Intracorporeal Knotting Versus Metal Endoclip Application for the Closure of the Appendiceal Stump During Laparoscopic Appendectomy in Uncomplicated Appendicitis

Endoloop Versus Metallic Clip for Stump Closure in Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis

Appendectomy is the treatment of choice for most cases of acute appendicitis, and, considering that the availability of technical variables for closing the appendicular stump raises questions for surgeons, analyzing which closure method provides the best results is necessary. This study aims to compare the variables of operating time, readmission rate, reoperation, and surgical wound infection regarding the endoloop and metallic clip techniques for closing the appendicular stump in laparoscopic appendectomy. Only randomized clinical trials that compared metallic clip and endoloop appendicular stump closing in laparoscopic appendectomy were used. Of these, those that did not fit the PICOT (Patient, Intervention, Comparison, Outcome, and Time) question and inclusion criteria were excluded, with five articles being included for the analysis phase. Five randomized clinical trials were included in the statistical analysis, totaling a population of 344 patients, with 181 patients in the metal clip group. It was observed that the operation time was significantly shorter in the metal clip group (STD -0.81, 95% CI: -1.13, -0.49, p < 0.00001, I² = 50%). To the extent that the reoperation rate (RR 1.27, 95% CI: 0.20, 7.88, p = 0.80, I² = 0%), the readmission rate (RR 0.93, 95% CI: 0.29, 2.91, p = 0.89, I² = 0%), and the surgical wound infection rate (RR 0.87, 95% CI: 0.24, 3.13, p = 0.83, I² = 0%) were statistically similar between the two groups. The findings of this study demonstrate that the closure of the appendicular stump using metal clips in laparoscopic appendectomy is faster, with similar rates of readmission, reoperation, and surgical wound infection between the two groups.

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

BACKGROUND

Appendicitis 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.

METHODS

A 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.

RESULTS

In 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.

CONCLUSION

Polymeric 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.

Effectiveness of different appendiceal stump closure methods in laparoscopic appendectomy a network meta-analysis

PURPOSE

Choosing the best stump closure method for laparoscopic appendectomy has been a debated issue, especially for patients with acute appendicitis. The lack of consensus in the literature and the diverse techniques available have prompted the need for a comprehensive evaluation to guide surgeons in selecting the most optimal appendiceal stump closure method.

METHODS

A comprehensive search was conducted on multiple databases from inception until December 2023 to find relevant studies according to eligibility criteria. The primary outcome was the incidence of total complications.

RESULTS

25 studies with a total of 3308 patients were included in this study, overall complications did not reveal a significant advantage for any intervention (RR = 0.72, 95% CI: 0.53; 1.01), Superficial and deep infection risks were similar across all methods, Operative time was significantly longer with endoloop and Intracorporeal sutures (MD = 7.07, 95% CI: 3.28; 10.85) (MD = 26.1, 95% CI: 20.9; 31.29).

CONCLUSIONS

There are no significant differences in overall complications among closure methods. However, Intracorporeal sutures and endoloop techniques were associated with extended operative durations.

Comparison of two methods: Clipping and suturing in laparoscopic appendectomy

Objective

Closure of the appendix stump after appendectomy is considered one of the most important parts of laparoscopic appendectomy. Various techniques are used during this surgery, commonly including endoclips and ligatures. Therefore, this study was conducted to compare endoclips with intra-corporeal ligatures in closing the appendix stump during laparoscopic appendectomy.

Methods

This retrospective study was conducted using data from 50 patients with acute appendicitis who underwent uncomplicated laparoscopic appendectomy. The data from patients whose stumps were closed using endoclips in 25 patients (Group I) and with intra-corporeal ligatures in 25 patients (Group II) were extracted and compared regarding the occurrence of intraoperative and postoperative complications.

