This study aimed to compare the clinical outcomes of laparoscopic appendectomy (LA) according to the method of appendiceal stump closure.
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.
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).
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.
In many countries, laparoscopic appendectomy (LA) has become the standard surgical procedure for treating acute appendicitis [
This study was approved by the Institutional Review Board of the Korea Cancer Center Hospital (No. KIRAMS 2021-02-002). The requirement for informed consent was waived by the Korea Cancer Center Hospital Institutional Review Board due to the retrospective nature of the study.
Medical records of patients who underwent LA for acute appendicitis between January 2010 and December 2020 at the Korea Cancer Center Hospital (Seoul, Korea) were reviewed retrospectively. Patients with pathologically confirmed appendicitis who underwent LA using LPC or LL were included in the analysis. The exclusion criteria were (1) open conversion, (2) use of a stapler for stump closure, and (3) presence of appendiceal cancer or neoplasm associated with appendicitis. Finally, 188 and 144 patients who underwent LA with LPC and LL, respectively were included in the analysis. The median follow-up duration was 5 months (range, 0–119 months).
Altogether, 11 surgeons performed LA. Among these, 3 surgeons were non-gastrointestinal (GI) surgeons. The GI surgeons were experts who performed more than 50 cases of laparoscopic operations a year. The non-GI surgeons performed less than 3 cases of laparoscopic operations a year. The number and placement of laparoscopic ports, need for drain insertion during surgery, wound closure method, and appendiceal stump closure method were determined according to the surgeon’s preference. Usually, 2 LPCs (X-large size) or 2 LLs were located on the appendiceal stump, and a 3rd LPC or LL was applied toward the specimen side of the appendix before division of the appendix. Additional suturing was not performed. Mesoappendiceal tissue dissection techniques were left up to the discretion of the surgeon. Monopolar electrocauterization was used in 13 cases of LA, and the remaining cases were performed with ultrasonic energy devices. The exposed appendiceal stump mucosa was electrocauterized. In most of the cases, trainees participated as scopists or assistants and occasionally as operators under the supervision of specialists.
The primary outcome measure was the rate of postoperative complications. The secondary outcome variables were operative time, length of hospital stay after surgery, and readmission within 30 days of surgery due to surgical complications.
The chi-square test or Fisher exact test was used to compare categorical variables and Mann-Whitney U-test was used for continuous data to calculate the associations between defined groups. To identify factors that affected postoperative complications after LA, logistic regression analysis was performed. For multivariate analysis, stepwise backward elimination was applied, and factors with a significance level of < 0.05 or < 0.2 in univariate analysis were selected for further multivariate analysis. All statistical analyses were 2-sided and statistical significance was set at P< 0.05. IBM SPSS Statistics ver. 23.0 (IBM Corp., Armonk, NY, USA) was used for all statistical analyses.
The characteristics of the patients who underwent LA with LPC (n= 188) or LL (n= 144) are presented in
The clinical outcomes after LA with LPC or LL are presented in
In a univariate analysis of risk factors for postoperative complications, only operative time above 60 minutes and the method of appendiceal stump ligation were significant factors. Multivariate analysis also confirmed a meaningful relationship between operative time above 60 minutes and the application of LPC, with postoperative complications (operative time above 60 minutes: hazard ratio [HR], 2.623; 95% confidence interval [CI], 1.283–5.363; P= 0.009; application of LPC: HR, 0.453; 95% CI, 0.243–0.843; P= 0.012) (
In the present study, we observed that the use of LL during LA was associated with a higher rate of total complications than the use of LPC. Among these, intraabdominal abscess is believed to be directly related to the method of appendiceal stump closure. Soll et al. [
Compared to the average operative times of LA with LPC (47.7 minutes; range, 31.1–66 minutes) or LL (54.8 minutes; range, 47–66 minutes) reported in other studies [
There has been a change in the rate of use of LPC and LL for 10 years. The use of LPC increased from 51.0% in the first half to 63.0% in the second half, while the use of LL decreased from 49.0% in the first half to 37.0% in the second half. Since we have never established a consensus on methods of LA, the increase in the use of LPC is thought to have simply increased with the operator’s preference (considering the benefits of ease of use, cost-effectiveness, etc.). The rate of complications in both groups was shown to decrease in the second half of the decade, compared to the first half. This is thought to be the result of improvement in perioperative management. However, the difference in complications between the 2 groups was still significant and there was no change in operating time in both groups, throughout the entire period. Therefore, it appears that the presence of a learning curve due to increased experience was not a substantial influence on these factors.
Reportedly, application of LPC during LA has several advantages over LL. LPC is cheaper than LA [
However, LPC has certain limitations. The maximum internal length of LPC is approximately 13 mm. Thus, it can only be applied if the diameter of the appendix is less than 12 mm [
Delibegović and Mehmedović [
This study has limitations inherent to its retrospective design. However, although this was a single-institution study, surgeons from a variety of branches participated in the surgery. Moreover, the study has strengths such as analysis using detailed variables that can affect postoperative complications.
In conclusion, the use of LPC during LA is expected to result in lower complication rates, lower readmission rates, and shorter operative times than the use of LL. Therefore, LPC might be considered a safer and more efficient closure method than LL during LA for appendicitis.
