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.

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 ).

Appendiceal Inversion Presenting as a Cecal Polypoid Mass on Screening Colonoscopy: A Case Report and Review of Available Diagnostic Adjuncts to Differentiate Benign From Malignant Colorectal Pathology.

Appendiceal inversion is uncommon. It may be a benign finding or seen in association with malignant pathology. When detected, it masquerades as a cecal polyp which poses a diagnostic dilemma with malignancy in the differential. In this report, we highlight a case of a 51-year-old patient with an extensive surgical history as a newborn in the setting of omphalocele and intestinal malrotation, who was found to have a 4 cm cecal polypoid growth on screening colonoscopy. He underwent a cecectomy for tissue diagnosis. Ultimately, the polyp was found to be an inverted appendix without evidence of malignancy. Currently, suspicious colorectal lesions which cannot be removed by polypectomy are primarily addressed with surgical excision. We reviewed the literature for available diagnostic adjuncts to better differentiate benign from malignant colorectal pathology. The application of advanced imaging and molecular technology will allow for improved diagnostic accuracy and subsequent operative planning.

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.

Laparoscopic appendectomy in complicated appendicitis with compromised appendix base: a retrospective cohort study.

BACKGROUND: Patients with compromised appendix base constitute a subgroup of patients with complicated appendicitis, and there is few available information. OBJECTIVE: To study the frequency of stump leaks and fistulae in patients with complicated appendicitis with compromised stump. METHOD: This is an observational, retrospective study of patients that underwent laparoscopic appendectomy with compromised appendix stump. RESULTS: From 2015 to 2019, 158 patients with complicated appendicitis were operated, of them 54 had compromised base or stump. There were 66.7% men, with a mean age of 38.7 years. For stump closure, a simple knot was employed in 57.4%, and in 42.6% an invaginated suture was employed. Regarding complications, 16.7% developed intraabdominal abscess, 7.4% ileus and 7.4% had wound infection. We found one stump leak and one stump fistula. The mean length of stay was 5.4 days (range: 1-20). There were 5 reoperations, 4 for abscess drainage and 1 for stump leak. CONCLUSIONS: Patients with acute complicated appendicitis with compromised appendicular base, laparoscopic surgery either with simple knot or with invaginated suture resulted in low frequency of stump leaks and fistula.

ANTECEDENTES: Los pacientes con base apendicular comprometida constituyen un subgrupo de pacientes con apendicitis complicada y existe poca información al respecto. OBJETIVO: Conocer la frecuencia de fístulas y fugas fecales en pacientes con apendicitis complicada con base apendicular comprometida. MÉTODO: Se trata de un estudio observacional, retrospectivo y transversal de pacientes operados de apendicectomía laparoscópica con base apendicular comprometida. RESULTADOS: De 2015 a 2019 se encontraron 158 casos de apendicitis complicada, de los cuales 54 tenían la base apendicular comprometida. Hubo predominio de varones (66.7%) y la edad media fue de 38.7 años. En el 57.4% de los casos se realizó un nudo simple y en el 42.6% un punto transfictivo con invaginación del muñón. En relación con las complicaciones, el 16.7% desarrollaron abscesos intraabdominales, el 7.4% íleo y el 7.4% infección de herida. Hubo un paciente con fuga del muñón y un paciente con fístula cecal. El tiempo medio de estancia hospitalaria fue de 5.4 días (rango: 1-20). Se realizaron cinco reintervenciones: cuatro para drenaje de absceso intraabdominal y una por fuga del muñón. CONCLUSIONES: En los pacientes con base apendicular comprometida, el manejo laparoscópico con ligadura simple o con punto transfictivo resulta en una baja frecuencia de fuga y fístula del muñón apendicular.

Absorbable polymeric surgical clips for appendicular stump closure: A randomized control trial of laparoscopic appendectomy with lapro-clips.

A randomized control trial was performed to evaluate the effectiveness and safety of absorbable polymeric clips for appendicular stump closure in laparoscopic appendectomy (LA). Patients were randomly enrolled into an experimental group (ligation of the appendicular base with Lapro-Clips, L-C group) or control group (ligation of the appendicular base with Hem-o-lok Clips, H-C group). We identified 1,100 patients who underwent LA between April 1, 2012 and February 3, 2015. Overall, 99 patients (9.0%, 99/1,100) developed a complication following LA (47 [8.5%] in the L-C group and 52 [9.5%] in the H-C group (P = 0.598). No statistically significant differences were observed in intra-abdominal abscesses, stump leakage, superficial wound infections, post-operative abdominal pain, overall adverse events, or the duration of the operations and hospital stays between the groups (all p > 0.05). Adverse risk factors associated with the use of absorbable clips in LA included body mass index ≥ 27.5 kg/m2, diabetes, American Society of Anesthesiologists degree ≥ III, gangrenous appendicitis, severe inflammation of the appendix base, appendix perforation, and the absence of peritoneal drainage. The results indicate that the Lapro-Clip is a safe and effective device for closing the appendicular stump in LA in select patients with appendicitis.

Mesoappendix and appendix stump treatment in laparoscopic appendectomy: a retrospective study in 1084 patients.

BACKGROUND: Laparoscopic appendicectomy (LA) rapresents a standard but questionable approach in the treatment of acute appendicitis. The scope of this study is to show our experience using different methods in the mesoappendix and appendix stump treatment. MATERIALS AND METHODS: A retrospective analysis of all patient with acute appendicitis that underwent to LA was obtained. The results have been analysed compareing the single techniques used in the treatment of mesoappendix and appendix stump. RESULTS: The study included 1084 patients (M=648; F=436; mean age 28,4 years). During laparoscopic procedure we have founded in 296 cases a CAA (27.3%). The rate of conversion to open has resulted 3,2%; the mean operative time was 57,1'; mean postoperative stay was 2,7 days. Eighteen patients have experienced surgical complications. From our data, in the treatment of mesoappendix (Clip =863, bipolar coagulation = 165, stapler = 22) and the appendix stump (endoloop =784; stapler = 265) we found no statistically difference about postoperative stay, and incidence of IAA; the operative time was longer (54,2 vs 66' p<0.05) when the surgeon prefered stapling the appendix stump; but in this group there was a higher incidence of CAA (35.2 % vs 18.7%). CONCLUSIONS: Laparoscopic appendicectomy is safe and effective. We judge that there isn't a better technique than others but various options that should be evaluated taking care about costs, the experience of the surgeon and the degree of inflammation of the appendix.