Results

There were no differences between the two methods in terms of intraoperative and postoperative complications. The duration of surgery in the ligature group was significantly longer than in the clip group (p = 0.044). The hospital stay duration was clinically longer in the ligature group, but this difference was not statistically significant (p > 0.05).

Conclusion

Endoclips for closing the appendix stump are safer with a shorter operating time and also a simpler method. Therefore, they could be a reliable alternative to the method of closing the appendix stump with ligatures.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Effect of endoscopic loop ties in acute appendicitis on wound infection rate: A meta-analysis

A meta-analysis study to measure the consequence of endoscopic loop ties (ELT) in acute appendicitis (AA) on wound infection rate. A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. The 27 chosen studies enclosed 15 093 subjects with AA in the chosen studies' starting point, 7141 of them were ELT, and 7952 were open surgery. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of ELT in AA on wound infection rate by the dichotomous and continuous styles and a fixed or random model. Open surgery had a significantly higher postoperative surgical site wound infection (SSWI). (OR, 1.41; 95% CI, 1.09-1.83, P = 0.009) with low heterogeneity (I2  = 34%) compared to ELT in AA subjects. Although no significant difference was detected between open surgery and ELT in intra-abdominal abscess rate (OR, 0.88; 95% CI, 0.56-1.40, P = 0.59) with moderate heterogeneity (I2  = 51%) in AA subjects. Open surgery had a significantly higher postoperative SSWI, however, no significant difference was found in intra-abdominal abscess rate compared to ELT in AA subjects. However, caused by the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.

Closure of the appendiceal stump in laparoscopic appendectomy: A systematic review of the literature

Background

Closure of the appendiceal stump is a key step performed during laparoscopic appendicectomy. Inadequate management of the appendiceal stump has the potential to cause significant morbidity. Several methods of stump closure have been described, however high-level evidence is limited. We performed a systematic review evaluating clinical outcomes and quality of the evidence for the methods of appendiceal stump closure.

Methods

A systematic literature search was performed using Medline, Embase, Cochrane Database and Google Scholar to identify studies comparing appendiceal stump closure methods in laparoscopic appendectomy for acute appendicitis from inception to October 2019. Data regarding operative duration, peri-operative complications, length of stay and costs were collated from all included studies.

Results

From 160 identified studies, 19 met the inclusion criteria. Endoloops and endoclips provide equivalent clinical outcomes at lower cost, while operative duration was shortest with endoclip closure. Endostapler devices have the lowest rate of peri-operative complications (3.56%), however their cost limits their regular use in many healthcare environments. Post-operative complication rate and length of stay were similar for all stump closure methods. Conclusion: Although there are no significant differences in method of stump closure in laparoscopic appendectomy, closure with endoclips provides the shortest operative duration. There is a need for robust and standardized reporting of cost data when comparing stump closure methods, together with higher level evidence in the form of multi-centre randomized controlled trials before firm conclusions can be drawn regarding the optimal method of stump closure.

•

Currently there is no robust higher order evidence which assesses clinical outcomes, cost and time efficiency of methods of stump closure in laparoscopic appendicectomy.

•

This is the first systematic review to investigate clinical outcomes, cost and quality of current evidence for all methods of laparoscopic appendiceal stump closure in acute appendicitis.

•

No difference was observed in methods of stump closure in complication rate, length of stay, cost, and time efficiency.

•

Endostaplers appear to provide most robust closure, albeit at a higher economic cost.

•

Endoloops appear to provide efficient and successful closure, and are currently the most frequently studied method of closure.

Meta-analysis of unplanned readmission to hospital post-appendectomy: an opportunity for a new benchmark

BACKGROUND

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. While many studies report readmission, a meta-analysis of readmission post-appendectomy has not been published. This meta-analysis was undertaken to determine rates and predictors of hospital readmission following appendectomy and to potentially provide a metric benchmark.

