Comparison of intracorporeal knot-tying suture (polyglactin) and titanium endoclips in laparoscopic appendiceal stump closure: a prospective randomized study

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.

Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review

Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.

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.

Acute appendicitis-advances and controversies

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon's practice. With the recent advancements in AA's management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon's repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic's repercussions on patients and how surgeons' practices have evolved in the context of AA.

Evidence-based surgery for laparoscopic appendectomy: A stepwise systematic review

Introduction

Appendectomy is a common emergency surgery performed globally. Despite the frequency of laparoscopic appendectomy, consensus does not exist on the best way to perform each procedural step. We identified literature on key intraoperative steps to inform best technical practice during laparoscopic appendectomy.

Methods

Research questions were framed using the population, indication, comparison, outcome (PICO) format for 6 key operative steps of laparoscopic appendectomy: abdominal entry, placement of laparoscopic ports, division of mesoappendix, division of appendix, removal of appendix, and fascial closure. These questions were used to build literature queries in PubMed, EMBASE, and the Cochrane Library databases. Evidence quality and certainty was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) definitions.

Results

Recommendations were rendered for 6 PICO questions based on 28 full length articles. Low quality evidence favors direct trocar insertion for abdominal entry and establishment of pneumoperitoneum. Single port appendectomy results in improved cosmesis with unclear clinical implications. There was insufficient data to determine the optimal method of appendiceal stump closure, but use of a specimen extraction bag reduces rates of superficial surgical site infection and intra-abdominal abscess. Port sites made with radially dilating trocars are less likely to necessitate closure and are less likely to result in port site hernia. When port sites are closed, a closure device should be used.

Conclusion

Key operative steps of laparoscopic appendectomy have sufficient data to encourage standardized practice.

"Misra's appendicular hitch" stich - Innovative technique for simplifying endo-suturing during laparoscopic appendectomy

Laparoscopic suture transfixation and free tie ligation are the most commonly used cost-effective technique of managing the base of the appendix during laparoscopic appendectomy in low resource settings such as India. This becomes technically cumbersome especially in the presence of the long friable appendix and for novice surgeons. We hereby describe an innovative technique of suspending the appendix using a transfacial suture to ease the placement of suture at the base of the appendix during laparoscopic appendectomy.

Comparison of Handmade Endoloop Versus Polymeric Endoclip for Stump Closure in Laparoscopic Appendectomy

Background Stump closure is an important stage of laparoscopic appendectomy. This study aimed to establish whether the handmade endoloop or polymeric endoclip method was more effective for stump closure in laparoscopic appendectomy. Methods The study included 76 patients who underwent laparoscopic appendectomy between October 2017 and January 2019. Patients' demographic characteristics, duration of surgery, length of hospital stay, and any complications were retrospectively recorded from files. Patients were divided into two groups according to stump closure method as polymeric endoclip and handmade endoloop. Results Among the patients, 59.2% (n = 45) were male and 40.8% (n = 31) were female. For stump closure, the polymeric endoclip method was used in 37 patients (48.7%) and the handmade endoloop method in 39 patients (51.3%). The two groups were not significantly different in terms of age and appendix diameter ( p=0.408, p=0.218). A total of four patients (5.3%) developed wound infection, including three from the handmade endoloop group and one from the polymeric endoclip group. One patient (1.3%) in the polymeric endoclip group developed ileus. The two groups were also not significantly different in terms of complications (p = 1.000). Conclusion We conclude that both stump closure methods are safe, and the more easily accessible handmade endoloop method can be performed reliably in all hospitals, including secondary healthcare facilities such as small hospitals.

Johan Forceps As a Knot Pusher for Extracorporeal Roeder Knot: An Inexpensive Alternative to an Endoloop Ligature in Laparoscopic Appendicectomy

