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Yildirim M, Koca B, Tufekci MF, Saglam AI, Ozkan N. Handmade Loop Versus Hem-o-Lok Clip in Closure of Appendiceal Stump During Laparoscopic Appendectomy: Limited Setting in a Peripheral University Hospital. J Laparoendosc Adv Surg Tech A 2024. [PMID: 38770657 DOI: 10.1089/lap.2024.0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background: Today, laparoscopy is frequently used in abdominal emergencies such as acute appendicitis. There are several techniques used to close the appendiceal stump during laparoscopic appendectomy. We aimed to compare the use of handmade loop and Hem-o-lok used to close the appendiceal stump in public hospitals where resources are limited, in terms of surgical outcomes and cost. Methods: Between January 2020 and December 2022, patients for whom handmade loops and Hem-o-loks were used to close the appendiceal stump during laparoscopic appendectomy in our clinic were included in the study. There were a total of 638 patients (mean age: 33 ± 13.5 years, 325 females and 313 males) in the patient cohort. Demographic and clinical data, duration of surgery, complications, hospital stay, pathology reports, mortality, and cost of supplies were compared between the two groups. Results: There were 308 patients in the handmade loop group (160 females, 148 males, mean age: 33.7 years, range: 18-85 years) and 330 patients in the Hem-o-lok group (166 females, 164 males, mean age: 32.5 years, range: 18-89 years). There was no significant difference between the two groups for American Society of Anesthesiologists score, duration of symptom, hospital stay, intensive care unit stay, preoperative laboratory values, histopathological results, mortality, and morbidity (P > .05). The mean operation time was 48.76 ± 16.16 minutes in the handmade loop group and 40.53 ± 11.63 minutes in the Hem-o-lok group (p = 0.001). In terms of cost, the cost per case of Hem-o-lok group was about 25.8 times as much as the group that used sutures ($31 versus $1.2). Conclusions: Both methods can be used safely in laparoscopic appendectomy. The use of Hem-o-lok has no advantage other than shortening the operation time. However, it is costlier. Especially in peripheral hospitals where resources are limited, closing the appendiceal stump using a handmade loop is an easy, safe, and cost-effective method.
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Affiliation(s)
- Murat Yildirim
- Department of General Surgery, Faculty of Medicine, Tokat Gaziosmanpasa University, Tokat, Türkiye
| | - Bulent Koca
- Department of General Surgery, Faculty of Medicine, Tokat Gaziosmanpasa University, Tokat, Türkiye
| | - Muzaffer Fatih Tufekci
- Department of General Surgery, Faculty of Medicine, Tokat Gaziosmanpasa University, Tokat, Türkiye
| | - Ali Ihsan Saglam
- Department of General Surgery, Faculty of Medicine, Tokat Gaziosmanpasa University, Tokat, Türkiye
| | - Namik Ozkan
- Department of General Surgery, Faculty of Medicine, Tokat Gaziosmanpasa University, Tokat, Türkiye
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Curwen O, Gaber M, Gerogiannis I. In Pursuit of the Most Cost-Effective Laparoscopic Appendicectomy: A Review of the Literature. Surg Innov 2023; 30:601-606. [PMID: 37080159 DOI: 10.1177/15533506231169072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
PURPOSE To review the literature and identify the most economical techniques for laparoscopic appendicectomy (LA) that do not compromise on patient care. METHODS We performed a search of the Cochrane Library, PubMed, EMBASE and Google Scholar for papers published between January 2001 and January 2021. The outcomes of the included studies were then grouped by theme of cost analysis, with the main areas of focus being the use of disposable equipment, appendiceal stump closure, and retrieval of the appendix. RESULTS After screening a total of 254 search results, 40 studies were included, representing 13 285 patient outcomes, having two main areas of focus: the use of reusable or disposable equipment and the different methods of appendiceal stump closure. Use of disposable instruments has been cost effective in LA in 2 studies. However, use of reusable trocars has reduced cost of procedure by €250 in another study. Appendiceal stump closure using ligature, endoloops or Endoclips had been cost-effective compared to Endostaplers in 25 studies. This can save up to €350. Endoscopic specimen bags are single use and represent further disposable equipment costs. The use of a sterile glove to replace this piece of kit can further provide cost benefit as shown in 2 studies. CONCLUSION Laparoscopic appendicectomy can be performed in a variety of ways with equivocal patient safety. We present the use of extracorporeal ligature of the appendiceal base, combined with the use of a surgical glove retrieval system as the most economic technique in laparoscopic appendicectomy.