METHODS

An ethically approved PROSPERO-registered (ID CRD42017069040) meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using databases PubMed and Scopus, was undertaken for studies published between January 2012 and June 2017. Articles relating to outcomes and readmissions after appendectomy were identified. Those scoring >15 for comparative studies and >10 for non-comparative studies, using Methodological Index for Non-Randomized Studies criteria were included in the final analysis. The odds ratios (OR) using random-effects, Mantel-Haenszel method with 95% confidence intervals (CI), were computed for each risk factor with RevMan5.

RESULTS

A total of 1757 articles reviewed were reduced to 45 qualifying studies for a final analysis of 836 921 appendectomies. 4.3% (range 0.0-14.4%) of patients were readmitted within 30 days. Significant preoperative patient factors for increased readmission were diabetes mellitus (OR 1.93, CI 1.63-2.28, P < 0.00001), complicated appendicitis (OR 3.6, CI 2.43-5.34, P < 0.00001) and open surgical technique (OR 1.39, CI 1.08-1.79, P < 0.00001). Increased readmission was not associated with gender, obesity or paediatric versus general surgeons or centres.

CONCLUSION

This meta-analysis identified that readmission is not uncommon post-appendectomy, occurring in one in 25 cases. The mean readmission rate of 4.3% may act as a quality benchmark for improving emergency surgical care. Targeting high-risk groups with diabetes or complicated appendicitis and increasing use of laparoscopic technique may help reduce readmission rates.

Re-evaluation of purse string suture in laparoscopic appendectomy

PURPOSE

The aim of this study was to compare the outcomes of laparoscopic appendectomy (LA) using purse string invaginating sutures (PS) with those using intracorporeal knotting (IK) or Hem-o-lock polymeric clips (HL).

METHODS

A total of 882 patients who underwent laparoscopic appendectomy from January 2015 to December 2017 were studied retrospectively. Of these, 538 patients used PS, 229 patients used IK and 115 patients used HL to close the appendiceal stump. Their demographic characteristics, intraoperative findings and postoperative complications were analysed retrospectively.

RESULTS

There were similar percentages of complicated cases in all the groups (21.7% in PS vs. 21.4% in IK vs. 24.3% in HL, p = 0.803). The mean length of hospital stay was shorter in PS group when compared to IK or HL group (3.72 + 2.35 in PS vs. 4.41 + 2.40 in IK, 4.43 + 2.66 in HL, p < 0.05) as well as lower ASA scores (1.7 + 0.6 in PS vs. 1.8 + 0.6 in IK vs. 1.7 + 0.6 in HL, p < 0.05). The overall complication rates for the PS, the HL and the IK groups were 12.1, 8.7 and 9.2%, respectively. The rate of wound infection was higher in PS group for uncomplicated appendicitis (5.0% in PS vs. 2.8% in IK and 1.1% in HL, p = 0.129). Furthermore, there were no differences in the rate of intra-abdominal infection among the groups in both uncomplicated and complicated cases.

CONCLUSIONS

Based on our results, purse string suture failed to demonstrate better postoperative outcome in laparoscopic appendectomy and is no longer recommended by our institution as initial approach.

Outcomes of Open and Laparoscopic Appendectomy With Single Endoloop Stump Closure

Background and Objectives:

Although laparoscopic appendectomy (LA) has been used for 35 years, the open approach (OA) is preferred worldwide. Widespread access to instrumentation in a number of centers has reduced economic and logistical obstacles. The aim of this work is to compare the results for patients with suspected appendicitis treated using an OA versus patients treated using LA.

Methods:

A retrospective study of all patients (N = 290) who underwent operation due to suspected appendicitis in the General Surgery Department from 2014 to 2017 was conducted. LA was performed in 91 patients, and OA was performed in 199 patients.

Results:

Average surgery duration was 67.8 minutes in the LA group and 62.9 minutes in the OA group (P =.082). It was necessary to perform 3 conversions (3.3%) from LA to OA. Wound infections occurred in 2.2% of patients in the LA group and in 12.6% of patients in the OA group (P = .007). A reduced duration of hospitalization was noted in the LA group (3.3 days) compared with the OA group (4.7 days) (P < .001).