No potential conflict of interest relevant to this article was reported.
None.
Characteristics of the enrolled patients
Characteristic | Locking polymeric clip group (n=188) | Loop ligature group (n=144) | P-value |
---|---|---|---|
Sex | > 0.999 | ||
Male | 99 (52.7) | 76 (52.8) | |
Female | 89 (47.3) | 68 (47.2) | |
Age (yr) | 40.5 (8–83) | 35.0 (6–83) | 0.305 |
Body mass index (kg/m2) | 23.0 (14.9–35.6) | 22.4 (13.9–38.1) | 0.202 |
Diabetes mellitus | 0.704 | ||
Yes | 16 (8.5) | 14 (9.7) | |
No | 172 (91.5) | 130 (90.3) | |
Hypertension | 0.195 | ||
Yes | 29 (15.4) | 15 (10.4) | |
No | 159 (84.6) | 129 (89.6) | |
Previous history of abdominal surgery | > 0.999 | ||
Yes | 27 (14.4) | 21 (14.6) | |
No | 161 (85.6) | 123 (85.4) | |
ASA PS classification | 0.744 | ||
I | 52 (27.7) | 44 (30.6) | |
II | 125 (66.5) | 90 (62.5) | |
III | 11 (5.9) | 10 (6.9) | |
Complicated appendicitis | |||
Perforated | 25 (13.3) | 19 (13.2) | > 0.999 |
Periappendiceal abscess | 5 (2.7) | 6 (4.2) | 0.541 |
Maximum diameter of appendix (mm) | 10 (5–19) | 11 (5–28) | 0.024 |
Drain insertion during operation | 0.612 | ||
Yes | 21 (11.2) | 19 (13.2) | |
No | 167 (88.8) | 125 (86.8) | |
Operator | 0.038 | ||
Gastrointestinal surgeon | 149 (79.3) | 127 (88.2) | |
Non-gastrointestinal surgeon | 39 (20.7) | 17 (11.8) | |
No. of ports | |||
Single | 68 (36.2) | 30 (20.8) | 0.002 |
Multiple | 120 (63.8) | 114 (79.2) | |
Perioperative use of antibiotics (day) | 3 (1–20) | 4 (1–18) | 0.133 |
Duration of operation (min) | 64.5 (15–144) | 71.5 (23–181) | 0.027 |
Values are presented as number (%) or median (range).
ASA, American Society of Anesthesiologists; PS, physical status.
Postoperative outcomes
Variable | Locking polymeric clip group (n=188) | Loop ligature group (n=144) | P-value |
---|---|---|---|
Total No. of complications | 20 (10.6) | 30 (20.8) | 0.013 |
Enterocolitis | 2 (1.1) | 2 (1.4) | > 0.999 |
Wound complications | 16 (8.5) | 17 (11.8) | 0.357 |
Intraabdominal abscess | 2 (1.1) | 6 (4.2) | 0.082 |
Postoperative ileus | 0 (0) | 4 (2.8) | 0.035 |
Pneumonia | 0 (0) | 1 (0.7) | 0.434 |
Clavien-Dindo classification | 0.502 | ||
I | 1 (0.5) | 2 (1.4) | |
II | 11 (5.9) | 19 (13.2) | |
III | 8 (4.3) | 9 (6.3) | |
Postoperative hospital stay (day) | 3 (2–20) | 4 (0–30) | 0.020 |
Readmission within 30 days of surgery | 2 (1.1) | 9 (6.3) | 0.012 |
Reoperation within 30 days of surgery | 0 (0) | 1 (0.7) | 0.434 |
Values are presented as number (%) or median (range).
Logistic regression analysis for the risk factors of postoperative complications after laparoscopic appendectomy
Variable | Univariate analysis |
Multivariate analysis |
||
---|---|---|---|---|
HR (95% CI) | P-value | HR (95% CI) | P-value | |
Age of > 60 yr | 2.418 (0.832–7.030) | 0.105 | 2.021 (0.681–5.997) | 0.205 |
Female sex | 1.063 (0.581–1.943) | 0.843 | ||
Diabetes mellitus | 1.142 (0.416–3.139) | 0.797 | ||
Hypertension | 1.078 (0.451–2.574) | 0.866 | ||
Complicated appendicitis | 1.755 (0.850–3.627) | 0.129 | 1.467 (0.674–3.190) | 0.334 |
Gastrointestinal surgeon | 0.911 (0.415–2.001) | 0.817 | ||
Previous history of abdominal surgery | 0.957 (0.403–2.272) | 0.920 | ||
Drain insertion during surgery | 1.777 (0.789–4.004) | 0.165 | 1.078 (0.350–3.319) | 0.895 |
Maximum diameter of appendix > 10 mm | 0.805 (0.440–1.471) | 0.481 | ||
Multiport surgery | 2.101 (0.979–4.510) | 0.057 | 1.794 (0.821–3.922) | 0.143 |
Operative time of > 60 min | 2.626 (1.292–5.339) | 0.008 | 2.623 (1.283–5.363) | 0.009 |
Locking polymeric clip | 0.452 (0.245–0.836) | 0.011 | 0.453 (0.243–0.843) | 0.012 |
HR, hazard ratio; CI, confidence interval.