Appendiceal Stump Closure Research Articles

Comparison of polymeric clip and endoloop in laparoscopic appendectomy: A systematic review and meta-analysis

BackgroundAppendicitis is a common surgical emergency with diverse clinical presentations, making its diagnosis challenging. Laparoscopic appendectomy has become the standard treatment, with various methods for appendiceal stump closure, including polymeric clips and endoloops. This study aims to compare the efficacy and safety of polymeric clips compared with endoloops in laparoscopic appendectomy. MethodsA systematic review and meta-analysis were conducted followingPreferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Medline, Scopus, and Embase were searched for studies up to March 25, 2024. ResultsIn total, 13 studies, including 6 randomized controlled trials, were analyzed. Polymeric clipping demonstrated significantly shorter surgical time compared with the endoloop (standardized mean difference 0.37, 95% confidence interval 0.22–0.53, P < .00001), with no difference in hospital stay or overall complications. However, the endoloop was associated with a greater incidence of intra-abdominal abscess (risk ratio 3.53, 95% confidence interval 1.56–8.00, P = .003). Other outcomes, including time from instrument application to appendiceal cutting, ileus, and surgical-site infection, showed no significant differences between the 2 techniques. ConclusionPolymeric clipping appears to be superior to endoloop in terms of shorter surgical time and lower risk of intra-abdominal abscess formation in laparoscopic appendectomy for uncomplicated appendicitis. However, both techniques have similar outcomes regarding hospital stay and overall complications. Further research addressing study limitations and exploring patient-centered outcomes is warranted to guide clinical practice.

Handmade Loop Versus Hem-o-Lok Clip in Closure of Appendiceal Stump During Laparoscopic Appendectomy: Limited Setting in a Peripheral University Hospital.

Background: Today, laparoscopy is frequently used in abdominal emergencies such as acute appendicitis. There are several techniques used to close the appendiceal stump during laparoscopic appendectomy. We aimed to compare the use of handmade loop and Hem-o-lok used to close the appendiceal stump in public hospitals where resources are limited, in terms of surgical outcomes and cost. Methods: Between January 2020 and December 2022, patients for whom handmade loops and Hem-o-loks were used to close the appendiceal stump during laparoscopic appendectomy in our clinic were included in the study. There were a total of 638 patients (mean age: 33 ± 13.5 years, 325 females and 313 males) in the patient cohort. Demographic and clinical data, duration of surgery, complications, hospital stay, pathology reports, mortality, and cost of supplies were compared between the two groups. Results: There were 308 patients in the handmade loop group (160 females, 148 males, mean age: 33.7 years, range: 18-85 years) and 330 patients in the Hem-o-lok group (166 females, 164 males, mean age: 32.5 years, range: 18-89 years). There was no significant difference between the two groups for American Society of Anesthesiologists score, duration of symptom, hospital stay, intensive care unit stay, preoperative laboratory values, histopathological results, mortality, and morbidity (P > .05). The mean operation time was 48.76 ± 16.16 minutes in the handmade loop group and 40.53 ± 11.63 minutes in the Hem-o-lok group (p = 0.001). In terms of cost, the cost per case of Hem-o-lok group was about 25.8 times as much as the group that used sutures ($31 versus $1.2). Conclusions: Both methods can be used safely in laparoscopic appendectomy. The use of Hem-o-lok has no advantage other than shortening the operation time. However, it is costlier. Especially in peripheral hospitals where resources are limited, closing the appendiceal stump using a handmade loop is an easy, safe, and cost-effective method.