Background: Securing of the appendix stump is one of the key steps in performing laparoscopic appendicectomy (LA). This can be achieved by a variety of methods including endoloops, stapler, and clips. An alternative technique, previously described by authors, is the use of Johan forceps as a knot pusher, to deploy an extracorporeal Roeder knot at the base of appendix. We aimed to evaluate the safety and cost-effectiveness of our technique. Patients and Methods: A single surgeon's, prospective cohort, and multicenter study was undertaken at three different hospitals in the United Kingdom. We collected data of all patients, who underwent LA by this technique between 2014 and 2019. Demographics, operative findings, postoperative complications and readmissions were recorded and analyzed. Results: In total, 227 appendicectomies were performed. Median age was 24 years (interquartile range [IQR]: 16-58) with 58% male preponderance. Operative findings were 57% (n = 130) acutely inflammatory appendicitis, 16.74% (n = 38) were complicated appendicitis (perforated, gangrenous). Rest of the operative findings were macroscopically normal appendix (with no other pathology in 18.06% (n = 41), and macroscopically normal appendix but with gynecological pathologies in 7.9% (n = 18). Postoperatively, there were no cases to report complication of blow out stumps neither clinically nor radiologically. Surgical site infections rate has been 3.5% (n = 8). One patient had small intra-abdominal abscess (0.4%), treated by IV antibiotics. Mean hospital stay was 1.89 days (standard deviation [SD] 1-5 days). Thirty days readmissions rate was 4.8%. None of the complications or readmissions was related to the surgical technique. There were no deaths recorded in this series. Cost of handmade endoloop was $0.69. Conclusion: Use of Johan forceps as knot pusher for extracorporeal Roeder knot is a safe, feasible, cost-effective, and easily reproducible technique for carrying out LA.

Factors affecting the length of hospital stay after laparoscopic appendectomy: A single center study

AIM

This study aimed to explore factors may affect the length of hospital stay after laparoscopic appendectomy.

METHODS

The data of 636 patients undergoing laparoscopic appendectomy between July 2016 and July 2019 in Beijing Tsinghua Changgung Hospital were retrospectively analyzed. The patients were divided into group A (hospital stay ≤3 days, 348 patients) and group B (hospital stay >3 days, 288 patients) according to their hospital stay.Sex, age, disease onset time(time from onset to admission), nausea, vomiting, diarrhea, peritonitis, comorbidities, and history of appendicitis; preoperative body temperature (T), white blood cell (WBC) count, percentage of neutrophilic granulocytes, and preoperative C-reactive protein (CRP) level; time from diagnosis to surgery. appendix diameter, appendicolith, and ascites in ultrasound or CT; surgical time(the surgery start time was the time of skin incision, and the end time was the time the anesthesia intubation was removed), intraoperative blood loss (the volume of blood infiltrating into a gauze was calculated by weighing the gauze infiltrated with water and calculating the volume of water), intraoperative adhesions or effusions, and stump closure methods, convert to open appendectomy, appendix pathology(perforated or gangrenous appendicitis were defined as complicated appendicitis and simple or suppurative appendicitis were defined as uncomplicated appendicitis) and antibiotic treatment schemes were analyzed.

RESULTS

Significant differences were detected between group A and group B in age (37.10 ± 13.52y vs 42.94 ± 15.57y, P<0.01), disease onset time (21.36 ± 16.56 h vs 32.52 ± 27.99 h, P <0.01), time from diagnosis to surgery (8.63 ± 7.29 h vs 10.70 ± 8.47 h, P<0.01); surgical time(64.09 ± 17.24 min vs 86.19 ± 39.96 min, P < 0.01); peritonitis(52.9% vs 74%, P < 0.01), comorbidities (12.4% vs 20.5%, P < 0.01), appendicolith (27.6% vs 41.7%, P < 0.01), ascites before the surgery(13.8% vs 22.9%, P < 0.01), intraoperative adhesions or effusions(56% vs 80.2%, P < 0.01); preoperative temperature (37.11 ± 0.64°C vs 37.54 ± 0.90°C, P < 0.01); preoperative WBC count (13.06 ± 3.39 × 109/L vs 14.21 ± 4.54 × 109/L, P = 0.04);preoperative CRP level(18.99 ± 31.72 mg/L vs 32.46 ± 46.68 mg/L, P < 0.01); appendix diameter(10.22 ± 2.59 mm vs 11.26 ± 3.23 mm, P < 0.01); intraoperative blood loss (9.36 ± 7.29 mL vs 13.74 ± 13.49 mL, P < 0.01); using Hem-o-lok for stump closure(30.7% vs 38.5%, P = 0.04); complicated appendicitis (9.5% vs 45.8%, P < 0.01); and using ertapenem for antibiotic treatment after the surgery(4.3% vs 21.5%, P < 0.01). Multivariate analysis demonstrated that age (OR = 1.021; 95%CI = 1.007-1.036), peritonitis (OR = 1.603; 95% CI = 1.062-2.419), preoperative WBC count (OR = 1.084; 95% CI = 1.025-1.046), preoperative CRP level (OR = 1.010; 95% CI = 1.005-1.015), time from diagnosis to surgery (OR = 1.043; 95% CI = 1.015-1.072), appendicolith (OR = 1.852; 95% CI = 1.222-2.807), complicated appendicitis (OR = 3.536; 95% CI = 2.132-5.863), surgical time (OR = 1.025; 95% CI = 1.016-1.034), use of Hem-o-lok for stump closure (OR = 1.894; 95% CI = 1.257-2.852), and use of ertapenem for antibiotic treatment (OR = 3.076; 95% CI = 1.483-6.378) were the risk factors for a prolonged hospital stay.

