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Were all urogynecologic procedures excluded or just those with an increased risk of needing/receiving mesh?

Robotic versus laparoscopic surgery in patients diagnosed with endometriosis: a systematic review and meta-analysis. We edited lines 63–65 in methods to read: “Each case included in the analysis had at least one Current Procedural Terminology (CPT) code listed representing laparoscopic surgery, which may include traditional laparoscopy or robotic-assisted surgery ". Our initial analysis did not examine whether cases were urgent or not, but we included this in further analysis.

We added these data to Table 1 and line 109-110 "Patients who underwent surgery without appendectomy were more likely to have emergency surgery (Table 1)." We also included this variable in our propensity matching noted on lines 94-95 "Surgical characteristics used were year of surgery, number of CPT codes, and emergency surgery." Rule 120 - Consider noting that this is a composite endpoint of all the listed complications compared between the 2 groups. This amendment was made and lines 87-88 now read "The primary outcome was a composite of post-operative complications compared between the two groups."

This was added in lines 92–95 to read: “Demographic data used for propensity matching included age, race, BMI, presence of medical comorbidities, and ASA class. As you noted, operative time and length of stay are listed in Table 2, not Table 1, and this statement has been removed. Correct values ​​(p<0.001) are given in the table and the text has been modified to match.

Lines 136-140 now read "The most common postoperative diagnoses by ICD-9 or ICD-10 codes in patients who are concurrent. Discussion – Line 206 – Would operative note review have provided information that could have changed your claim as to whether the appendectomy was indicated or elective We agree that the ability to review operative findings, pathology, or use of intraoperative antibiotic prophylaxis would all have provided very useful information, specifically regarding whether the appendectomy was "indicated" or "elective."

We have edited line 179-183 to read "There may be contributing factors not captured by the database, including the patient's preoperative hemodynamic status, appropriate antibiotic use or prophylaxis, intraoperative findings, surgical strategy, difficulty of surgery secondary to Factors such as severe endometriosis or intra-abdominal adhesions and the experience of the surgeon on a list of many other factors.

Reviewer #2

Reviewer #3

• Were all of these surgeries performed by general gynecologists - or could specialists such as gynecologic oncologists be the surgeons?
• Who performed the appendectomies in this study? I think it would be helpful to know if they were done by general surgeons or gynecologists- and if type of surgeon is at all associated with
• In figure 2- I think it would be helpful to know the indications for surgery in the control group as well (at least in the propensity score matched patients)- to see if there are differences in
• Were patients who had contaminated cases included? For example- someone presents with signs of peritonitis with unclear etiology and undergoes diagnostic laparoscopy by gyn- and not
• Are prophylactic antibiotics recommended for laparoscopic appendectomy? Are you able to get info from this database whether pts received prophylactic antibiotics? If prophylactic
• If available, would be helpful to know the pathology for the appendix specimens

Are all these operations performed by general gynecologists - or can they be specialist surgeons such as gynecological oncologists. Unfortunately, NSQIP does not report the breakdown of surgical specialties, but reports general specialties such as Gynecology, Urology, Obstetrics or General Surgery. We limited operations to those performed by Gynecology, but cannot comment on additional training (MIGS, FPMRS, GYN Oncology) of the operating surgeon.

I think it would be helpful to know if they were performed by general surgeons or gynecologists - and if the type of surgeon is even associated with were performed by general surgeons or gynecologists - and if the type of surgeon is even associated with complications. We limited the study to only gynecology as the primary specialty (Figure 1), but cannot comment on whether the appendectomy was performed by a general surgeon, as NSQIP only reports the primary surgical specialty. In figure 2- I think it would be useful to know the indications for surgery also in the control group (at least in the propensity score matched patients) - to see if there are differences in also (at least in the propensity score matched) patients )- to see if there are differences in indications for surgery associated with these findings.

However, we now exclude "dirty or infected" wound cases (lines 74-76), and we have added wound classification to Table 2. This finding has been added to lines 133-135 "Wound classification was statistically significant in both the pooled and propensity-weighted analyzes with the appendectomy group more tended to be classified as grade 3 or The overall complication rate remained increased in the appendectomy group in both the overall and propensity-matched analyses.

Sepsis rates were increased in the appendectomy group in the overall analysis but were not significant in the propensity-matched analysis. These findings are discussed in lines 152-164, where it is written: “Existing literature is inconsistent, with some studies emphasizing the safety of concurrent appendectomy and others demonstrating an increased rate of postoperative infection.9,10 Although we found no statistically significant differences in deep appendectomy site infections surgical intervention, organ space infections or sepsis, we found an increase in surface infections at the site of the surgical intervention. Surgical wound classification has been validated as a predictor of surgical site infections.13 However, the classification of surgical wounds, especially for appendectomy, is subject to a wide range of interpretations, and there are often discrepancies in wound classification based on who reports the data—surgeon versus operating room physician. sisters.14,15 At the same time.

The NSQIP database does not capture granular data on whether antibiotics were administered and which antibiotics were given.

STATISTICAL EDITOR COMMENTS

If prophylactic antibiotics are not currently recommended - perhaps this intervention can help reduce the rate of complications. We agree that pathology would provide very useful information, but are unfortunately limited by the data available in NSQIP. It now reads, “A matched group was created by calculating the propensity scores and the results were again compared between the groups.

All appendectomy patients were matched 1:1 to a unique non-appendectomy patient using a greedy matching based on. Clearly, there was a 1:1 match and all appendectomy cases in the original cohort were matched with a control case. We performed a 1:1 match using the "closest" option in the R package match to perform a greedy match on the propensity score.

We did not require any fixed gauge value and let the algorithm find the closest remaining control patient to the treatment (appendectomy patient), we observe that 2.3% of matched pairs have propensity scores that are more than 0.01 units apart. While we agree that SMDs are slightly more important for assessing fit, we have decided to continue reporting means/ratios/p values ​​as most readers will be more familiar with this. We find that many characteristics/variables before matching have high SMD (variables with |SMD|>0.1 include year, age, Hispanic race, white race, normal BMI, obese BMI, severe obesity, hypertension, emergency surgery, and CPT code number ).

Please see lines 95-99 “All appendectomy patients were matched 1:1 to a unique non-appendectomy patient by greedy matching based on the propensity score estimated with a gradient boosting approach. We agree that many of the individual complications are so rare that they have low power to detect differences and have added the following to our limitations on rules 184-186: "Despite using a large database of operations for analysis, many post-operative.

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