As a general surgeon, you’re likely familiar with the routine practice of ordering a “group and save” (G&S) blood test before many surgeries. This test, which identifies a patient’s blood type and screens for certain antibodies, is often performed before common procedures like cholecystectomy (gallbladder removal) and appendectomy (appendix removal). But is this testing always necessary? Recent research suggests that it may not be. This blog post will examine the evidence and discuss what general surgeons need to consider when deciding whether to order a preoperative G&S test.

The Current Practice of Preoperative Blood Typing

In many hospitals, it’s standard procedure to perform a G&S test before any surgery. This practice stems from the belief that it’s necessary to have blood products readily available in case of a significant bleed during the procedure. However, in the case of laparoscopic cholecystectomy and appendectomy, which are usually minimally invasive, the risk of needing a blood transfusion is often low.

What Does the Research Say?

A recent systematic review published in Langenbeck’s Archives of Surgery analyzed 15 studies, encompassing a total of 477,437 patients who underwent cholecystectomy or appendectomy [1]. Here’s what the research found:

Low Transfusion Rates: The perioperative blood transfusion rate was remarkably low—only 2.1% for cholecystectomy and even lower (0.1-0.2%) for appendectomy [1].
Routine Testing Not Warranted: All 15 studies concluded that routine G&S testing was not necessary for all patients undergoing cholecystectomy or appendectomy [1]. Studies like those by Blank et al. [2] and Tandon et al. [3] specifically support this point.
Specific Risk Factors Identified: Preoperative risk factors associated with the need for blood transfusion were identified as cardiovascular co-morbidity, coagulopathy (including patients on anticoagulants), moderate anaemia, and haematological malignancy [1]. Studies like that by Fong et al. also highlight pre-existing conditions as a risk factor for transfusion [4].
Financial Implications: The review highlighted significant financial implications associated with routine G&S testing, costing an average hospital £12,908 per year just for these two procedures alone [1]. Ghirardo et al. [5] also highlight cost as a factor to consider.

The Role of General Surgeons

General surgeons are at the forefront of this debate, as they are the ones performing these procedures. Here’s what they need to know:

Understanding Risk: Most cholecystectomies and appendectomies, especially laparoscopic ones, are low-risk for major bleeding, and thus a preoperative blood typing may not be needed [1]. Studies have also noted that the rates of major vascular injury are low for laparoscopic cholecystectomy [6]
Selective Testing: General surgeons should be selective in ordering G&S tests, only ordering them when specific risk factors are present in their patients, rather than as a blanket approach [1]. This approach is supported by the work of Quinn et al. [7] who suggested adopting targeted approaches.
Emergency Protocols: Surgeons should ensure that in the rare case of a major vascular injury, O negative blood is immediately available, as time is of the essence in these situations, and the time taken to obtain cross-matched blood may prove detrimental [1].
Evidence-Based Practice: Rely on evidence and guidelines to guide preoperative testing, moving away from routine testing and adopting a more tailored approach [1].

When to Consider a G&S Test

While routine G&S is not recommended, there are times when general surgeons should consider ordering this test:

Pre-existing Conditions: If the patient has a history of cardiovascular disease, bleeding disorders, anaemia, or a haematological malignancy [1].
Anticoagulant Use: If the patient is taking anticoagulant medications [1].
Planned Open Surgery: Though laparoscopic approaches are more common, open procedures are associated with higher bleeding risks [1].
Patient Factors: If the patient is elderly or has other severe medical conditions that could increase the risk of complications [1].
Complex Procedures: If a conversion to open surgery is a high possibility [1].

Benefits of a Targeted Approach

A targeted approach to preoperative blood typing, where tests are ordered only for high-risk patients, can result in several benefits:

Reduced Costs: Eliminating unnecessary testing can significantly reduce healthcare costs, both directly related to the tests and staff hours [1]. As demonstrated by the study from Usal et al., routine testing is not always cost effective [8]
Reduced Delays: Avoiding the testing process can speed up surgical procedures, especially emergency cases [1].
Better Use of Resources: More efficient use of blood bank resources, ensuring that the focus is placed on patients who truly need a blood transfusion [1].
Improved Patient Experience: Reduced exposure to invasive procedures and blood draws, leading to better patient comfort [1].

Conclusion

Routine preoperative blood typing for cholecystectomy and appendectomy is not always necessary, and evidence suggests that general surgeons should adopt a more selective, evidence-based approach [1]. By understanding the risk factors for blood transfusion and reserving G&S tests for high-risk patients, surgeons can improve patient outcomes, reduce costs, and make better use of healthcare resources.

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References

[1] Fadel, M. G., Patel, I., O’Leary, L., Behar, N., & Brewer, J. (2022). Requirement of preoperative blood typing for cholecystectomy and appendectomy: a systematic review. Langenbeck’s Archives of Surgery, 407(7), 2205–2216.
[2] Blank, R. M., Blank, S. P., & Roberts, H. E. (2018). An audit of perioperative blood transfusions in a regional hospital to rationalise a maximum surgical blood ordering schedule. Anaesthesia and Intensive Care, 46(5), 498-503.
[3] Tandon, A., Shahzad, K., Nunes, Q., Shrotri, M., & Lunevicius, R. (2017). Routine preoperative blood group and save testing is unnecessary for elective laparoscopic cholecystectomy. Journal of Ayub Medical College, Abbottabad: JAMC, 29(3), 373-377.
[4] Fong, M. L., Urriza Rodriguez, D., Elberm, H., & Berry, D. P. (2021). Are Type and Screen Samples Routinely Necessary Before Laparoscopic Cholecystectomy?. Journal of Gastrointestinal Surgery, 25(2), 447-451.
[5] Ghirardo, S. F., Mohan, I., Gomensoro, A., & Chorost, M. I. (2010). Routine preoperative typing and screening: a safeguard or a misuse of resources. J Soc Laparoendoscopic Surg, 14(3), 395-398.
[6] Usal, H., Sayad, P., Hayek, N., Hallak, A., Huie, F., & Ferzli, G. (1997). Major vascular injury during laparoscopic cholecystectomy an institutional review of experience with 2589 procedures and literature review. Surgical Endoscopy, 11(5), 520.
[7] Quinn, M., Suttie, S., Li, A., & Ravindran, R. (2011). Are blood group and save samples needed for cholecystectomy? Surgical Endoscopy, 25(8), 2505-2508.
[8] Usal, H., Nabagiez, J., Sayad, P., & Ferzli, G. (1999). Cost effectiveness of routine type and screen testing before laparoscopic cholecystectomy. Surgical Endoscopy, 13(2), 146-147.