Methods for closure of appendix stump during laparoscopic appendectomy procedure

Comparison of three different methods for stump closure in laparoscopic appendectomy: Endoloop, Hem-o-lok clip, and endostapler

BACKGROUND

Acute appendicitis is a common surgical emergency that causes acute abdominal pain and affects approximately 7-8% of the population during their lifetime. The closure of the appendix stump during laparoscopic appendectomy is one of the most critical steps of the surgery to prevent life-threatening complications such as postoperative fistula, peritonitis, and sepsis. The mate-rial chosen for appendix stump closure must be effective, safe, and economical. However, there is still no consensus on the optimal method for stump closure. In this study, we aimed to compare the advantages and reliability of three different methods used for appendix stump closure.

METHODS

At Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Department of General Surgery, cases that underwent laparoscopic appendectomy for acute appendicitis between January 2022 and April 2024 were retrospectively analyzed using the hospital's data system. The patients' demographic data, laboratory values, pathology reports, surgical notes, duration of hospital stay, duration of surgery, total hospital costs, complications related to the surgery within 30 days postoperatively, and the management of these complications were examined.

RESULTS

The study included a total of 150 individuals, with 83 (55.33%) males and 67 (44.67%) females. The average age of the participants was 38.45±14.48 years. In terms of the materials used for stump closure, endoloop was used in 82 (54.67%) cases, Hem-o-lok clip in 30 (20.00%) cases, and endostapler in 38 (25.33%) cases. In 144 (96%) cases, no Clavien-Dindo (CD) complications were observed, while complications occurred in six (4%) cases. These six complications included two intra-abdominal abscesses (CD Grade 3), two wound infections (CD Grade 1), one case of bleeding (CD Grade 2), and one pulmonary embolism (CD Grade 4).

CONCLUSION

The use of endoloop, polymeric clips, and endostapler in laparoscopic appendectomy is safe and effective for appendectomy. All three methods can be successfully applied without an increase in intraoperative or postoperative complications. However, due to the higher treatment costs associated with endostapler, its use should be reserved for situations where securing the appendix stump cannot be achieved with endoloop or Hem-o-lok clip.

Comparison of Stump Closure Methods in Laparoscopic Appendectomy: Hem-o-Lok Clip and Laparoscopic Titanium Clip

Background

Appendectomy for acute appendicitis is the most common acute abdominal surgery. Open and laparoscopic appendectomy surgeries are performed with different techniques. Laparoscopic appendectomy has become a widespread method due to its advantages. The aim of this study is to compare the complications, surgery time, hospitalization length, and cost-effectiveness of titanium clips and hem-o-lok clips for stump closure in laparoscopic appendectomy.

Methods

This study included 187 patients who were operated on laparoscopically for acute appendicitis at our hospital between April 2019 and June 2022. The patients' follow-up for 30 days after surgery was evaluated. The data of 179 patients in whom titanium and hem-o-lok clips were inserted during an appendectomy were included in the study.

Results

Between April 2019 and June 2022, 179 patients were included in the study retrospectively. When the correlation between complications and surgical methods was analyzed, 98.8% of the hem-o-lok clip group and 99% of the titanium clip group had no complications. No statistically significant difference was observed between complications and surgery type (P > .05). In the hem-o-lok and titanium clip groups, the operative time was 52.4 minutes and 53.1 minutes, and the hospitalization times were 1.7 days and 1.8 days, respectively.

Conclusions

It is concluded that the use of titanium clips that completely close the root of the appendix is as safe, accessible, feasible, practical, and effective as the hem-o-lok clip method. It was observed to be used safely as an alternative to other appendix root closure methods.

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

PURPOSES

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.

METHODS

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.

RESULT

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).

CONCLUSION

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.

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

PURPOSE

Polymeric 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.

METHODS

This 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.

RESULTS

One 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.

CONCLUSIONS

The 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 ).

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.

Laparoscopic appendectomy, stump closure and endoloops: A meta-analysis

BACKGROUND

Acute appendicitis (AA) is one of the main indications for urgent surgery. Laparoscopic appendectomy (LA) has shown advantages in terms of clinical results and cost-effectiveness, even if there is still controversy about different devices to utilize, especially with regards to the endoloop (EL) vs endostapler (ES) when it comes to stump closure.

AIM

To compare safety and cost-effectiveness of EL vs ES.

