The influence of the different forms of appendix base closure on patient outcome in laparoscopic appendectomy: a randomized trial

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.

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

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

Introduction

Appendiceal stump closure (ASC) is a key step in performing laparoscopic appendicectomy. Currently, there is no gold standard method to achieve this goal. The ideal method should be safe, easily available, and have a short learning curve. Out of all those appendiceal stump closure methods, the use of hem-o-Lok demonstrates its feasibility in replacing the traditionally used endoloop. In this systematic review and meta-analysis, the authors aim to review the currently available evidence addressing the topic of interest.

Method

The PubMed and Embase databases were searched with the paired search terms appendicitis, clip, and endoloop by two authors separately. The quality of the randomized controlled trials was assessed with the Cochrane risk of bias tool, and the quality of the observational studies was assessed with the Newcastle-Ottawa scale. Meta-analysis was conducted with Cochrane Review Manager version 5.4.

Result

Eighteen studies were included for quantitative analysis. The appendiceal stump closure time was shortened by 2 min 7 s using a hem-o-lok with 95% CI 1 min 48 s-2 min 26 s, p less than 0.00001. The pooled results of 6 randomized controlled trials demonstrated a statistically significant reduction in operative time of 5.15 min from adopting the hem-o-lok approach (p=0.001, 95% CI -2.05 to -8.24 min). Both endoloop and hem-o-lok demonstrated a comparable postoperative hospital stay and infective complication profile.

Conclusion

The application of Hem-o-Lok demonstrates a comparable to endoloop ligation in terms of operative time and a potential benefit on the complication. When considering financial and technical aspects, it serves as an alternative to endoloop.

Challenges to implement laparoscopic appendectomy as the first-line treatment for acute appendicitis: a fifteen-year experience in a tertiary hospital in Brazil

BACKGROUND

the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil.

MATERIALS AND METHODS

retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes.

RESULTS

we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team's adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period.

CONCLUSION

the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

Safety and Cost Savings Using Polymeric Clips in Appendectomies in the Pediatric Population: Single-center Experience

INTRODUCTION

Although laparoscopic appendectomy is standard management for appendicitis, management of the appendiceal stump remains debated. Even though most surgeons can agree on the safety and effectiveness of various closure methods for the appendiceal stump, such as the surgical stapler (SS) or the Endoloop, the cost of these methods should also be considered. A relatively new alternative method, the polymeric clips (PC), has been gaining acceptance in the surgical community as it has repeatedly proven to be as safe as other methods, while being significantly cheaper.

METHODS

For the period of January 2019 to December 2021, we performed a retrospective chart review of a single surgeon's laparoscopic appendectomies in children 18 years or younger for acute, non-complicated appendicitis and grouped the cases by appendiceal stump management (SS or PC). Demographics collected included gender, age, BMI percentile, race, and ASA score. Surgical variables included length of stay, surgical time, and anesthesia time. Outcomes were number of intra- and post-operative complications, reoperations, ER visits within 30 days, and total implant cost. Mann-Whitney U tests were performed to test for differences between SS and PC groups in surgical variables. Chi-square or Fisher's exact tests were performed to test differences in demographics and outcome variables.

RESULTS

There were 107 patients identified. The PC group represented 16% (n = 17) of our study population. The PC group was significantly younger than the SS group at 10 years (2.8) vs 12 years (3.5) p = 0.04. No differences were observed in length of stay and anesthesia time between the two groups. However, a significantly longer length of surgery was observed in the PC group at 33.5 min [30.0-43.3] when compared to the SS group at 28.0 min [23.0-36.0] (p = 0.003). No significant differences were seen in post-op complications, post-op ED visits and reoperations within 30 days. The median total implant cost of the PC closure method was significantly lower than the SS method ($35.36 vs. $375.67 p = <0.001).

CONCLUSION

There were no significant differences in clinical outcomes. However, the significant difference in the implant cost between the 2 methods could favor the use of PC for selected cases. The increase in length of surgery can be attributed to the learning curve associated with a new device.