Single versus double Hem-o-lok clips to secure the apendiceal stump during laparoscopic appendectomy: a prospective randomized multicentric clinical trial

PurposePolymeric clips (Hem-o-lok ligation system) are now widely used to securing the base of the appendix during laparoscopic appendectomy. Studies comparing the use of single or double hem-o-lok clips are limited. The aim of this study was to compare the reliability of a single hem-o-lok clips with a double hem-o-lok clips for closure of an appendiceal stump.MethodsThis prospective randomized study includes patients from two centers who underwent laparoscopic appendectomy with the diagnosis of appendicitis between September 2020 and March 2023. Demographic, operative and clinical outcomes of the use of single or double hem-o-lok clips for closure of the appendiceal stump were compared. Factors affecting long postoperative hospital stay were investigated using univariate and multivariate analyzes.ResultsOne hundred forty two (48.3%) patients in the single hem-o-lok arm and 152 (51.7%) patients in the double hem-o-lok arm were included in the analysis.The shortest operative time was noted in the single hem-o-lok group (52.1 ± 19.9 versus 61.6 ± 24.9 min, p < 0.001). The median hospital stay was 1 day (range 1–10) in the single hem-o-lok group and 1 day (range 1–12) in the double hem-o-lok group, and was shorter in the single hem-o-lok arm (1.61 ± 1.56 vs 1.84 ± 1.69, p = 0.019). Based on multivariate analysis, drain placement was identified as an independent predictive factor for long hospital stay.ConclusionsThe use of single hem-o-lok clips for appendiceal stump closure during laparoscopic appendectomy is safe and effective.Trial registration NCT04387370 (http://www.clinicaltrials.gov).

Is LigaSure Alone Sufficient for the Closure of the Appendix Stump?

Closure of the appendix stump is necessary for laparoscopic appendectomy. Problems that occur during the appendix stump closure can cause severe morbidity. Several methods of stump closure have been described. This study aimed to investigate the adequacy of LigaSure alone in closing the appendix stump. Patients who were operated on with the diagnosis of acute appendicitis between October 2021 and January 2022 were evaluated retrospectively. The patients were divided into two groups according to the closure technique of the appendix stump hemoclip(group I) and LigaSure only(group II). In addition, demographic data (age, gender), body mass index (BMI), presence of comorbid disease, perioperative appendicitis classification, operation time, postoperative hospital stay, radiological and pathological appendix size of the patients included in the study were recorded. Clavien Dindo was used for postoperative complication assessment. The study included 77 patients. 48(62.3%) of the patients were in group I, and 29(37.7%) were in group II. There was no statistical difference between the groups regarding age, gender distribution, BMI, presence of comorbid disease (P > .05). The operation time of group I was longer than group II (P < .001). There was no difference between the groups in terms of both radiological and pathological appendix size. There was no statistical difference between the groups regarding postoperative complications and severity of complications (P = .76, P = .99, respectively). Appendiceal stump closure can be performed with Ligasure, but it should be noted that this procedure can be performed on selected patients, as in the study group, not on all patients.

Comparison of the non-absorbable polymer clips, knot-tying, and loop ligature appendiceal stump closure methods in laparoscopic appendectomy

Comparison of the non-absorbable polymer clips, knot-tying, and loop ligature appendiceal stump closure methods in laparoscopic appendectomy

Clips closure versus endoloop ligation in laparoscopic appendectomy: a systematic review and meta-analysis of comparative studies.

Appendiceal stump closure (ASC) is a key step in performing laparoscopic appendicectomy. Currently, there is no gold standard method to achieve this goal. The ideal method should be safe, easily available, and have a short learning curve. Out of all those appendiceal stump closure methods, the use of hem-o-Lok demonstrates its feasibility in replacing the traditionally used endoloop. In this systematic review and meta-analysis, the authors aim to review the currently available evidence addressing the topic of interest. The PubMed and Embase databases were searched with the paired search terms appendicitis, clip, and endoloop by two authors separately. The quality of the randomized controlled trials was assessed with the Cochrane risk of bias tool, and the quality of the observational studies was assessed with the Newcastle-Ottawa scale. Meta-analysis was conducted with Cochrane Review Manager version 5.4. Eighteen studies were included for quantitative analysis. The appendiceal stump closure time was shortened by 2 min 7 s using a hem-o-lok with 95% CI 1 min 48 s-2 min 26 s, p less than 0.00001. The pooled results of 6 randomized controlled trials demonstrated a statistically significant reduction in operative time of 5.15 min from adopting the hem-o-lok approach (p=0.001, 95% CI -2.05 to -8.24min). Both endoloop and hem-o-lok demonstrated a comparable postoperative hospital stay and infective complication profile. The application of Hem-o-Lok demonstrates a comparable to endoloop ligation in terms of operative time and a potential benefit on the complication. When considering financial and technical aspects, it serves as an alternative to endoloop.