Conclusion:

The duration of LA is not considerably longer than that of OA. LA in patients with suspected appendicitis reduces the number of operation site infections compared with OA. LA with single endoloop stump closure is a safe method and may be recommended for wider applications.

Absorbable polymeric surgical clips for appendicular stump closure: A randomized control trial of laparoscopic appendectomy with lapro-clips

A randomized control trial was performed to evaluate the effectiveness and safety of absorbable polymeric clips for appendicular stump closure in laparoscopic appendectomy (LA). Patients were randomly enrolled into an experimental group (ligation of the appendicular base with Lapro-Clips, L-C group) or control group (ligation of the appendicular base with Hem-o-lok Clips, H-C group). We identified 1,100 patients who underwent LA between April 1, 2012 and February 3, 2015. Overall, 99 patients (9.0%, 99/1,100) developed a complication following LA (47 [8.5%] in the L-C group and 52 [9.5%] in the H-C group (P = 0.598). No statistically significant differences were observed in intra-abdominal abscesses, stump leakage, superficial wound infections, post-operative abdominal pain, overall adverse events, or the duration of the operations and hospital stays between the groups (all p > 0.05). Adverse risk factors associated with the use of absorbable clips in LA included body mass index ≥ 27.5 kg/m2, diabetes, American Society of Anesthesiologists degree ≥ III, gangrenous appendicitis, severe inflammation of the appendix base, appendix perforation, and the absence of peritoneal drainage. The results indicate that the Lapro-Clip is a safe and effective device for closing the appendicular stump in LA in select patients with appendicitis.

Closure methods of the appendix stump for complications during laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy is amongst the most common general surgical procedures performed in the developed world. Arguably, the most critical part of this procedure is effective closure of the appendix stump to prevent catastrophic intra-abdominal complications from a faecal leak into the abdominal cavity. A variety of methods to close the appendix stump are used worldwide; these can be broadly divided into traditional ligatures (such as intracorporeal or extracorporeal ligatures or Roeder loops) and mechanical devices (such as stapling devices, clips, or electrothermal devices). However, the optimal method remains unclear.

OBJECTIVES

To compare all surgical techniques now used for appendix stump closure during laparoscopic appendectomy.

SEARCH METHODS

In June 2017, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6) in the Cochrane Library, MEDLINE Ovid (1946 to 14 June 2017), Embase Ovid (1974 to 14 June 2017), Science Citation Index - Expanded (14 June 2017), China Biological Medicine Database (CBM), the World Health Organization International Trials Registry Platform search portal, ClinicalTrials.gov, Current Controlled Trials, the Chinese Clinical Trials Register, and the EU Clinical Trials Register (all in June 2017). We searched the reference lists of relevant publications as well as meeting abstracts and Conference Proceedings Citation Index to look for additional relevant clinical trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared mechanical appendix stump closure (stapler, clips, or electrothermal devices) versus ligation (Endoloop, Roeder loop, or intracorporeal knot techniques) for uncomplicated appendicitis.