LEVEL OF EVIDENCE: 3

Isolated Appendectomy Technique Without Mesoappendix in Laparoscopic Appendectomy

BACKGROUND

Laparoscopic appendectomy is among the most common general surgical procedures performed in developed countries. Among the most critical steps in laparoscopic appendectomy is transection of the appendix meso. This study evaluates the postoperative and economic outcomes between total mesoicular excision and isolated (traditional) appendectomy technique during appendix transsection, in line with the patients' clinicopathologic data.

MATERIALS AND METHODS

Patients who were operated on with the diagnosis of acute appendicits in our clinic between October 2021 and January 2022 were evaluated retrospectively. Patients were divided into 2 groups. In the first group, there is the isolated appendectomy technique in which the appendix meso is dissection from the tip of the appendix to the base of the cecum, while in the second group there is the technique in which the appendix meso is dissected from the base of the cecum. In addition, demographic data (age, sex), body mass index, presence of comorbid disease, operation time, postoperative hospital stay, health care costs, appendix size of the patients included in the study were recorded.

RESULT

During the study, 157 patients were included in the study. Seventy-one (45.2%) of the patients were in group 1, and 86 (54.8%) were in group 2. There was no difference between the groups regarding age, sex, body mass index, presence of comorbid disease, appendix size, and postoperative hospital stay ( P >0.05). However, operation time and health care costs were statistically higher in group 2 than in group 1 ( P =0.01).

CONCLUSION

Although there was no difference in postoperative complications between the isolated appendectomy technique and the mesoicular technique, the operation time was shorter, and the operation cost was lower in the isolated appendectomy technique.

Validation of appendiceal stump invagination in laparoscopic appendectomy

INTRODUCTION

There are various methods for appendiceal stump dissection, but the necessity for stump invagination remains unclear. This study aimed to assess the efficacy of appendiceal stump invagination in patients with acute appendicitis after laparoscopic appendectomy (LA).

METHODS

We enrolled 327 patients with acute appendicitis who underwent LA between 2012 and 2020. Perioperative variables and surgical outcomes were analyzed between the invagination of the appendiceal stump and noninvagination groups. Propensity score-matched analysis (PSM) was performed.

RESULTS

More patients experienced severe inflammation and severe intra-abdominal contamination in the noninvagination group than in the invagination group. Patients in the noninvagination group had an older age, higher body mass index, and poorer American Society of Anesthesiologists physical status than the invagination group. Severe inflammation in the noninvagination group was associated with longer hospital stays and poorer postoperative complications than in the invagination group. PSM analysis was performed to minimize bias in the two groups. After PSM analysis, there were no significant differences in surgical site infection, postoperative intra-abdominal abscess, Clavien-Dindo class ≥IIIa, or postoperative stay between the two groups. During the follow-up period, the postoperative adhesive ileus was not significantly different between the invagination and noninvagination groups.

CONCLUSION

Invagination of the appendiceal stump during LA is not necessary to prevent short- and long-term complications. Even in cases dissected using a laparoscopic endostapler, the appendiceal stump per se is not related to postoperative adhesive ileus.

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.

Single-port laparoscopic appendectomy using a needle-type grasping forceps compared with conventional three-port laparoscopic appendectomy for patients with acute uncomplicated appendicitis: a single-center retrospective study

Objective

To compare the clinical outcomes between single-port laparoscopic appendectomy using a needle-type grasping forceps (SLAN) and conventional three-port laparoscopic appendectomy (CLA) for patients with uncomplicated appendicitis.

Methods

We retrospectively collected clinical data of patients with uncomplicated appendicitis who underwent SLAN or CLA from May 2019 to May 2021 in our center. The patients’ baseline characteristics, perioperative outcomes, and follow-up data were compared between the two groups. Additionally, baseline characteristics were compared with postoperative outcomes in the SLAN group.