A Hypothetical New Challenging Use for Indocyanine Green Fluorescence during Laparoscopic Appendectomy: A Mini-Series of Our Experience and Literary Review.

Laparoscopic appendectomy (LA) is a well-standardized surgical procedure, but there are still controversies about the different devices to be used for the appendiceal stump closure and the related postoperative complications. Indocyanine green (ICG) fluorescence angiography (FA) has already been shown to be helpful in elective and emergency surgery, providing intraoperative information on tissue and organ perfusion, thus guiding the surgical decisions and the technical strategies. According to these two aspects, we report a mini-series of the first five patients affected by gangrenous and flegmonous acute appendicitis intraoperatively evaluated with ICG-FA during LA. The patients were admitted to the Emergency Department with an usual range of symptoms for acute appendicitis. The patients were successfully managed by fully LA with the help of a new hypothetical challenging use of ICG-FA.

In Pursuit of the Most Cost-Effective Laparoscopic Appendicectomy: A Review of the Literature.

To review the literature and identify the most economical techniques for laparoscopic appendicectomy (LA) that do not compromise on patient care. We performed a search of the Cochrane Library, PubMed, EMBASE and Google Scholar for papers published between January 2001 and January 2021. The outcomes of the included studies were then grouped by theme of cost analysis, with the main areas of focus being the use of disposable equipment, appendiceal stump closure, and retrieval of the appendix. After screening a total of 254 search results, 40 studies were included, representing 13285 patient outcomes, having two main areas of focus: the use of reusable or disposable equipment and the different methods of appendiceal stump closure. Use of disposable instruments has been cost effective in LA in 2 studies. However, use of reusable trocars has reduced cost of procedure by €250 in another study. Appendiceal stump closure using ligature, endoloops or Endoclips had been cost-effective compared to Endostaplers in 25 studies. This can save up to €350. Endoscopic specimen bags are single use and represent further disposable equipment costs. The use of a sterile glove to replace this piece of kit can further provide cost benefit as shown in 2 studies. Laparoscopic appendicectomy can be performed in a variety of ways with equivocal patient safety. We present the use of extracorporeal ligature of the appendiceal base, combined with the use of a surgical glove retrieval system as the most economic technique in laparoscopic appendicectomy.

Appendiceal stump closure using LigaSureTM alone in laparoscopic appendectomy in children: ıs it safe and feasible?

Appendiceal stump closure using LigaSureTM alone in laparoscopic appendectomy in children: ıs it safe and feasible?

Self-Locking Polymeric Clips Are Safe for the Closure of Appendiceal Stump in Laparoscopic Appendectomy.