METHODS

From a prospectively maintained database, data of 996 consecutive patients treated by LA with a 3 years-follow up in the department of Emergency General Surgery - St Orsola University Hospital, Bologna (Italy) were retrieved. A meta-analysis was performed in terms of surgical complications, in comparison to the international literature published from 1995 to 2021.

RESULTS

The meta-analysis showed no evidence regarding wound infections, abdominal abscesses, and total post-operative complications, in terms of superiority of a surgical technique for the stump closure in LA.

CONCLUSION

Even when AA is complicated, the routine use of EL is safe in most patients.

Comparison of Two Stump Closure Techniques in Laparoscopic Appendicectomy: A Single-Centre Prospective Cohort Study

Introduction Acute appendicitis is a frequent illness that manifests as an emergency and most of the cases necessitate surgical intervention. One of the most critical processes in a laparoscopic appendicectomy is the closure of the appendicular stump. For the closure of the stump of the appendix, several approaches have been employed and explored, but the one with the best outcomes has yet to be proved. The purpose of this study was to evaluate the medical results and cost analyses of laparoscopic appendicectomy with two of the commonly used stump closure techniques - ENDOLOOP^® and Hem-o-lok^®. Materials and methods A two-year prospective hospital-based cohort study was conducted from June 2019 to July 2021. All the patients in the study were randomly assigned to one of two experimental arms (ENDOLOOP^® and Hem-o-lok^®). The clinical and follow-up data of these patients were collected and tabulated into a data sheet and analyzed. Results In total, 180 individuals were included in the research (90 in each arm). No statistically significant difference was found in comparing the age, gender or diameter of the appendix among the two groups. The time taken for surgery showed significant differences among the two study groups. The time taken for the procedure in the Hem-o-lok® group was significantly lower than the ENDOLOOP® group (40.3 ± 12.3 minutes vs 50.83 ± 10.5 minutes, p < 0.001). No intraoperative or immediate postoperative complications were noted in either of the groups. The average duration of hospital stay was 2.7 ± 0.9 days in the Hem-o-lok® group, while it was 3.1 ± 0.8 days in the ENDOLOOP® group (p = 0.986). The material cost for the stump ligation with Hem-o-lok® was Rs. 310 ± Rs. 76 while that using ENDOLOOP^® was Rs. 630 ± Rs. 118 (p < 0.001). In the Hem-o-lok^® subset of patients, the mean direct expenses of laparoscopic appendicectomy were considerably lower. During the 12-week follow-up period, none of the patients had any post-operative complications. Conclusion According to the results of this study, both the technical variations of appendix stump closure are equal in terms of postoperative complications. When compared to the ENDOLOOP^® group, the Hem-o-lok® group had a shorter duration of surgery and ended up spending less money. Hem-o-lok® clips have the potential to become the preferred way of anchoring the appendix base during laparoscopic appendicectomy.

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.

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.

A systematic review on the cost evaluation of two different laparoscopic surgical techniques among 996 appendectomies from a single center

Acute appendicitis is one of the main indications for urgent surgery representing a high-volume procedure worldwide. The current spending review in Italy (and not only in this country) affects the health service and warrants care regarding the use of different surgical devices. The aim of our study is to perform a cost evaluation, comparing the use of endoloops and staplers in complicated acute appendicitis (phlegmonous and gangrenous), taking into consideration the cost of the device in relation to the management of any associated postoperative complications. We retrospectively evaluated 996 laparoscopic appendectomies of adult patients performed in the Emergency General Surgery-St. Orsola University Hospital in Bologna (Italy). Surgical procedures together with the related choice of using endoloops or staplers were performed by attending surgeons or resident surgeons supervised by a tutor. A systematic review was performed to compare our outcomes with those reported in the literature. In our experience, the routine use of endoloop leads to a real estimated saving of 375€ for each performed laparoscopic appendectomy, even considering post-operative complications. Comparing endoloop and stapler groups, the total number of complications is significantly lower in the endoloop group. Our systematic review confirmed these findings even if the superiority of one technique has not been proved yet. Our analysis shows that the routine use of endoloop is safe in most patients affected by acute appendicitis, even when complicated, and it is a cost-effective device even when taking into consideration extra costs for potential post-operative complications.

Volvulus caused by a free intraperitoneal staple after laparoscopic appendectomy: A case report

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Free intraperitoneal staples are usually inert but can have complications.

