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

Evaluation of the Appropriate LigaSure™ Device to Transect the Appendix-A Comparison between 5 mm and 10 mm Laparoscopic Devices in an Ex Vivo Trial

Background and Objectives: A topic of greatinterest in the surgical field comprises cost and time reduction operative techniques with high efficiency rates. Thus, the aim of this paper is to evaluate whether a transection of the appendix using only a laparoscopic LigaSure™ device is feasible and, if so, which size of the laparoscopic device is optimal. Materials and Methods: Appendectomy specimens were sealed and cut using LigaSure^TM V (5 mm) and LigaSure Atlas^TM (10 mm) devices ex vivo. Analysis criteria included handling, resistance to bursting pressure of the appendicular stump (adequacy), eligibility, durability and airtightness. Results: Twenty sealed areas were measured. While the 5 mm instrument was not able to transect the appendix in one attempt in any of the cases, the 10 mm device could be applied successfully without any handling difficulties. The adequacy of the sealed area was rated as complete and dry in all 10 cases using the 10 mm device and as oozing in 8 of the cases using the 5 mm device. There was no leakage in terms of air and liquid tightness using the 10 mm device, in contrast to six sealed segments with air and liquid leakage when using the 5 mm device. The resistance to bursting pressure was on average 285 mmHg and 60.5 mmHg with the 10 mm and 5 mm devices, respectively. The durability and eligibility of the 10 mm device were rated as very sufficient in 9 of 10 cases (1 perforation) in contrast to the 5 mm device, where the sealing in 9 of 10 cases was not sufficient (9 perforations). Conclusions: Using the 10 mm laparoscopic LigaSure™ device for the transection of the appendix seems to be feasible, safe and resistant to 300 mmHg bursting pressure. The 5 mm LigaSure™ instrument is inadequate to seal the appendix in humans.

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.

Laparoscopic Partial Cecal Resection With an Endoscopic Linear Stapler in Complicated Appendicitis: A Single Center Experiences

Introduction

It can be challenging to perform an appendectomy laparoscopically in patients with complicated appendicitis with severe inflammation or perforation of the appendix base. This study aimed to introduce a simple alternative surgical treatment that can be used safely in difficult appendectomy cases.

Case presentation

We retrospectively reviewed the medical records of 14 patients who underwent laparoscopic partial resection of the cecum with a linear stapler between January 2015 and December 2016 in our hospital. Fourteen patients were included in this study, and no surgical complications were observed. Enteral feeding was resumed on the third or fourth postoperative day, and the average length of hospital stay was 7.6 days (range, 5 to 12 days).

Conclusion

The results suggest that laparoscopic partial cecal resection with an endostapler is a safe, simple surgical procedure that can be a good alternative in patients with complicated appendicitis.

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).

A comparison of non-absorbable polymeric clips and staplers for laparoscopic appendiceal stump closure: analysis of 618 adult patients

PURPOSE

The aim of this long-term study was the comparison of appendiceal stump closure with polymeric clips or staplers with respect to perioperative costs and surgical outcome under routine conditions in a university centre.

METHODS

For this retrospective chart review, a total of 618 patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2010 and 2017 were reviewed: 410 patients in the stapler group and 208 patients in the clip group. The database contained demographic data, operation time, inflammation parameters, closure method of the stump, surgeon status, length of hospital stay, and complications as well as histology reports. The costs were also compared.

RESULTS

Clip application was more likely among younger patients (mean age 33.6 years vs. 41.7 years). Histopathological evidence for appendiceal pathology was found in 96.6% of patients in the clip group and 99.5% of patients in the stapler group. Laparoscopic appendectomy in the clip group was more frequently performed by resident physicians (69.2%) than in the stapler group (57.8%). The mean postoperative stay was 2.9 days in the clip group and 3.7 days in the stapler group. The use of the polymeric clip resulted in considerable cost savings (19.94€ vs. 348.70€).

CONCLUSIONS

The use of polymeric clips for appendiceal stump closure during appendectomy is safe and effective. The base of the appendix is amenable to clipping in 32% of appendectomies in adult patients. This study supports the use of polymeric clips over staplers to decrease cost and environmental impact.