one

of

which

can

be

historic)

are

required

by

blood

transfusion

laboratories

before

crossmatching

in

the

United

Kingdom.

The

CO2

equivalent

(CO2e)

of

an

inpatient

G&S

sample

has

been

estimated

at

0.43kg

(

7

).

A

number

of

single

centre

studies

(

8

;

9

;

10

),

a

multi-centre

study

(

11

)

and

a

systematic

review

(

12

)

have

suggested

that

the

transfusion

rate

in

laparoscopic

appendicectomy

is

rare

enough

that

universal

G&S

testing

of

patients

is

not

required

pre-operatively.

There

is

no

published

data

to

support

that

hypothesis

in

the

wider

Scottish

population

and

healthcare

system.

The

aim

of

this

audit

is

to

examine

the

current

blood

transfusion

sample

practice

in

emergency

appendicectomy

and

the

rate

of

transfusion

across

multiple

hospitals

in

Scotland,

to

recommend

practice

change

that

can

be

applied

nationally.

Materials

And

Methods

Data

were

gathered

from

8

health

boards

in

Scotland

utilising

the

local

network

of

site

repre-

sentatives

from

the

Scottish

Perioperative

Medicine

Society

(SPOMS).

SPOMS

provided

each

local

representative

with

a

standardised

data

collection

set

and

a

standard

operating

procedure

document

to

guide

the

data

collection

process.

Caldicott

Guardian

approval

was

obtained

at

each

site,

and

the

study

was

registered

with

local

audit

committees.

Data

were

obtained

from

theatre

recording

systems

for

all

adult

patients

(aged

16

and

over)

undergoing

emergency

appendicec-

tomy

(laparoscopic,

converted

to

open,

larger

resection)

by

the

general

surgical

team

at

each

hospital

over

a

consecutive

12-month

period

falling

between

1st

January

2023

and

31st

December

2024.

Patients

having

an

appendicectomy

electively

or

as

part

of

another

procedure

were

excluded.

Baseline

demographics,

pre-operative

haemoglobin,

number

of

G&S

samples

obtained,

and

blood

transfusions

within

7

days

of

surgery

were

collected.

The

data

were

submitted

to

the

lead

investigator

and

collated

for

analysis

using

a

Numbers

spreadsheet

(Numbers,

Apple

Inc.,

California,

USA).

The

primary

outcome

was

the

proportion

of

patients

receiving

a

blood

transfusion

within

7

days

of

appendicectomy.

The

secondary

outcomes

were

the

rate

of

pre-operative

G&S

sampling,

the

number

of

G&S

samples

obtained

per

patient,

and

the

estimated

ﬁnancial

and

carbon

cost

of

G&S

sampling.

Results

A

total

of

1546

patients

undergoing

emergency

appendicectomy

were

included

from

16

hospitals

(53.7%

were

teaching

hospitals

and

46.3%

were

large

district

general

or

rural

hospitals).

The

majority

were

laparoscopic

(91.2%),

with

a

4.4%

conversion

to

open

appendicectomy,

a

3.4%

open

appendicectomy

rate,

and

1%

converted

to

larger

resections.

The

median

age

of

patients

was

38

(IQR

[26-55]),

52%

were

male,

and

the

majority

of

patients

were

ASA

1

(41.7%)

or

ASA

2

(46.9%).

The

median

pre-operative

haemoglobin

was

140

(IQR

[129.5-150])

g

L-1.

There

were

11

patients

who

had

a

pre-operative

haemoglobin

below

100

g

L-1.

There

was

a

total

of

6

transfusions

(see

Table

1)

occurring

within

7

days

of

surgery,

giving

a

transfusion

rate

of

0.4%.

There

were

12

hospitals

out

of

16

where

no

transfusions

occurred.

There

were

a

total

of

2029

G&S

samples

taken,

with

311

(20.1%)

patients

having

0

samples,

477

(30.9%)

having

1

sample,

and

757

(49%)

having

2

or

more

samples.

The

estimated

cost

of

G&S

sampling

was

between

£28,000

(at

£13.80/sample)

and

£76,736

(at

£37.82/sample),

and

CO2e

of

872

kg.

211/

213

Discussion

This

national,

multi-centre,

retrospective

audit

demonstrates

that

perioperative

blood

transfusion

in

laparoscopic

appendicectomy

is

rare.

This

work

supports

the

position

that

G&S

samples

can

be

safely

omitted

in

the

vast

majority

of

patients

undergoing

laparoscopic

appendicectomy.

This

has

been

shown

across

multiple

hospitals

of

varying

sizes,

serving

a

diverse

population

and

geographical

distribution.