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Early obstructive symptoms after appendectomy should warrant prompt work-up.

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Volvulus can occur due to free staples after laparoscopic appendectomy.

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Small bowel necrosis due to a free malformed staple required small bowel resection.

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We recommend removing free staples when seen in order to prevent complications.

Introduction

Laparoscopic appendectomies are routinely performed using linear staplers. Few case reports have discussed complications from free intraperitoneal staples after appendectomy. We present the first case of a volvulus caused by a free staple that subsequently required bowel resection.

Presentation of case

A 27-year-old female underwent laparoscopic appendectomy for uncomplicated appendicitis. The base of the appendix was divided using a laparoscopic gastrointestinal anastomosis (GIA) stapler and the mesoappendix was divided using a LigaSure device. The patient was discharged the following day. Eight days later, the patient returned to the emergency department with severe abdominal pain, emesis, and peritoneal signs. Computed tomography (CT) showed significant pneumoperitoneum and nonspecific small bowel edema. Exploratory laparotomy was performed revealing a necrotic small bowel segment from a malformed, free staple caught on the peritoneum of the small bowel mesentery causing a closed loop obstruction. After reduction and detorsion, the small bowel segment was not viable and required resection. She was discharged on postoperative day four with no additional perioperative complications.

Discussion

Mechanical staplers are commonly used in laparoscopic appendectomy and free intraperitoneal staples are generally considered inert. A high index of suspicion should be maintained for the early postoperative appendectomy patient with obstructive symptoms.

Conclusion

Inspection of the staple line, choosing the appropriate staple size and cartridge, and removing free malformed staples if seen should be employed during appendectomy to prevent rare but devastating complications.

Appendectomy in Switzerland: how is it done?

More than 10,000 appendectomies are performed every year in Switzerland. The aim of this study was to investigate the treatment strategy for appendicitis among Swiss surgeons with particular interest in laparoscopic technique, method of appendiceal stump closure, and abdominal lavage. We performed an anonymous survey among 540 members of the Swiss Surgical Society. Technical details and differences between the surgical procedures in adults and children as well as in complicated and non-complicated appendicitis were investigated. The overall response rate was 45% (n = 243). 78% of the surgeons perform laparoscopic appendectomies in children and 95% in adult patients. Only 3% use a single incision site technique. Surgeons consider pus or stool in the abdomen (94%), an abscess (86%) or perforation of the appendix (82%), but not an inflamed appendiceal base (16%) as complicated appendicitis. 41% of surgeons use endoloops, 36% a stapling device, and 20% polymeric clips in non-complicated appendicitis for appendiceal stump closure. However, 82% of the surgeons use a stapler in complicated appendicitis. Most (76%) of surgeons do not plunge the appendiceal stump. 24% of surgeons lavage the abdomen with > 1 L of fluid independent of the intraabdominal finding. Most Swiss surgeons perform multiport laparoscopic appendectomies. Endoloops and staplers are mostly used for appendiceal stump closures in uncomplicated appendicitis, and staplers in complicated appendicitis. Only a minor part of surgeons plunge the appendiceal stump or perform routine abdominal lavage.

Laparoscopic appendectomy: Hem-o-lok versus Endoloop in stump closure

There are several techniques described to close the appendicular stump during laparoscopic appendectomy. The aim of this study was to investigate the safety and usefulness of the Hem-o-lok clip for the closure of appendicular stump, comparing these data with those concerning the endo-loop. We conducted a retrospective study that compared two groups of patients who underwent laparoscopic appendectomy from 2010 to 2015 at our institution. We used the Endoloop to close the stump in the first group (group I) and the Hem-o-lok in the second group (group II). We reviewed patient's data including: complications, operative time, length of stay, costs. There were 121 patients in group I and 138 patients in group II. The mean operative times were 40.5 min in group I and 36.4 min in the group II. No intraoperative complications and no mortality were observed in either group. The mean postoperative length of hospital stay was similar for both groups. There was no rehospitalization after discharge. The complication rate did not reach statistical significance between the groups. The cost of the procedure using the Hem-o-lok has been lower than using the Endoloop. Both the Endoloop and Hem-o-lok are safe for the closure of the appendicular stump. Hem-o-lok appears to be superior than Endoloop in terms of easeness of use and cheapness, maintaining the same safety.