Background: Closure of the appendix stump is critical to avoid serious postoperative complications. There are a number of options, but the best one has not been identified yet. The purpose of this study is to evaluate the outcomes of appendiceal stump closure using self-locking polymeric clips and endoloops. Methods: A retrospective analysis of the prospectively maintained database of patients with acute appendicitis was performed. Patient demographic details and surgical characteristics, including the duration of hospital stay, postoperative complications, and also the cost of the appendix stump closure, were recorded. Patients were divided into two groups according to the appendix stump closure method: the clips group if it was closed with self-locking polymeric clips and the loops group if Vicryl or PDS loops were used. Statistical analysis was performed using Pearson's chi-squared test, Wilcoxon rank sum (Mann-Whitney U) test, and Fisher's exact test in R statistical software package version 4.2.1. Results: 515 patients were included in the study from June 2016 to April 2021. There were no significant differences in terms of demographics (p-value in comparison of groups' sex > 0.99, age p-value 0.16), postoperative complications (p-value > 0.99), histological findings (p-value 0.27), or length of hospital stays (p-value 0.18) between the two patient groups (clips group, N = 454 and loops group, N = 61). The price of operation while using different appendiceal stump closures is significantly different. In a laparoscopic appendectomy, one stump closure with self-locking clips costs 7.69 €, with Vicryl loops-91.35 €, with PDS loops-96.51 €, and with a stapler-514.50 €. Conclusions: Self-locking polymeric clips can be used for the safe and effective closure of an appendiceal stump. There were no significant differences in the postoperative time (30 days) or complication rates among patients in both (clips and loops) groups. Thus, this might be a technique to reduce expenses while maintaining good postoperative results after laparoscopic appendectomy.

The use of the extracorporeally prepared hand-made endo-loop technique in laparoscopic appendectomy.

Acute appendicitis is the leading emergency condition among surgical abdominal diseases. The treatment of choice for appendicitis is open or laparoscopic appendectomy. There are different methods for appendiceal stump closure. Laparoscopic ap-pendectomy became more applicable with hand-made endo-loop applications to close the appendiceal stump, especially in state hospi-tals where the resources were limited. This article aims to evaluate the outcomes of patients undergoing laparoscopic appendectomy with the appendiceal stump closure using a hand-made endo-loop. Fifty patients undergoing laparoscopic appendectomy with the appendiceal stump closure using a hand-made endo-loop in the General Surgery Department of our hospital between June 2014 and December 2018 were evaluated. The ages, genders, length of stay in the hospital, complications, and histopathological investigation results of the patients were gathered retrospectively. Lapa-roscopic appendectomy was performed with three ports. The appendiceal stump was closed using two hand-made endo-loops. The loop was made with a modification of Roeder's loop whose safety was proven in the literature. The first port was introduced to the abdomen with the open method. SPSS 26.0 statistical program was used for statistical analysis. Thirty-one (62%) of patients were males and 19 (38%) of them were females. The mean age was 32.2±11.9 years. The age ranged between 19 and 74 years. The median length of stay in the hospital of the patients was 1.12±0.47 days. One of the patients was 21 weeks pregnant. A surgical site infection occurred in one patient during the post-operative period. Recovery was obtained with antibiotherapy. No leakage through the base of the appendix or cecal fistula was determined in none of the patients. One of the most important parameters in the cost of laparoscopic appendectomy is the closure technique of the stump. The cost comes into question much more especially in state hospitals where the resources are limited. Appendiceal stump closure using a hand-made endo-loop is an easy, safe, and cost-effective method.

Appendiceal Base Ligation With The Hand-Made Polydioxanone (Pds) Extracorporeal Knot

Objective: This study describes our experience with a low cost handmade polydioxanone (PDS) extracorporeal knot to reduce the cost of laparoscopic appendectomy in a surgical practice.&#x0D; Methodology: This retrospective study was conducted from January 2018 to December 2019 in a general surgical unit of the University College Hospital Ibadan. The files of 20 patients with complete data for whom extracorporeal hand-made PDS’0’ knots were used for appendiceal stump closure during laparoscopic appendectomy were retrieved.&#x0D; Results: The mean age was 28.4 ± 13.2 years. There were nine male and eleven female patients. All the operations were performed by the same surgical team. The mesoappendix was coagulated with bipolar cautery and cut with scissors. The appendix base was double ligated with two extracorporeal knots and divided. The mean duration of surgery was 59.2 ± 31.2minutes. The median length of hospital stay was 2days. The mean duration of follow up was 2.80 ± 0.50 months. One patient developed superficial port site infection.&#x0D; Conclusion: The handmade extracorporeal knot used in this retrospective study for securing appendicular stump was found to be safe and cheaper than pre-tied extracorporeal loop. This will reduce dependency upon preformed endoloops making the procedure cheaper. There was no incidence of failed application of the handmade extracorporeal knot.