Results

Ninety-six patients were enrolled (SLAN group, n = 32; CLA group, n = 64). The SLAN group had a shorter hospital stay, lower 24-hour postoperative visual analogue scale scores, shorter postoperative fasting time, lower frequency of antibiotic administration, and longer operative time than the CLA group. In the SLAN group, younger patients had a longer appendix and male patients had a thicker appendix; additionally, patients with an appendiceal diameter of 0.6 to 1.0 cm had a longer postoperative hospital stay and higher frequency of antibiotic administration.

Conclusions

Compared with CLA, SLAN may be less invasive, provide faster postoperative recovery, and result in better cosmesis for patients with uncomplicated appendicitis. Further research should be performed to evaluate the long-term outcomes.

A new approach to laparoscopic appendectomy in children-clipless/sutureless Harmonic scalpel laparoscopic appendectomy

BACKGROUND

The aim of this study was to investigate Harmonic scalpel performance in laparoscopic appendectomy for sealing the base of the appendix in children.

METHODS

During the study period, a total of 312 patients who underwent laparoscopic appendectomy were included in prospective bicenter clinical trial. The patients were divided in two study groups in regard to technique used for appendiceal base closure. In the first group (n = 197) the appendiceal base was secured using a polymeric clip while in the second group (n = 115) the Harmonic scalpel was used for sealing the base in a stepwise manner, without placing any clip or suture. Outcomes of treatment, including complication rates, duration of surgery and length of hospital stay were compared between the groups.

RESULTS

A total of 312 patients with a median age of 11 years (IQR 8, 15) were included in study. Of these, 191 were males (61.2%). Both groups were symmetric in regard to baseline characteristics of the patients. A total of 10 (5.1%) postoperative complications (postoperative abscess n = 7 and ileus n = 3) were recorded in the polymeric clip group while none of the patients from the clipless group had postoperative complications (P = 0.015). In the group who received a polymeric clip appendectomy, fever lasting 0-72 h and > 72 h was recorded in 16 (8.1%) and 12 (6.1%) children, respectively, while in the clipless group, it was observed in 2 (1.7%) and 5 (4.3%) children, respectively (P = 0.048). Significantly shorter surgical times were found in the clipless group compared to the polymeric clip group (21 min (IQR 18, 25) vs. 30 min (IQR 22, 40), P < 0.0001). Also, length of hospital stay was significantly shorter in the clipless group of the patients (2 days (IQR 2, 3) vs. 3 days (IQR 2, 4), P < 0.0001).

CONCLUSION

Clipless harmonic scalpel laparoscopic appendectomy is a safe and effective method in children for treatment of acute appendicitis with lesser number of complications and shorter duration of surgery compared to laparoscopic appendectomy in which the appendiceal base is secured with clip.

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.

Use of hem-o-lok clips for laparoscopic appendectomy in children: retrospective analysis and comparison to ligature loop and endoscopic surgical stapler

Background

There are multiple techniques used for laparoscopic appendectomy (LA): ligature loop (LL), surgical stapler (SS) (Endopath Ets-Flex-Endoscopic Articulating Linear Cutter 33 mm Standard Ref Atb 35. Ethicon, Somerville, New Jersey, US), and hem-o-lok clips (HOL) (Weck Closure System. Triangle Park, NC, USA). The application of the LL usually demands dexterity and training, whilst using HOL may be more advantageous due to its simplicity in terms of application and its low cost in contrast with the SS. The objective of this study is to determine safety and efficacy of the different devices that can be used in the surgical procedure.

Methods

From June 2016 to December 2019, 253 consecutive children aged to 1 to 18 years were retrospectively reviewed. They were divided into three groups depending on the device used to secure the appendix: (I) in the first group, the base of the appendix was secured by double LL, (II) in the second group the base of the appendix was secured with SS, and (III) in the third group the base of the appendix was secured with two non-absorbable HOL. The data collected includes age, gender, operative time, device used to ligate the base of the appendix, previous tests (blood analysis, imaging), antibiotic prophylaxis administered, length of hospital stay, intraoperative and postoperative complications, shoulder pain and histological study of the specimen.