DATA COLLECTION AND ANALYSIS

Two review authors identified trials for inclusion, collected data, and assessed risk of bias independently. We performed the meta-analysis using Review Manager 5. We calculated the odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included eight randomised studies encompassing 850 participants. Five studies compared titanium clips versus ligature, two studies compared an endoscopic stapler device versus ligature, and one study compared an endoscopic stapler device, titanium clips, and ligature. In our analyses of primary outcomes, we found no differences in total complications (OR 0.97, 95% CI 0.27 to 3.50, 8 RCTs, very low-quality evidence), intraoperative complications (OR 0.93, 95% CI 0.34 to 2.55, 8 RCTs, very low-quality evidence), or postoperative complications (OR 0.80, 95% CI 0.21 to 3.13, 8 RCTs, very low-quality evidence) between ligature and all types of mechanical devices. However, our analyses of secondary outcomes revealed that use of mechanical devices saved approximately nine minutes of total operating time when compared with use of a ligature (mean difference (MD) -9.04 minutes, 95% CI -12.97 to -5.11 minutes, 8 RCTs, very low-quality evidence). However, this finding did not translate into a clinically or statistically significant reduction in inpatient hospital stay (MD 0.02 days, 95% CI -0.12 to 0.17 days, 8 RCTs, very low-quality evidence). Available information was insufficient for reliable comparison of total hospital costs and postoperative pain/quality of life between the two approaches. Overall, evidence across all analyses was of very low quality, with substantial potential for confounding factors. Given the limitations of all studies in terms of bias and the low quality of available evidence, a clear conclusion regarding superiority of any one particular type of mechanical device over another is not possible.

AUTHORS' CONCLUSIONS

Evidence is insufficient at present to advocate omission of conventional ligature-based appendix stump closure in favour of any single type of mechanical device over another in uncomplicated appendicitis.

Optimal stump management in laparoscopic appendectomy: A network meta-analysis by the Minimally Invasive Surgery Synthesis of Interventions and Outcomes Network

BACKGROUND

Laparoscopic appendectomy is the predominant method of treatment of acute appendicitis. There is insufficient evidence on the most effective management of the appendix stump. The aim of this study was to investigate the relative effectiveness and provide a treatment ranking of different options for securing the appendix stump.

METHODS

Electronic databases were searched to identify randomized controlled trials comparing ligation methods of the appendix. The primary outcomes were organ/space infection and superficial operative site infection. We performed a network meta-analysis and estimated the pairwise relative treatment effects of the competing interventions using the odds ratio and its 95% confidence interval. We obtained a hierarchy of the competing interventions using rankograms and the surface under the cumulative ranking curve.

RESULTS

Forty-three randomized controlled trials were eligible and provided data for >5,000 patients. Suture ligation seemed to be the most effective treatment strategy, in terms of both organ/space infection and superficial operative site infection. Statistical significance was reached for the comparisons of clip versus endoloop (odds ratio 0.56, 95% confidence interval, 0.32-0.96) for organ/space infection; and suture versus clip (odds ratio 0.20, 95% confidence interval 0.08-0.55) and clip versus endoloop (odds ratio 2.22, 95% confidence interval 1.56-3.13) for superficial operative site infection. The network was informed primarily by indirect treatment comparisons.

CONCLUSION

The use of suture ligation of the appendix in laparoscopic appendectomy seems to be superior to other methods for the composite parameters of organ/space and superficial operative site infection.

Comparison of the results of laparoscopic appendectomies with application of different techniques for closure of the appendicular stump

Background

Nowadays laparoscopy is used frequently not only in elective surgery but also in abdominal emergencies, including acute appendicitis. There are several techniques used to close the appendicular stump during laparoscopic appendectomy. The aim of the study was to present and compare the results of minimally invasive appendectomies performed with the use of endoscopic staplers (group A), titanium endoclips (group B) and invaginating sutures (group C).

Methods

Three hundred seven patients (mean age = 35.6; SD = 15.9; 178 males,129 females) operated on laparoscopically for acute appendicitis from January 2010 to December 2014 at our department were included in the study. We reviewed retrospectively patients’ data including: age, sex, duration of the surgical procedure and hospital stay, mortality, intraoperative and postoperative complication rates in all analyzed groups.