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy

BackgroundLaparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database. MethodsWe queried the Pediatric Health Information System (PHIS) for patients ages 3–18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 – 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation. ResultsIn total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8–14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 – 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 – 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis. ConclusionSBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method. Level of evidenceLevel III. Study typeRetrospective Comparative Study.

Energy Devices for Clipless-Sutureless Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis on Utility and Safety.

Background and Objectives: While laparoscopic appendectomy is standardized, techniques for appendiceal stump closure and mesoappendix division remain variable. Novel vessel sealing techniques are increasingly utilized ubiquitously. We sought to systematically summarize all relevant data and to define the current evidence on the safety and utility of energy devices for clipless-sutureless laparoscopic appendectomy in this systematic review and meta-analysis. Materials and Methods: This review was conducted following the PRISMA guidelines. PubMed, Embase, Scopus, and Web of Science were systematically searched. Inclusion criteria included studies with laparoscopic appendectomy for appendicitis. The intervention included patients undergoing division of mesoappendix and/or securing of the appendicular base using diathermy (Monopolar or Bipolar or LigaSure Sealing Device) or Harmonic Scalpel (Group A) compared to patients undergoing division of mesoappendix and/or securing of the appendicular base using endoclip or Hem-o-lok or ligature (Group B). The methodological quality of the included studies was assessed using the Downs and Black scale. The outcomes of surgical site infection (SSI) or intra-abdominal collection, postoperative ileus, average operative duration, and length of hospital stay (LHS) were compared. Results: Six comparative studies were included; three were retrospective, two were prospective, and one was ambispective. Meta-analysis revealed a shorter operative duration in Group A with respect to appendicular base ligation (MD -12.34, 95% CI -16.57 to -8.11, p &lt; 0.00001) and mesoappendix division (MD -8.06, 95% CI -14.03 to -2.09, p = 0.008). The pooled risk ratios showed no difference in SSI between groups. Additionally, no difference was observed in LHS. The risk of postoperative ileus was higher in group B regarding mesoappendix division (RR 0.56, 95% CI 0.34 to 0.93, p = 0.02), but no difference was found concerning appendicular base ligation. The included studies showed a moderate-to-high risk of bias. Conclusions: Clipless-sutureless laparoscopic appendectomy is safe and fast. Postoperative ileus seems less common with energy devices for mesoappendix division. However, the studies included have a moderate-to-high risk of bias. Further studies addressing the individual devices with surgeons of similar levels are needed.

Use of a Bipolar Device (LigaSure) to Seal the Appendiceal Stump in Pediatric Laparoscopic Appendectomy: 10-year Latin-American Experience

BackgroundClosure of the appendiceal stump is a critical step during an appendectomy. There is a lack of knowledge about the feasibility of using electrosurgical devices for the occlusion of the appendix. This study aims to determine the safety of this technique in pediatric patients. MethodsWe performed a cross-sectional analytical study in patients less than 18 years of age treated at Hospital Militar Central Colombia between 2012 and 2021. Our institution's ethics committee approved the study. We analyzed the data using SPSS 22 statistical program. We present frequencies for qualitative variables and measures of central tendency or dispersion for quantitative variables depending on the distribution measured by the Kolmogorov-Smirnov test. In addition, we measured the association of nominal variables with the Chi-square test or Fisher's exact test. For numerical variables, the difference of means with the Student's t-test or the difference of medians with the Mann-Whitney U test. ResultsWe treated 209 patients. One hundred sixteen (55.5%) were boys, and the mean age was 9.7 years (SD 3.2). The median intraoperative time was 60 min, and the hospital stay was 2.8 days on average. There were no cases of stump leakage, and only two patients (1%) had an organ-space surgical site infection, which was unrelated to the closure technique. We found no association between procedural complications and appendicular status (p = 0.450). ConclusionsOur research suggests that using a bipolar sealing device (Ligasure, Medtronic, USA) for appendiceal stump closure in pediatric patients undergoing laparoscopic appendectomy is feasible and should be further studied. Type of StudyTreatment study. Level of evidenceLevel III