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Affiliation(s)
- Oliver Curwen
- Department of General and Emergency Surgery, Kingston Hospital NHS Foundation Trust, London, UK
| | - Mohannad Gaber
- Department of General and Emergency Surgery, Kingston Hospital NHS Foundation Trust, London, UK
| | - Ioannis Gerogiannis
- Department of General and Emergency Surgery, Kingston Hospital NHS Foundation Trust, London, UK
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Zorzetti N, Lauro A, Bellini MI, Vaccari S, Dalla Via B, Cervellera M, Cirocchi R, Sorrenti S, D’Andrea V, Tonini V. Laparoscopic appendectomy, stump closure and endoloops: A meta-analysis. World J Gastrointest Surg 2022; 14:1060-1071. [PMID: 36185568 PMCID: PMC9521468 DOI: 10.4240/wjgs.v14.i9.1060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/22/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Noemi Zorzetti
- Department of General Surgery, Ospedale Civile A Costa, Porretta Terme 40046, Italy
- Department of Surgical Sciences, Sapienza University, Rome 00161, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University, Rome 00161, Italy
| | | | - Samuele Vaccari
- Department of Surgical Sciences, Sapienza University, Rome 00161, Italy
- Department of General Surgery, Ospedale di Bentivoglio, Bologna 40010, Italy
| | - Barbara Dalla Via
- Department of Emergency Surgery, St Orsola University Hospital, Bologna 40138, Italy
| | - Maurizio Cervellera
- Department of General Surgery, Ospedale Santissima Annunziata, Taranto 74121, Italy
| | - Roberto Cirocchi
- Department of General Surgery, Ospedale di Terni, Università di Perugia, Terni 05100, Italy
| | | | - Vito D’Andrea
- Department of Surgical Sciences, Sapienza University, Rome 00161, Italy
| | - Valeria Tonini
- Department of Emergency Surgery, St Orsola University Hospital, Bologna 40138, Italy
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Variability in pediatric appendectomy: The association between disposable supply cost and procedure duration. Surgery 2022; 172:729-733. [DOI: 10.1016/j.surg.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022]
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Kim S, Jeon BH, Cho SS, Shin US, Moon SM. Clinical outcomes of locking polymeric clip for laparoscopic appendectomy in patients with appendicitis: a retrospective comparison with loop ligature. Ann Coloproctol 2022; 38:160-165. [PMID: 35038819 PMCID: PMC9021853 DOI: 10.3393/ac.2021.00598.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/27/2021] [Indexed: 11/06/2022] Open
Abstract
Purpose This study aimed to compare the clinical outcomes of laparoscopic appendectomy (LA) according to the method of appendiceal stump closure. Methods Patients who underwent LA for appendicitis between 2010 and 2020 were retrospectively reviewed. Patients were classified into locking polymeric clip (LPC) and loop ligature (LL) groups. Clinical outcomes were compared between the groups. Results LPC and LL were used in 188 (56.6%) and 144 patients (43.4%), respectively for appendiceal stump closure. No significant differences were observed in sex, age, comorbidities, and the severity of appendicitis between the groups. The median operative time was shorter in the LPC group than in the LL group (64.5 minutes vs. 71.5 minutes, P=0.027). The median hospital stay was longer in the LL group than in the LPC group (4 days vs. 3 days, P=0.020). Postoperative incidences of intraabdominal abscess and ileus were higher in the LL group than in the LPC group (4.2% vs. 1.1%, P=0.082 and 2.8% vs. 0%, P=0.035; respectively). The readmission rate was higher in the LL group than that in the LPC group (6.3% vs. 1.1%, P=0.012). Conclusion Using LPC for appendiceal stump closure during LA for appendicitis was associated with lower postoperative complication rate, shorter operative time, and shorter hospital stay compared to the use of LL. Operative time above 60 minutes and the use of LL were identified as independent risk factors for postoperative complications in LA. Therefore, LPC could be considered a more favorable closure method than LL during LA for appendicitis.