Results

There were 102 patients in group A (mean age = 35.8;SD = 15.4; 57 males, 45 females). The average hospital stay in this group was 4.3 days (SD = 1.7), average operation time was 62.0 min (SD = 15), postoperative complication rate was 5.9 %. There were 160 patients in group B (mean age = 35.0; SD = 16.3; 96 males, 64 females). The average hospital stay in this group was 3.6 days (SD = 1.4), average operation time was 62.9 min (SD = 13.5), postoperative complication rate was 5.6 %. There were 45 patients in group C (mean age =37.3; SD = 15.8; 25 males, 20 females). The average hospital stay in this group was 4.6 days (SD = 2.0), average operation time was 73.9 min (SD = 20.8), postoperative complication rate was 6.7 %. There were no intraoperative complications and no mortality in all compared groups of patients operated on laparoscopically for acute appendicitis.

Conclusions

Laparoscopic appendectomies with application of different techniques for closure of the appendicular stump are useful and safe. In our study the shortest hospital stay and lowest complication rate were observed in patients operated with the use of titanium endoclips. The longest hospital stay and operation time and the highest complication rate was associated with the use of invaginating sutures.

The TICAP-Study (titanium clips for appendicular stump closure): A prospective multicentre observational study on appendicular stump closure with an innovative titanium clip

Background

To evaluate the effectiveness and safety of the DS Titanium Ligation Clip for appendicular stump closure in laparoscopic appendectomy.

Methods

Overall, 502 patients undergoing laparoscopic appendectomy were recruited for this observational multicentre study in nine study centres between October 2011 and July 2013. The clip was finally applied in 390 patients. Primary outcome variables were feasibility of the clip, intra-abdominal surgical site (abscesses, stump leakages) and superficial wound infections. Patients were followed 30 days after surgery.

Results

The clip was applicable in nearly 80 % of patients. Reasons for not applying the clip were mainly an inflamed caecum or a too large diameter of the appendix base. Superficial wound infections were found in nine (2.31 %), intra-abdominal abscesses in five (1.28 %), appendicular stump leak in one (0.26 %), and other adverse events in 22 (5.64 %) patients. In total, 12 (3.08 %) patients were re-admitted to hospital for treatment. Seven re-admissions were surgery-related; ten (2.56 %) patients had to be re-operated. One patient died during the course of the study due to persisting peritonitis (mortality 0.26 %).

Conclusions

The results suggest that the DS Titanium Ligation Clip is a safe and effective option in securing the appendicular stump in laparoscopic appendectomy. The complication rates found with the use of the DS-Clip are comparable to the rates in the literature when other methods are used.

Trial Registration

NCT01734837.

Management of appendiceal stump in laparoscopic appendectomy--clips or ligature: a systematic review and meta-analysis

BACKGROUND

Appendicular stump closure is a crucial step during laparoscopic appendectomy. Recently, endoclips (ECs) have been described for ligation of the appendicular stump. The objective of this review was to compare outcomes with EC versus endoligature (EL) for appendiceal stump closure during laparoscopic appendectomy.

MATERIALS AND METHODS

A literature search of Medline, Embase, Cochrane Database, and Google Scholar was performed to identify studies comparing use of EL versus EC in laparoscopic appendectomy between January 1992 and September 2013. Reviews of each study were conducted, and data were extracted. The random-effects model was used to combine data, and between-study heterogeneity was assessed.

RESULTS

Seven of the 101 identified studies met the inclusion criteria: four randomized controlled trials and three case controlled series. For the primary outcome of perioperative and postoperative complications, there was no significant difference between the EC versus EL groups. No differences were noted in length of hospital stay. However, a significant reduction in operative time was observed with EC as opposed to EL (standardized mean difference=-0.90, 95% confidence interval=-1.26 to -0.54, P=.001). Moreover, EC procedures were less expensive than EL procedures.

CONCLUSIONS

EC application in the management of appendiceal stump during laparoscopic appendectomy appears to be simple, efficacious, safe, and a cost-effective alternative.

Laparoscopic appendectomy: State of the art. Tailored approach to the application of laparoscopic appendectomy?