CONCLUSIONS

The patient with appendicitis was older and had peritonitis, higher preoperative WBC count or CRP level, longer time from diagnosis to surgery, appendicolith, and complicated appendicitis, predicting a prolonged hospital stay. Shorter surgical time and the use of silk ligation for stump closure and cephalosporins + metronidazole for antibiotic treatment might be better choices to obtain a shorter hospital stay.

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.

Long-term outcomes of single-port laparoscopic myomectomy using a modified suture technique

Objective

To evaluate the long-term outcomes, including the pregnancy outcome and recurrence rate after single-port laparoscopic myomectomy (LM) using a modified suture technique with a Hem-o-lok clip (Choi's LM) and conventional 4-port LM.

Methods

A retrospective study of patients who underwent Choi's LM (n=55) and 4-port LM (n=102) in a single institutional hospital was conducted. Patients with <3 symptomatic myomas sized <10 cm each and operated on by a single surgeon were included. Recurrence was confirmed when a myoma measuring ≥3 cm was detected.

Results

The patients in both groups had similar demographic characteristics. Single (76.4% vs. 62.7%) and intramural (52.7% vs. 56.9%) tumors were commonly detected in both groups in the mean diameter (6.8±1.5 cm vs. 7.0±1.6 cm; P=0.40). In Choi's LM, 16 patients (29.1%) needed an additional port; those who were nulliparous and/or had a large leiomyoma more frequently required an additional port (P=0.023 and 0.04, respectively). During a median follow-up period of 69 months, 17 patients (7.1% vs. 14.6%) had recurrence. The size of dominant myomas at recurrence was significantly smaller in patients who underwent Choi's LM (3.4±0.7 cm vs. 5.7±2.4 cm; P=0.004). All 13 patients in both groups who successfully conceived had a full-term delivery. No major complications occurred during pregnancy.

Conclusion

Although an additional port was frequently used, the long-term outcomes of patients who experienced recurrence and pregnancy after Choi's LM were acceptable. Considering its usability, Choi's LM is feasible for the treatment of uterine leiomyoma.

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.

Feasibility and Efficacy of Using Hem-o-lok Polymeric Clips in Appendicular Stump Closure in Laparoscopic Appendectomy

Laparoscopic appendectomy is becoming the gold standard for the management of acute appendicitis. Appendicular stump closure is a critical step in this procedure, and several methods have been used to secure the appendicular stump during laparoscopic appendectomy. We highlight the feasibility and efficacy of ‘Hem-o-lok’ polymeric clips in securing the base of the appendix. We selected 20 consecutive patients who underwent laparoscopic appendectomy using a single or double ‘Hem-o-lok’ clip to secure the base of the appendix for acute appendicitis from October 2011 to August 2013. Thirteen study participants were men, and seven were women. There were no instances of clip slippage, obstruction due to adhesion to the clip or postoperative collections. Laparoscopic appendectomy using polymeric ‘Hem-o-lok’ clips to secure the base of the appendix is a feasible and efficacious option.

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.

Clip closure and division instead of stapling for the last small gastric bridge between gastric pouch and remnant stomach in laparoscopic Roux-en-Y gastric bypass

INTRODUCTION

Here, a modification during gastric pouch forming was implemented in laparoscopic Roux-en-Y gastric bypass (LRYGB). We aimed to examine the feasibility of metallic clip closure for the remaining small stomach bridges (<1 cm) between the pouch and the remnant stomach.

