This study aimed to compare outcomes of different techniques for closing the appendix stump during laparoscopic appendectomy (L-APPE). In a randomized clinical trial, 180 patients undergoing L-APPE for uncomplicated acute appendicitis were assigned to have their appendix stump closed using an endoloop, Hem-o-lok clips, or stapler. The stapler group had a significantly longer operative time and higher rate of intraoperative complications compared to the other groups. Postoperative complication rates were low across groups but costs were highest for the stapler technique. Hem-o-lok clips resulted in the shortest operative time and lowest costs, making them a reasonable option for appendix stump closure during L-

1. A randomized clinical trial of
technical modifications of appendix
stump closure during laparoscopic
appendectomy for uncomplicated
acute appendicitis
Journal Club Presentation

2. Author information
Department of Surgery, University Hospital Ostrava, 17.listopadu 1790,
Ostrava, 708 52, Czech Republic
Peter Ihnát, Milan Tesař & Lubomír Tulinský
Department of Forensic Medicine, University Hospital Ostrava,
17.listopadu 1790, Ostrava, 708 52, Czech Republic
Lucia Ihnát Rudinská
Department of Cardiovascular Surgery, University Hospital Ostrava,
17.listopadu 1790, Ostrava, 708 52, Czech Republic
Okaikor Okantey
Department of Oncosurgery, Faculty of Medicine, Commenius
University Bratislava, Spitalska 24, Bratislava, 813 72, Slovakia
Lucia Ihnát Rudinská & Štefan Durdík

3. Received
04 December 2020
Accepted
25 May 2021
Published
31 May 2021
BMC Surg 21
Article number: 272 (2021).

4.  Prospective randomized clinical trial
 University Hospital Ostrava(Czech Republic)
 2-year study period
 Three trial arms

5. Introduction
 reduced postoperative pain
 faster recovery
 better cosmetic results
 reduced wound infection rate

6. • Closure of the appendix stump presents the most critical part of
L-APPE
• Several technical modifications of stump closure during L-APPE are
currently available
 closure with a clip(Hem-o-lok)
 closure with a endoloop
 Stapler

7. The aim of the this clinical trial was
1. compare medical outcomes
2. Cost of laparoscopic appendectomy

8. Design and setting
Material and methods
 prospective randomized clinical trial
 conducted in the University
Hospital Ostrava, Czech Republic
 study period :1st January 2018–31st
December 2019
 inclusion criteria were
1. Age ≥ 18 years
2. Clinical signs of acute appendicitis
3. suitability for laparoscopic surgery

9.  exclusion criteria were
1. Peroperative findings of necrosis
2. Advanced inflammatory changes in the
area of the appendix stump
3. Conversion to laparotomy due to diffuse
peritonitis

10. Each study subject was randomized
to one of
3 trial arms
 endoloop
 Hem-o-lok
 stapler

11.  Trial sample size - 180 patients(60 in each trail)
 Primary outcome measures of the study
1. Operative time
2. Intraoperative complications
3. Postoperative complications

12. Surgical technique
 L-APPE was performed by certified surgeons experienced in
advanced laparoscopic surgery
 Surgery was performed under general anaesthesia
 Patient was placed in the supine, Trendelenburg position
 3-port technique
1. 10-mm camera port in periumbilical region
2. 5-mm port in the left lower quadrant
3. 10-mm port in suprapubic region
 Mesoappendix was dissected using a harmonic scalpel.

13.  In the first group
Appendix base was secured using a total of three
vicryl endoloops (two loops on the appendix
base and one on the distal part which would be
removed).

14.  In the second group
Three Hem-o-lok clips were used to secure the appendix
base (two clips on the appendix base and on the distal
part of the appendix)

15.  In the third group
The 10-mm port in a suprapubic region was
changed for a 12-mm port and the appendix base
was dissected by means of a 45 mm stapling device

16. Results

17.  Mean age of study patients was 35.8 ± 16.9 years
 103 (57.2%) women and 77 (42.8%) men
 Mean BMI was 25.7 ± 4.2 kg/m2

19.  Mean operative time was 42.0 ± 13.0 min [ shortest with
hem-o-lok subgroup of patients (37.9 ± 12.5 min)]
 Mean length of hospital stay (3.6 ± 1.7 days)
 7 (11.7%) intraoperative complications in the stapler subgroup
(bleeding from the stapler line)
 No intraoperative complications were noted in the endoloop and
hem-o-lok subgroups.
 postoperative complications was manifested in 6.1%(11 patients)
• 8 Superficial SSI
• 3 Deep SSI

21. Highest costs- Stapler
Lowest costs- Hem-o- lok

22. Discussion
 L-APPE presents the preferred surgical technique for the
treatment of acute appendicitis
 Advantages are-
 better exploration of the abdominal/pelvic cavity
 reduced surgical trauma
 faster recovery rates
 faster recovery rates
 better cosmetic results

23.  All L-APPE were performed by certified laparoscopic
surgeons(experienced in all three techniques of appendix
stump closure) in all the study patients
 There were statistically significant differences in clinical
parameters between our study subgroups
 age
 BMI
 Type of appendicitis
 Patients in the stapler subgroup were older
 Patients in the hem-o-lok subgroup had the highest BMI
 Patients in the stapler subgroup has phlegmonous appendicitis

24.  Postoperative surgical complications after L-APPE was very
low in all the study subgroups,may be due to
 many young patients with minimal co-morbidities
 very minimal surgical trauma during L-APPE
 The technique of appendix stump closure has an impact
on postoperative complications
 endoloop technique-risk of leaving the knot loose
 Appendix stump closure with clips (metal, plastic, absorbable
polymeric) may be limited by
1. diameter of appendix base
2. risk of clip opening and sliding off
 endostapler is more comfortable- but Costly

25. Therefore hem-o-lok clips seem to be a
reasonable solution,as
1. Securing the appendix stump with a minimal risk of sliding off
2. Technically easy
3. Cost-effective
4. Shortest operative time(may be due to uneven distribution of
severe inflammations between the study subgroups.

26. Conclusion
 L-APPE presents a well-established surgical technique in
the treatment of acute appendicitis
 Operative time is significantly longer when the endoloop
is employed for stump closure
 Stapler technique is significantly the most
expensive
 Taking all these facts into account, hem-o-lok clips seem
to have the potential for becoming the preferred method
of securing the appendix base during L-APPE.

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