Influence of the Different Ways of Appendix Stump Closure on Patient Outcome in Laparoscopic Appendectomy
Influence of the Different Ways of Appendix Stump Closure on Patient Outcome in Laparoscopic Appendectomy
During laparoscopic appendectomy, the base of the appendix is usually secured by an endoloop
 ligature or the stapler. Non-absorbable plastic hem-o-lok clip was shown as an alternative
 technique with which laparoscopic appendectomy was done faster and cheaper than the standard
 techniques. However, biocompatibility of different materials udes in securing the base of
 appendix is different. It was observed that stapler's clips made by titanium caused the
 mildest inflammatory reaction and creation of adhesions. Disadvantages of stapler's are their
 high price.

 Titanium clips made for the use in laparoscopic appendectomy are safe and effective option in
 securing the appendicular stump in laparoscopic appendectomy. They have potential advantages
 over stapler, because they have the same bio compatibility, and their price is lower.
Prospective study was conducted in the period from 02. October 2016 to 30. December 2016. The
 patients were randomly divided into four groups; in the first group, the base of the appendix
 was secured using one endoloop ligature, in the second group using the 45-mm stapler, in
 third group using only one non-absorbable Hem-o-lok clip and in fourth group using titanium
 DS clip.

 Patients were assessed for eligibility at the emergency station by the surgeon on-call once
 the diagnosis of acute appendicitis was established. A dedicated study nurse assigned
 randomly to Endoloop (E group) or Stapler (S group), or Hem-o-lock (H group), or DS clip (DS
 group) by picking out of a box and opening a sealed opaque randomization envelope in
 operating theatre. The details of the allocated treatments (''E'' or ''S'', or (''H'' or
 (''Ds'' ) were given on cards contained in sealed opaque envelopes. All sealed opaque
 envelopes were previously prepared with a 1 : 1 ratio, well shuffled, and put into a box by
 the dedicated study nurse. No blinding was performed.

 Data collected included age, gender, surgery time, time of hem-o-lok clip application,
 hospital stay, costs associated with these and intra- and post-operative complications.

 Technique

 The patient was placed in supine position, combined with Trendelenburg position and left
 lateral position (10º - 15º, incline towards the surgeon). The surgeon used the French
 position (between legs of patient) and an assistant stood on the left side, and monitor was
 on the right side of the patient. The bladder was decompressed with the Foley catheter to
 avoid an injury during insertion of the supra-pubic ports. Pneumoperitoneum was established
 with the Veress needle through the umbilicus and then an endoscope was introduced. Under
 direct vision, one 12 mm trocar was inserted in suprapubic region, a little to the left, and
 5 mm trocar in the right lower quadrant, to the level of the first 12 mm port, in order to
 acquire triangulation. After that the abdominal cavity was inspected.

 When the decision was made to perform appendectomy, mesoappendix was mobilized and dissected
 using an harmonic scalpel (Ethicon, Endosurgery, Cincinnati, OH). In the first group, the
 base of the appendix was secured using one endoloop, and on the distal part which would be
 removed, another endoloop was used. In the second group, the appendix was secured by a 45 mm
 stapler (thick charge) (Ethicon, Endosurgery, Cincinnati, OH). In the third group, one
 hem-o-lok clip, size XL (Hem-o-lock, Weck Closure Systems, Research Triangle Park, NC, USA)
 was placed on the base the appendix by a special applier for the hem-o-lok clip, and on the
 distal part which would be removed, another clip was used. In the fourth group, one titanium
 DS clip (Aesculap AG, Tuttlingen, Germany) was placed on the base of appendix by endoscopic
 clip applier (12 mm) and on the distal part which would be removed, another DS clip was used.
Inclusion Criteria:

 -  Patient with accute appendicits

 Exclusion Criteria:

 -  Patient younger than 18 years