METHODS

During pouch creation, after the last stapler firing, the remaining small bridge was closed with clips and divided instead of using a new stapler. Metallic clips for this aim were used in 41 of 520 LRYGP between September 2010 and January 2017. Preoperative mean body mass index (BMI) was 47.3 ± 5.3 kg/m² (male/female: 6/35, mean age 37.8 ± 9.1 years).

RESULTS

Gastric bridges in 41 patients were successfully closed with metallic clips and divided. In one patient, intraoperative methylene blue test was positive from the anastomosis (not from the clipped place) and repaired by intracorporeal sutures. Abdominal drain was used selectively (32%). No postoperative leakage or other complications were seen. Mean length of hospital stay was 3.8 ± 1.1 days. Mean BMI was 30.3 ± 6.1 kg/m² after mean 17.6 ± 11.3 months follow-up.

CONCLUSION

In LRYGB metallic clip closure for a stomach bridge (<1 cm) between the pouch and the remnant stomach is an easy, safe and reliable method.

Endostapler versus Hem-O-Lok clip to secure the appendiceal stump and mesoappendix during laparoscopic appendectomy

BACKGROUND

Our study evaluates the safety and cost of using the Hem-O-Lok (HOL) clip in laparoscopic appendectomy (LA).

METHOD

We prospectively compared 30-day postoperative outcomes and cost between HOL clip and endoscopic stapler (ES) in LA at a single institution.

RESULTS

HOL clip was used in 45 out of 92 LA. Perforated appendicitis (29.8% vs. 11.1%, P = 0.027) and postoperative complications were more common in the ES group (19.2% vs. 2.2%, p = 0.009). In multivariate analysis, HOL clip was associated with lower complications rate (OR = 0.05, 95% CI 0.003-0.744; p = 0.030). In propensity score matched cohort, complications were not different (p > 0.05). In patients with non-perforated appendicitis, HOL use increased operative time by 10 min on average (p = 0.004). Minimum ES cost per single appendectomy was $273.13, while HOL clip cost was $32.14.

CONCLUSION

The use of HOL clip in LA is safe and it reduced the costs of the procedure in comparison to the use of ES.

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.

Laparoscopic Appendectomy Using Hem-o-lok Polymer Clips: A Single-Center Experience

Although the surgical technique of laparoscopic appendectomy (LA) stump has been well understood, there are many alternative techniques in relation to torocar positioning and closure of appendicular stump. In recent times, Hem-o-lok polymer clips (HOLP) was implemented in several studies in the closure of appendicular stump because of its lower cost and easy implementation. The purpose of this study to investigate the safety, usefulness, and cost effectiveness of HOLP for the closure appendecular stumps in LA. The study was carried out between December 2011 and December 2013. Patients with acute appendicitis were included in the study. Two groups were defined as patients with the HOLP and patients with endoloop. The prospectively collected data, including age, sex, body mass index, operative time, hospital stay, cost effectiveness, intraoperative, and postoperative complications were retrospectively analyzed. A total of 66 (35 male, 31 female) LA were performed. The endoloop group consisted of 30 patients (16 male, 14 female, and mean age, 30.4 ± 1.8), while the HOLP group consisted of 36 patients (19 male, 17 female, and mean age, 28.6 ± 1.6). The mean operative time was 42.5 ± 1.3 in the HOLP group and 53.8 ± 1.5 in the endoloop group (P &lt; 0.0001). The mean hospital stay was 2.1 ± 0.2 days in HOLP group and 2 ± 0.2 in the endoloop group (P = 0.73). Both patient groups had no intraoperative complication, and no cases were converted to open procedure. Total hospital cost was 1170.8 ± 6.3 dollars in the HOLP group and 1094 ± 6.9 dollars in the endoloop group (P &lt; 0.0001). The use of HOLP for the appendicular stumps in LA is a feasible, safe, and cost-effective procedure in patients with uncomplicated acute appendicitis.

Laparosocopic Appendectomy, Cost-Effectiveness of Three Different Techniques Used to Close the Appendix Stump

It is generally agreed that laparoscopic appendectomy is a valuable operative method. The aim of the study was to evaluate cost-effectiveness of three different techniques used to close the appendix stump.

MATERIAL AND METHODS

We conducted a retrospective study that compared three groups of patients who were operated on laparoscopically for acute appendicitis in 2013 at our institution. We used an endoscopic clip to close the appendix stump in the first group (n=20), endoscopic stapler was applied in the second group (n=20), and in the third group of patients the appendix base was closed with a laparoscopic suture (n=20). These groups were matched by age, sex and BMI.