How Can Laparoscopic Appendectomy Become the First-Line Treatment for Acute Appendicitis in Lower-Income Countries: A 15-Year Experience

Introduction: The barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource cost and availability. The present study evaluates the impact of actions took over 15 years in a single academic center aiming to implement the routine use of laparoscopy for acute appendicitis. Methods: Retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared with 4 major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. Results: We identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p < 0.001). Since 2016 the standard of care in our institution is appendiceal stump closure with polymeric clips, even in complicated acute appendicitis. Conclusion: The development of a feasible, reproducible, and safe technical standardization is one of the cornerstones for a consistent and viable change in the current practice for appendectomies in lower-income countries.

Proper use of appendiceal stump closure methods for surgical site infection in laparoscopic appendectomy.

Although some studies have reported on the relationship between appendiceal stump closure methods and postoperative complications, there is no fixed method for this procedure. This study aimed to compare treatment outcomes of the existing procedures. We retrospectively analyzed the records of 200 patients who underwent urgent laparoscopic surgeries and investigated whether the difference in the appendiceal stump closure method was a risk factor for surgical site infection. The patients were divided into the Endoloop and endostapler groups, and 45 propensity score-matched patients were included. The treatment outcomes of the two groups were compared. The patients with high body temperature showed significantly developed surgical site infection in multivariate analysis (P=.036). There was no significant difference in the appendix stump methods (Endoloop vs endostapler). Regarding postoperative complications, superficial and deep incisional surgical site infection, organ/space surgical site infection, ileus, and complications of Clavien-Dindo grade IIIa or higher; there was no significant difference between the endoloop and endostapler groups after propensity score matching (P=.725, 1.000, .645 and .557, respectively). By properly using the Endoloop and endostapler according to the severity of inflammation, the Endoloop can be safely performed in many cases. Inexpensive Endoloop as an option for stump closure methods should positively impact medical costs.

A Systematic Review and Meta-Analysis of Harmonic Scalpel Versus Conventional Techniques of Appendiceal Stump Closure in Laparoscopic Appendicectomy.

Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining popularity over open appendicectomy in the current surgical practice. The advantages of laparoscopic appendectomy are early recovery, fewer wound complications, less pain and better cosmesis. One of the most critical steps in laparoscopic appendicectomy is a secure appendicular stump closure. Life-threatening postoperative complications are often encountered following the breakdown of appendicular stump closure. There are several methods to achieve appendicular stump closure such as intra-corporeal knotting, endoloops, external corporeal knotting and pushing knot inside, endoscopic linear cutting stapler (endo GIA), and endoclips. A meta-analysis on the technique of appendicular stump closure in laparoscopic appendicectomy failed to demonstrate the superiority of one method over the other. In the last few years, many authors have evaluated the outcome of sutureless appendicectomy performed using devices like a harmonic scalpel. This systematic review and meta-analysis is aimed to summarise the current evidence regarding the utility and safety of harmonic scalpel in sutureless appendicectomy.This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. A systematic, detailed search was carried out by the authors in the electronic database, including Medline, Embase, CENTRAL, Scopus, Google scholar and clinical trial registry. Studies were selected and compared based on outcomes such as operative time, hospital stay, postoperative paralytic ileus, wound infection, and total complications. Statistical analysis was performed using the random effect model, fixed-effect model, pooled risk ratio, pooled mean difference and I2 heterogeneity.Four comparative studies with a total of 642 patients (376 male and 266 females) were included in the analysis. There were 359 patients in the conventional technique of appendicular stump closure group and 283 patients in the harmonic scalpel for appendicular stump closure group. Pooled analysis of the outcome measure of total complications showed that the use of harmonic scalpel for closure of appendiceal stump does not result in an increased incidence of complications as compared to the conventional technology of appendiceal stump closure. Pooled analysis of the outcome measure of mean operative time revealed a statistically significant reduction in the operative time in the patients where harmonic scalpel has been used for the management of appendiceal stump as compared to conventional methods (pooled mean difference of -12.96 with 95% CI -15.42, -10.50). Appendiceal stump closure during laparoscopic appendectomy by harmonic scalpel (HS) is comparable with the conventional techniques in terms of hospital stay, wound infection, postoperative paralytic ileus, and total complications. The use of a harmonic scalpel for closure of appendicular stump is associated with a reduction of the mean operative time of laparoscopic appendicectomy.