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Affiliation(s)
- Seokwon Kim
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Byong Ho Jeon
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sang Sik Cho
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Ui Sup Shin
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sun Mi Moon
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
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Heise JW, Kentrup H, Dietrich CG, Cosler A, Hübner D, Krumholz W. Laparoscopic Appendectomy: A Safe and Definitive Solution for Suspected Appendicitis. Visc Med 2020; 37:180-188. [PMID: 34250075 DOI: 10.1159/000510487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/27/2020] [Indexed: 12/29/2022] Open
Abstract
Introduction Since conservative antibiotic treatment in uncomplicated appendicitis might not solve the clinical problem definitively, it has to compete with the results of today's laparoscopic appendectomy. Methods In a county hospital, accommodating also a pediatric department, all cases of appendectomy for suspected appendicitis over 15 years were analyzed retrospectively for the following items: beginning of symptoms, time from admission to surgery, surgical technique as "open," "laparoscopic" or "converted," if perforated at operation and histological confirmation of acute inflammation. Surgical morbidity was detected in distinct categories. To evaluate changes over time, 3 time periods of 5 years each were defined. Results Resulting in a total of 1,956 cases there were 731 in group I, 633 in group II and 592 in group III within the 3 time periods, respectively. The median age was 17 years. The percentage of perforations was 16.8%. Those patients had - with 47 compared to 27 h - a significantly prolonged time from the beginning of symptoms to admission (p = 0.0001). The proportion of laparoscopic surgery rose from 83.3 (group I) to 98.3% (group III; p = 0.0001). The median postoperative hospital stay diminished from 4 to 3 days in nonperforated (p = 0.0001) and from 8 to 7 days in perforated cases (p = 0.0009). Surgical morbidity was reduced from 4.1% in the first to 1.7% in the third observation period (p = 0.0144). There were no surgical site infections during the last 5 years. Conclusions Timely laparoscopic appendectomy in case of suspected appendicitis can be offered with an extraordinary low morbidity. Taking into account the complete solution of the otherwise pending threat, compared to conservative antibiotic treatment, it is safe and definitive.
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Affiliation(s)
- Joachim Wilfried Heise
- Department of General, Visceral and Thyroid Surgery, Bethlehem Gesundheitszentrum Stolberg (Rhld.), Stolberg, Germany
| | - Heiner Kentrup
- Department of Pediatrics, Bethlehem Gesundheitszentrum Stolberg (Rhld.), Stolberg, Germany
| | | | - Ansgar Cosler
- Department of Gynecology and Obstetrics, Bethlehem Gesundheitszentrum Stolberg (Rhld.), Stolberg, Germany
| | - Dolores Hübner
- Department of Radiology and Pediatric Radiology, Bethlehem Gesundheitszentrum Stolberg (Rhld.), Stolberg, Germany
| | - Werner Krumholz
- Department of Anesthesiology, Bethlehem Gesundheitszentrum Stolberg (Rhld.), Stolberg, Germany
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Makaram N, Knight SR, Ibrahim A, Patil P, Wilson MSJ. Closure of the appendiceal stump in laparoscopic appendectomy: A systematic review of the literature. Ann Med Surg (Lond) 2020; 57:228-235. [PMID: 32802324 PMCID: PMC7419254 DOI: 10.1016/j.amsu.2020.07.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- N Makaram
- Department of General Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - S R Knight
- Usher Institute, University of Edinburgh, Edinburgh, EH16 4XU, UK
| | - A Ibrahim
- Department of General Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - P Patil
- Department of General Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - M S J Wilson
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK
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A systematic review on the cost evaluation of two different laparoscopic surgical techniques among 996 appendectomies from a single center. Updates Surg 2020; 72:1167-1174. [PMID: 32474801 DOI: 10.1007/s13304-020-00817-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/20/2020] [Indexed: 02/08/2023]
Abstract
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.