RESULTS

The average operative cost was the highest in the second group. Cost of the laparoscopic appendectomy with the application of the endoscopic clip was significantly lower (first group) and comparable to the third group. Observed differences in total hospitalization costs were associated only with the chosen appendix stump closure technique.

CONCLUSIONS

Clip closure of the appendix base is an easy and cost-effective procedure. The laparoscopic suture technique is the cheapest but technically demanding. According to our experience endoscopic stapler may be useful in some cases, although it is the most expensive method.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Comparison the effect of stump closure by endoclips versus endoloop on the duration of surgery and complications in patients under laparoscopic appendectomy: A randomized clinical trial

Background:

Laparoscopic appendectomy is a well-described surgical technique. However, concerns still exist regarding whether the closure of the appendiceal stump should be done with a clip, an endoloop, or other techniques. In this study, the effect of stump closure on duration of surgery and complications by endoclips was compared with endoloop in patients under laparoscopic appendectomy. The study was carried out as a prospective randomized clinical trial between 2013 and 2015 in Shariati Hospital of Tehran.

Materials and Methods:

Seventy-six patients under laparoscopic appendectomy were enrolled and randomly assigned to receive either endoclips or endoloop for stump closure. The results in terms of the operating time, length of hospital stay, and the complications were compared and analyzed between two groups. After collecting the essential data by using a checklist and examination of patients, the data were analyzed with SPSS.

Results:

The mean age was 23.13 ± 5.07 years and 44.7% of the patients were male. Moreover, in this study, it was seen that the mean duration of surgery was 23.2 min versus 21.5 min in endoloop and endoclips groups, respectively (P = 0.021). There was no difference between hospital stay among two groups (P > 0.05). Furthermore, the complications were same in two groups (P > 0.05).

Conclusion:

The effect of stump closure with endoloop versus endoclips is not different for complications, but the duration of surgery was shorter in endoclips method. Both methods could be used based on the opinion of the surgeon without expecting a statistically significant difference in the results.

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.

Methods for closure of appendix stump during laparoscopic appendectomy procedure

The most frequent abdominal pathology requiring emergent surgery is acute appendicitis. Laparoscopic appendectomy has been performed for the treatment of acute appendicitis since 1983. Closure of the appendix stump is vital to prevent severe postoperative complications. Different methods are described for closure such as stapler, endoloop, titanium clips, non-absorbable polymer clips (hem-o-lok clip), handmade loops, transsection by Ligasure or with bipolar cautery. The ideal method should be safe, applicable and cheap. The most appropriate method remains to be controversial. All methods are reported as safe, but some have higher costs, and some prolong the operation. In this article, we reviewed clinical and experimental studies on different methods of stump closure, and we tried to compare the benefit of these methods over others.

Comparison of outcomes of laparoscopic intracorporeal knotting technique in patients with complicated and noncomplicated acute appendicitis

Background and aim

In our study we aimed to compare laparoscopic intracorporeal knotting technique (base of the appendix was ligated with 20 cm of 2.0 silk) in patients with complicated acute appendicitis (CAA) and noncomplicated acute appendicitis.

Patients and methods

Ninety patients (female/male: 40/50, age ranging from 16 to 60 years, median age and interquartile range [IQR]: 25 [20; 32] years) who underwent laparoscopic appendectomy were included in the study. The patients were evaluated for the type of acute appendicitis, duration of operation, duration of hospital stay, and postoperative complications.

Results

The number of cases diagnosed as CAA was 28 (31.1%), and the number of noncomplicated cases was 62 (68.9%). We found that there was no significant difference in postoperative complication rates between complicated and noncomplicated appendicitis cases. Incision site infection was seen in seven cases (7.8%) and ileus was seen in two cases (2.2%). Bleeding, intra-abdominal abscess, and appendix stump leakage were not observed in any of the cases. Median and IQR duration of operation were 42 (35; 52) minutes and median and IQR duration of hospital stay were detected as 2 (1; 2) (range 1–10) days.

Conclusion

Laparoscopic intracorporeal knotting technique may be a safe, effective, and reliable technique as the materials needed for closing the appendix stumps are easily available for both CAA cases and noncomplicated cases.

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.