Appendiceal stump closure with hem-o-lok clips in laparoscopic appendectomy

Various appendiceal stump closure techniques are used in laparoscopic appendectomy (LA). The purpose of this study was to investigate the safety and usefulness of the Hemolok clip for the closure of appendicular stumps in LA. From January 2015 to October 2018, a total of 87 consecutive patients underwent LA by three surgeons with planned use of Hemolok clips. In 9 (10.3%) patients, hemolok clips could not be used for the closure of the stump. The remaining 78 patients were included for analysis. The demographics, operation time, hospitalization time and complications were recorded. Of these 78 patients, 39 (50%) were male and 39 (50%) were female. The mean age was 28.55 ± 10.61 (18- 73) years and median operation time was 51.3 (30-160) minutes. Twenty-two (28.2%) of the patients had complicated appendicitis (perforated, necrotic). The median time until oral diet allowance was 10.48 (4-36) hours after surgery and median hospitalization time was 22.92 (6-72) hours. Postoperative complications were seen in 4 (5.1%) patients; two had abdominal pain, one had abdominal distention and one had trocar site infection. None of the complications were associated with the use of hemolok clips. None of the patients required reoperation. The appendiceal diameter was found to be greater in patients without hemolok closure compared to patients with hemolok closure (p = 0.003). The closure of the appendix stump with hemolok in LA is an appropriate, safe, fast and cost-effective technique. It is important to note that the appendix stump should not be extremely edematous or necrotic in order to be able to apply hemolok clips. Ideally, the stump should have a diameter smaller than 1 cm.

Comparison of the non-absorbable polymer clips, knot-tying, and loop ligature appendiceal stump closure methods in laparoscopic appendectomy.

In laparoscopic appendectomy (LA), closure of the appendix stump is important. This method must be safe and easy-to-use as well as an economical one. We compared three methods of the appendix stump closure in terms of safety, easiness, and financial cost. Three-hundred and ten LA patients operated between January 2011 and December 2019 and appendix stump was closed using one of the three methods, namely, non-absorbable polymeric clips (Group 1, n = 126), knot-tying group (Group 2, n = 101), and laparoscopic loop ligature group (Group 3, n = 83) were retrospectively analyzed in terms of stump leakage, infection, operation, and hospital stay duration. There were 148 female and 162 male patients. The mean age was 33.57 ± 12.60 years. There was not any appendiceal stump leakage nor intra-abdominal infection in none of the groups. Local trocar site infection in 11 patients was medically treated. Surgical site infection and hospital stay period did not show statistically important difference among the groups. The operation duration in Group 1 was found to be shorter compared to the other groups. All three techniques are safe in LA. Non-absorbable polymer clips provide a shorter operation time. Extracorporeal knot-tying with knot-pusher provides the cheapest closure of the stump.