Results

There were 253 patients that underwent laparoscopic appendectomy during the study time, with a mean age of 10.3±4.1 in the LL group, 9.4±2.7 in the SS group and 10.4±3.3 in the HOL group, P=0.165. Distribution by gender was 77.8% for males in the LL group, 65.2% in the SS group and 61.3% in the HOL group, P=0.559. The mean surgical time with IQR in brackets was 60.0 (10.0) minutes (min), in the first group in which the base of the appendix was secured with LL, in the second group in which the base of the appendix was secured with SS 60.0 (15.0) min and finally in the third in which the base of the appendix was secured with HOL 40.0 (30.0) min, P<0.001. HOL clips have a significantly lower cost than their analogues. Specifically, 5 HOL clips have a cost of EUR 26.75, while three LL have a cost of EUR 53.70 and a single SS has a cost of EUR 276.58. Postoperative complications were found in 14.3% of the LL group, 9.8% in the SS group and 4.6% in the HOL group, P=0.137. Efficacy and safety in controlling the base of appendix were the same in all groups.

Conclusions

The HOL are safe and reduce surgical costs during laparoscopic appendectomy in children.

A randomized clinical trial of technical modifications of appendix stump closure during laparoscopic appendectomy for uncomplicated acute appendicitis

Background

Closure of the appendix stump presents the most critical part of laparoscopic appendectomy. The aim of the present study was to compare the medical outcomes and cost analysis of laparoscopic appendectomy with respect to the different methods of stump closure.

Methods

This was a prospective randomized clinical trial conducted in a single institution (University Hospital Ostrava) within a 2-year study period. All included patients were randomized into one of three trial arms (endoloop, hem-o-lok clips or endostapler).

Results

In total, 180 patients (60 patients in each arm) were enrolled into the study. The mean length of hospital stay (3.6 ± 1.7 days) was comparable in all study arms. The shortest operative time was noted in the hem-o-lok subgroup of patients (37.9 ± 12.5 min). Superficial surgical site infection was detected in 4.4% of study patients; deep surgical site infection was noted in 1.7% of the patients. The frequency of surgical site infections was comparable in all study arms (p = 0.7173). The mean direct costs of laparoscopic appendectomy were significantly the lowest in the hem-o-lok subgroup of patients. Laparoscopic appendectomy is not a profit-making procedure in our institution (mean profit of made from the study patients was—104.3 ± 579.2 Euro). Closure of the appendix stump by means of endostapler presents the most expensive and the highest loss-incurring technique (p = 0.0072).

Conclusions

The present study indicates that all technical modifications of appendix stump closure are comparable with regards to postoperative complications. The stapler technique is significantly the most expensive. We concluded that hem-o-lok clips have the potential for becoming the preferred method of securing the appendix base during laparoscopic appendectomy. Trial registration NCT03750032 (http://www.clinicaltrials.gov).

Is the use of endoloops safe and efficient for the closure of the appendicular stump in complicated and uncomplicated acute appendicitis?

INTRODUCTION

There is still controversy regarding the ideal technique to close the appendicular stump in laparoscopic appendectomy (LA). The objective of this study was to determine the safety and efficiency of the use of an endoloop (EL) and endostapler (ES) in complicated and uncomplicated acute appendicitis.

METHODS

Retrospective cohort study of patients undergoing LA from February 2013 to December 2019. Acute uncomplicated and complicated appendicitis were analysed separately, establishing two groups according to the stump closure technique: EL or ES. Seven hundred-nine patients were included (535 uncomplicated and 174 complicated). In uncomplicated appendicitis, an EL was used in 447 of the patients (83.55%) and an ES was used in 88 patients (16.45%). In complicated appendicitis, an EL was used in 85 patients (48.85%) and an ES was used in 89 patients (51.15%). An analysis of effectiveness and a cost analysis of each technique were performed.