Acute appendicitis is the most common surgical emergency in developed countries. The treatment of acute appendicitis is either open or laparoscopic appendectomy. The latter has gained wide acceptance in the past years, although the debate on the true merits of laparoscopic appendectomy is still on going. Some authors prefer this approach as the gold standard for all patients, but in our opinion a tailored approach is warranted for specific patient groups. In addition, a standardised guideline on the technical aspects is still lacking. In the current article, open versus laparoscopic appendectomy and several technical aspects, such as stump closure, appendix extraction and single incision are discussed laparoscopic appendectomy are being addressed. In the future perspectives we will briefly discuss the third 'newly' introduced antibiotic treatment.

Appendiceal stump closure by metal endoclip in the management of complicated acute appendicitis

Background

Closure of appendicular stump has been performed in different ways; however, the use of the metal endoclip in complicated grades of acute appendicitis, has not been evaluated yet in a prospective way.

Objective

To establish the effectiveness of appendiceal stump closure by metal endoclip for complicated appendicitis.

Method

From January 2009 to January 2011 were evaluated 131 consecutive patients who underwent a laparoscopic appendectomy for complicated acute appendicitis. From those, 118 underwent appendiceal stump closure by metal endoclip. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 52.7% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix, which may lead to abscess formation and degrees of peritonitis. The outcomes viability, operative time, infection complication, operative complications, and conversion rate were chosen to evaluate the procedure.

Results

The appendiceal stump closure by metal endoclip was used in 90% of cases. The presence of appendix base necrosis was the most important factor involved in failure of the procedure. Laparoscopic knot (1.5%), laparoscopic endo-suture (3.8%) and video assisted laparotomy (4.7%) were the alternatives used in difficult cases. The mean operative time was (67.54 ± 28.13 minutes). The wound and intra-abdominal infection rates were 2.54% and 5.08%, respectively. There were no operative complications and the conversion rate was 0.85%.

Conclusion

The appendiceal stump closure by metal endoclip, in complicated grades of acute appendicitis, is a safe and effective procedure. In patients with appendix base necrosis it should be avoided in favor of other alternatives.

Analysis of intracorporeal knotting with invaginating suture versus endoloops in appendiceal stump closure

Introduction

Laparoscopic appendectomy is a well-described surgical technique and has gained wide clinical acceptance. Laparoscopic appendectomy offers fewer wound infections, faster recovery and an earlier return to work in comparison to open surgery. However, concerns still exist regarding the appendiceal stump closure.

Aim

The aim of this study was to compare the overall incidence and specific intraoperative and postoperative complications after application of intracorporeal knotting with invaginating suture versus endoloops for stump closure in laparoscopic appendectomy.

Material and methods

One hundred fifty two consecutive patients according to the following inclusion criteria were included in the study: 1. Laparoscopic appendectomy was performed during the study period; 2. Acute phlegmonous or gangrenous appendicitis without perforation was diagnosed during operation. Exclusion criteria - patients with acute perforated appendicitis and local or diffuse peritonitis. Data was grouped according to the appendiceal stump closure technique, with either endoloops – 112 patients (73.7 percent) or intracorporeal knotting with invaginating suture – 40 patients (26.3 per cent). The primary outcome measure was the rate of intraabdominal surgical-site infection, defined as post-operative intra-abdominal abscess. Secondary outcome variables were intraoperative and postoperative complications, duration of operation, hospital stay.

Results

There were no significant differences between the two groups in overall intraoperative and postoperative complications rate and in hospital stay. The median duration of operation was significantly shorter when the endoloop was used. The use of intracorporeal knotting with invaginating suture instead of endoloop to close the appendiceal stump decreased the total cost of laparoscopic appendectomy.

Conclusions

According our study results, intracorporeal knotting with invaginating suture appendiceal stump closure technique is acceptable laparoscopic procedure, which intraoperative and postoperative results do not differ from endoloops technique. The total cost of this procedure is 80 € cheaper then endoloops technique.