Our

ﬁndings

are

largely

in

line

with

which

have

shown

transfusion

rates

for

laparoscopic

appendicectomy

in

the

range

of

0-0.4%

(

8

;

9

;

10

;

11

;

12

).

These

studies

have

been

replicated

both

in

the

UK

and

internationally,

and

have

consistently

shown

a

transfusion

rate

to

be

low.

The

rate

of

conversion

to

open

appendicectomy

of

4.4%

is

consistent

with

published

studies

(

13

).

The

demographics

of

our

patients

show

that

the

majority

are

younger,

with

66%

being

under

the

age

of

50,

and

less

comorbid,

with

89%

being

ASA

1

or

2.

The

requirement

for

blood

transfusion

laboratories

in

the

United

Kingdom

to

have

two

chronologically

distinct

G&S

samples

means

that

the

cohort

of

patients

undergoing

laparoscopic

appendicectomy

in

this

audit

may

be

less

likely

to

have

a

historical

G&S

sample

because

they

were

younger

and

had

fewer

co-morbidities,

thus

requiring

two

samples

to

be

taken

during

the

admission

before

crossmatching.

A

strength

in

our

audit

is

the

large

cohort

of

patients

taken

from

16

hospitals

from

8

Scottish

health

boards,

representing

a

population

of

approximately

3.6

million

people

(

65%

of

the

Scottish

population),

and

hospitals

ranging

in

size

from

34

beds

to

1109

beds.

There

were

6

episodes

of

transfusion

(see

Table

1)

within

7

days

of

surgery,

giving

insight

into

the

potential

risk

factors

for

perioperative

transfusion:

all

patients

were

over

the

age

of

50,

the

majority

were

converted

to

open

procedures,

and

underlying

anaemia

or

anticoagulation

was

present

in

half

the

patients

transfused.

Extrapolating

these

ﬁndings

to

the

Scottish

population,

we

estimate

the

annual

cost

of

G&S

sampling

for

appendicectomy

in

Scotland

to

be

between

£43,000

and

£119,000,

with

associated

carbon

emissions

of

approximately

1.4

tonnes

CO2e,

indicating

the

potential

for

substantial

ﬁnancial

and

environmental

savings.

The

audit

was

conducted

retrospectively;

therefore,

we

were

unable

to

obtain

metrics

such

as

delays

to

theatre

as

a

result

of

G&S

sampling.

Due

to

the

diﬀerent

electronic

patient

record

systems,

it

was

not

possible

to

include

the

number

of

rejected

G&S

samples

across

the

whole

cohort,

which

could

represent

another

source

of

delay

and

unnecessary

patient

discomfort,

in

addition

to

a

more

costly

healthcare

encounter.

We

were

not

able

to

determine

when

G&S

samples

were

sent

on

the

diagnostic

journey,

and

patients

presenting

with

undiﬀerentiated

abdominal

pain

may

have

G&S

samples

sent

as

part

of

their

diagnostic

work-up.

We

did

not

speciﬁcally

collect

data

on

patients

with

disorders

of

coagulation

or

platelets,

who

may

have

required

G&S

for

blood

products

other

than

packed

red

cells.

We

would

argue

that

future

studies

should

not

focus

on

the

rate

of

perioperative

transfusion

in

laparoscopic

appendicectomy,

but

instead

on

identifying

patients

at

increased

risk

of

transfusion

to

inform

guidelines

to

standardise

and

reduce

unnecessary

testing.

We

would

go

further

and

suggest

that

institutions

should

examine

their

local

policies,

as

there

is

scope

to

broaden

the

scope

of

this

work

and

utilise

the

same

methodology

to

examine

whether

G&S

is

required

prior

to

other

surgical

procedures.

Conclusion

This

audit

lends

further

weight

to

the

evidence

that

the

“just

in

case”

GS

is

not

required

routinely

for

emergency

laparoscopic

appendicectomy.

It

is

an

unnecessary

use

of

increasingly

precious

resources

and

may

cause

delays

to

theatre

with

no

corresponding

patient

beneﬁt.

Of

course,

212/

213

clinicians

may

wish

to

make

reasonable

exceptions

in

certain

cases

or

for

those

patients

in

very

remote

and

rural

areas

where

the

balance

of

risk

may

be

diﬀerent.

SPOMS

intends

to

continue

this

work

with

support

from

the

Centre

for

Sustainable

Delivery

in

Scotland

with

the

introduction

of

a

national

guideline

and

hopes

to

encourage

expansion

of

this

work

with

other

surgical

procedures.

Conﬂict

Of

Interest

Author

declare

no

conﬂict

of

interest

and

no

funding

for

this

study.

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