RESULTS

In uncomplicated appendicitis, we found no differences with respect to global complications, although there were significant differences in the total mean hospital stay (EL group 1.55 (SD 1.48) days; ES group 2.21 (SD 1.69) days; p = 0.046). This meant a savings of 514.12€ per patient using the EL p < 0.001). In complicated appendicitis, the reoperations classified as Clavien-Dindo IIIB in the EL group (6.4%) were greater than in the ES group (0%) (p = 0.012), although the rate of postoperative abscesses (p = 0.788) and the mean volume of abscesses (p = 0.891) were similar.

CONCLUSION

The systematic use of an EL could reduce costs in uncomplicated appendicitis, while in complicated cases, both options are valid. Prospective studies with a greater number of patients are needed to observe differences in postoperative complications.

Ultrasound features and the diagnostic strategy of subhepatic appendicitis

Background

This study aimed to compare the differences of ultrasound findings between subhepatic appendicitis and appendicitis at a normal position, then discuss the diagnostic strategies and improve the accuracy of diagnosis.

Methods

A retrospective analysis was performed in our hospital. One thousand five hundred ninety-one patients with appendicitis were diagnosed from January 2014 to January 2018. Eighteen patients with subhepatic appendicitis and 25 patients with appendicitis with regular positions were selected randomly as the control group. The difference in ultrasound features between the two groups was studied. Comparisons between the two groups showed statistically significant differences in the frequencies of the fishbone sign, enlarged appendix, appendicoliths, and hyperechoic omental cap (P<0.05).

Results

Statistical significance was not observed with the difference in the frequency of whether there was lymphadenectasis (P>0.05) in the abdominal cavity between the two groups. The Pareto chart was drawn to look for the main factors associated. The results of interpretation on the critical points of diagnosis for subhepatic appendicitis: (I) the fishbone sign of a dilated ileum in the right lower abdomen; and (II) the fishbone sign of a dilated ileum in the right lower abdomen + presence of an enlarged appendix in the right upper abdomen.

Conclusions

An abnormally dilated ileum in the right lower abdomen – the fishbone sign, is a vital sign leading to the diagnosis of subhepatic appendicitis. The fishbone sign of a dilated ileum in the right lower abdomen + whether there is a vermiform structure is an important diagnostic indicator for subhepatic appendicitis.

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.

Comparison of stump closure techniques during laparoscopic appendectomies for complicated appendicitis - results from Pol-LA (Polish laparoscopic appendectomy) multicenter large cohort study

Background: In general, the three main options for stump closure in laparoscopic appendectomy are clips, endoscopic staplers and endoloops. However, there is no gold standard, especially regarding complicated acute appendicitis which is generally associated with worse outcomes.Objectives: We aimed to assess the outcomes of different stump closure techniques during laparoscopic appendectomies for complicated appendicitisMethods: Our multicenter observational study of 18 surgical units assessed the outcomes of 1269 laparoscopic appendectomies for complicated appendicitis that used the three main stump closure techniques: clips, staplers and endoloops. Groups were compared in terms of peri- and postoperative outcomes.Results: Staplers were superior in terms of overall morbidity (9.79 vs. 3.29% vs. 7.41%, p = .017) and length of stay (4 vs. 3 vs. 4 days, p < .001) respectively for clips, staplers and endoloops. However, no differences in major complication rates, postoperative intraabdominal abscess formation, reintervention rates and readmission rates were found.Conclusion: Although our results show some clinical benefits of staplers for appendix stump closure, they are based on a non-randomized group of patients and are therefore prone to selection bias. Further well-designed trials taking into consideration not only the clinical benefits, but also, the economic aspects of the surgical treatment of complicated acute appendicitis are needed to confirm our results.

Appendiceal stump closure with polymeric clips is a reliable alternative to endostaplers

Objective

Polymeric (Hem-o-lok) clips represent a novel technique with which to ligate the appendiceal stump following laparoscopic appendectomy. We compared the outcomes of using polymeric clips versus endostaplers for complicated and uncomplicated appendicitis.

Methods

Six hundred seventy-three consecutive patients undergoing laparoscopic appendectomy with polymeric clips or endostaplers for acute appendicitis were assessed. The primary outcome was the incidence of intra-abdominal abscesses. Predictors of postoperative intra-abdominal abscesses were calculated using univariate and multivariate analyses.