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Cost containment: an experience with surgeon education and universal preference cards at two institutions. Surg Endosc 2019; 34:5148-5152. [PMID: 31844970 DOI: 10.1007/s00464-019-07305-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND As the cost of health care increases in the US, focus has been placed upon efficiency, cost reduction, and containment of spending. Operating room costs play a significant role in this spending. We investigated whether surgeon education and universal preference cards can have an impact on reducing the disposable supply costs for common laparoscopic general surgery procedures. METHODS General surgeons at two institutions participated in an educational session about the costs of the operative supplies used to perform laparoscopic appendectomies and cholecystectomies. All the surgeons at one institution agreed upon a universal preference card, with other supplies opened only by request. At the other, no universal preference cards were created, and surgeons were free to modify their own existing preference cards. Case cost data for these procedures were collected for each institution pre- (July 2014-December 2014) and post-intervention (February 2015-November 2017). RESULTS At the institution with an education only program, there was no statistically significant change in supply costs after the intervention. At the institution that intervened with the combined education and universal preference card program, there was a statistically significant supply cost decrease for these common laparoscopic procedures combined. This significant cost decrease persisted for each appendectomies and cholecystectomies when analyzed independently as well (p = 0.001 and p < 0.001 respectively). CONCLUSIONS In this study, surgeon education alone was not effective in reducing operating room disposable supply costs. Surgeon education, combined with the implementation of universal preference cards, significantly maintains reductions in operating room supply costs. As health care costs continue to increase in the US and internationally, universal preference cards can be an effective tool to contain cost for common laparoscopic general surgery procedures.
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Commentary to Ceresoli M, Tamini N, Gianotti L et al. "Are endoscopic loop ties safe even in complicated acute appendicitis? A systematic review and meta-analysis". Int J Surg 2019; 68:173. [PMID: 31323341 DOI: 10.1016/j.ijsu.2019.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Development of a Two Port Laparoscopic Appendectomy Technique at a Rural Hospital. Minim Invasive Surg 2019; 2019:9761968. [PMID: 31236293 PMCID: PMC6545795 DOI: 10.1155/2019/9761968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023] Open
Abstract
Background Laparoscopic appendectomy (LA) is most commonly performed using two 5-mm and one 10/12-mm ports. Various attempts to reduce the number and size of ports have been made and new technologies such as single port LA have been introduced. Appendix and mesoappendix are usually divided with a stapler or energy device with electrocautery, clips, and endoloop being cheaper options. Patients and Methods This study includes 51 consecutive LAs performed at a rural hospital. Patients were divided into 4 groups: group 1 was the standard technique group (n=12), group 2 served as a “try-out” (n=12), group 3 served as feasibility group (n=12), and group 4 was the final patient cohort in which the optimized technique was preferably used (n=15). Results Median age of the study cohort was 35.4 (range: 6.2-80.6) years, and 55% of patients were male. Whereas in G1 all patients had standard port placement (10/12-mm, 2x5-mm), in an increasing number of patients in G2-4 only two 5-mm ports and the 2.3-mm Teleflex minigrasper were inserted. Usage of staplers and/or energy devices was reduced from 100% in G1 to 20% in G4, and in the majority of cases both the appendix and the vascular pedicle were secured with an endoloop. The new technique did not add time to the procedure or total OR time. No stump-leaks or surgical site infections were encountered in this series, and there were no conversions to open surgery. Cost savings when not using a stapler or energy device are approximately 400$ per case; the minigrasper added approximately 200$ to the case. Discussion LA with use of two ports and a portless needle grasper is feasible in the majority of cases and was associated with high patient satisfaction and excellent cosmetic results. Avoiding energy devices and staplers is cost saving; the endoloop securely controls appendix and mesoappendix.
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