Results

Polymeric clips were used in 65% of patients and endostaplers were used in 35%. Hem-o-lok clips were not only applied in patients with uncomplicated appendicitis (83%), but also in those with complicated appendicitis (26%). The frequency of intra-abdominal abscesses using polymeric clips and endostaplers was similar in both patients with uncomplicated appendicitis (1% vs. 3%, respectively) and complicated appendicitis (2% vs. 6%, respectively). The univariate and multivariate analyses showed that the stump closure technique was not a risk factor for postoperative abscesses.

Conclusions

Closure of the appendiceal stump using the nonabsorbable Hem-o-lok ligation system in patients with both uncomplicated and complicated appendicitis is a safe alternative to the application of endostaplers.

Are endoscopic loop ties safe even in complicated acute appendicitis? A systematic review and meta-analysis

BACKGROUND

Appendectomy is amongst the most common general surgical procedures and the laparoscopic approach is recognized and recommended by international guidelines as a valid option. The different closure techniques of the appendicular stump constitute a matter of debate since their possible implication in determining postoperative infectious complications. The aim of the present meta-analysis is to compare endostapler versus endoscopic loop ties for stump closure during laparoscopic appendectomy.

METHODS

This is a systematic review with meta-analysis of randomized trials and cohort studies comparing endostapler with endoscopic loop ties for the closure of appendicular sump in laparoscopy appendectomy. Subgroup analysis of pediatric patients and patients with complicated appendicitis were performed when data were available. Complicated acute appendicitis was defined as in case of gangrenous/necrotic appendix or perforated appendix. Main outcomes were wound infection rate, intra-abdominal infection rate, length of stay, readmission and reoperation rates.

RESULTS

a total of 5934 patients from 14 studies were included in the analysis. Endostapler was associated with a similar intra-abdominal abscess rate (RR 0.88, 95%C.I. 0.54-1.43) but a lower incidence of wound infection (RR 0.54, 95%C.I. 0.22-0.97) Length of stay, readmission and reoperation rates were similar. In subgroups analysis endostapler reduces significantly the wound infection rate in pediatric patients; no differences in main outcomes were observed in patients with complicated acute appendicitis.

CONCLUSION

In complicated acute appendicitis the stump closure technique did not affect outcomes; the use of endostapler seems to be associated to a reduction of wound infection rate in pediatric patients with non-complicated acute appendicitis.

Comparison of Polymeric Clips and Endoscopic Staplers for Laparoscopic Appendectomy

INTRODUCTION

Appendectomy is the most common pediatric surgical procedure. To decrease the cost and environmental impact of single incision pediatric endosurgery (SIPES) appendectomy, we switched from using endoscopic staplers to polymeric clips placed with nondisposable laparoscopic appliers. The aim of this study was to compare the resulting reduction in cost and amount of waste generated per case, as well as to compare the perioperative variables and outcomes in patients in whom clips were used, with those of historical patients in whom staplers were used.

MATERIALS AND METHODS

Retrospective chart review of SIPES appendectomies was performed and patients in whom clips were used were compared with patients in whom staplers were used. Demographic, operative, and clinical data were collected. t-Test, Mann-Whitney test, and chi squared test were used to analyze the data as appropriate. The cost to the hospital of the clips and staplers was compared. The disposable waste generated from clips and the staplers was weighed.

RESULTS

A total of 246 patients were included: 111 in stapler group and 135 in clip group. There were no statistically significant differences between the groups in operative time, estimated blood loss, length of stay, and complications. There were no complications related to use of clips. In the clip group, staplers were used in 10% because base of appendix was too large, gangrenous, or perforated and could not be clipped. Use of polymeric clips was less expensive and generated less waste.

CONCLUSIONS

Use of polymeric clips for appendectomy is safe and effective, and results are comparable with those of stapling. Based on our data, in 90% of appendectomies, the base of appendix is amenable to clipping. This study supports use of clips over staplers to decrease cost and environmental impact.