While the Laparoscopic Appendectomy Is the Gold Standard in the Treatment of Acute Appendicitis, What Should Be the Preference for Closure of the Appendix Stump?

Abstract

Aim: While laparoscopic appendectomy is the gold standard in the treatment of acute appendicitis, there is no consensus on reliable closure of the appendix stump. The aim of this study was to examine appendiceal stump closure techniques and their reliability during laparoscopic appendectomy. Material and Methods: Between January 2019 and August 2021, 692 patients who underwent laparoscopic appendectomy with the diagnosis of acute appendicitis were included in the study. Demographic characteristics, length of hospital stay, pathology, appendix stump closure methods, operation time, complications, and cost results were analyzed retrospectively. Results: Intracorporeal knotting (ICK) was used in 66.9% (n=463), and endoclip (EC) was used in 33.1% (n=229) of the patients. There was no statistically significant difference between the two groups in terms of length of hospital stay (p=0.054). While the mean operative time was 55.1±15.6 minutes in the ICK group, it was 45.7±16.5 minutes in the EC group (p<0.001). The general complication rate was 1.7% (n=12). While the complication rate was 2.2% (n=10) in ICK group, it was 0.9% (n=2) in EC group (p=0.354). While pericecal hematoma and ileus were seen only in the ICK group, the fistula was seen only in the EC group. EC was found to be more costly than ICK (p<0.001). Conclusion: It was concluded that closure of the appendix stump with an EC in patients who underwent laparoscopic appendectomy is more useful, regardless of the severity of appendicitis, with a shorter operation time and shorter length of hospital stay, low complication rate, and ease of application.

Keywords

• Appendectomy
• Laparoscopic surgery
• Postoperative Complications

Akut Apandisit Tedavisinde Laparoskopik Apendektomi Altın Standart Olurken, Apendiks Kökünün Kapatılmasında Tercih Ne Olmalı?

Abstract

Amaç: Akut apandisit tedavisinde laparoskopik apendektomi altın standart olurken, apendiks kökünün güvenilir bir şekilde kapatılması konusunda ise bir fikir birliği yoktur. Bu çalışmanın amacı laparoskopik apendektomi sırasında apendiks güdüğü kapatma tekniklerinin ve bu tekniklerin güvenilirliğinin incelenmesidir. Gereç ve Yöntemler: Ocak 2019 ile Ağustos 2021 tarihleri arasında, akut apandisit tanısı ile laparoskopik apendektomi yapılmış olan 692 hasta bu çalışmaya dahil edildi. Demografik özellikler, hastanede kalış süresi, patoloji, apendiks kök kapatma yöntemleri, ameliyat süresi, komplikasyonlar ve maliyet sonuçları geriye dönük olarak analiz edildi. Bulgular: Hastaların %66,9’unda (n=463) intrakorporeal düğümleme (intracorporeal knotting, ICK) yapılırken, %33,1’inde (n=229) ise endoklip (endoclip, EC) uygulandı. Hastanede kalış süresi bakımından iki grup arasında istatistiksel olarak anlamlı bir farklılık yoktu (p=0,054). Ortalama ameliyat süresi ICK grubunda 55,1±15,6 dakika iken, EC grubunda ise 45,7±16,5 dakika idi (p<0,001). Genel komplikasyon oranı %1,7 (n=12) idi. Komplikasyon oranı ICK grubunda %2,2 (n=10) iken, EC grubunda ise %0,9 (n=2) idi (p=0,354). Periçekal hematom ve ileus sadece ICK grubunda görülürken, fistül ise sadece EC grubunda görüldü. EC, ICK’ye göre daha maliyetli olarak bulundu (p<0,001). Sonuç: Apandisit şiddeti ne olursa olsun, laparoskopik apendektomi yapılan hastalarda apendiks kökünün EC ile kapatılmasının, daha kısa ameliyat süresi ve daha kısa hastanede kalış süresi, düşük komplikasyon oranı ve uygulama kolaylığı ile daha faydalı olduğu sonucuna ulaşılmıştır.

Keywords

• Apendektomi
• laparoskopik Cerrahi
• postoperatif komplikasyonlar

References

1. Snyder MJ, Guthrie M, Cagle S. Acute appendicitis: Efficient diagnosis and management. Am Fam Physician. 2018;98(1):25-33.
2. Karakaş DÖ, Yeşiltaş M, Gökçek B, Eğin S, Hot S. Is language disability a risk factor for complicated appendicitis? A retrospective cohort study. J Surg Med. 2020;4(8):631-5.
3. Wagner M, Tubre DJ, Asensio JA. Evolution and current trends in the management of acute appendicitis. Surg Clin North Am. 2018;98(5):1005-23.
4. 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;57:228-35.
5. Lucchi A, Berti P, Grassia M, Siani LM, Gabbianelli C, Garulli G. Laparoscopic appendectomy: Hem-o-lok versus Endoloop in stump closure. Updates Surg. 2017;69(1):61-5.
6. Mayir B, Ensari CÖ, Bilecik T, Aslaner A, Oruç MT. Methods for closure of appendix stump during laparoscopic appendectomy procedure. Ulus Cerrahi Derg. 2015;31(4):229-31.
7. Durán Muñoz-Cruzado V, Anguiano-Diaz G, Tallón Aguilar L, Tinoco González J, Sánchez Arteaga A, Aparicio Sánchez D, et al. Is the use of endoloops safe and efficient for the closure of the appendicular stump in complicated and uncomplicated acute appendicitis? Langenbecks Arch Surg. 2021;406(5):1581-9.
8. Lasek A, Wysocki M, Mavrikis J, Myśliwiec P, Bobowicz M, Dowgiałło-Wnukiewicz N, et al. Comparison of stump closure techniques during laparoscopic appendectomies for complicated appendicitis - results from Pol-LA (Polish laparoscopic appendectomy) multicenter large cohort study. Acta Chir Belg. 2020;120(2):116-23.

9. Lippert H, Koch A, Marusch F, Wolff S, Gastinger I. [Open vs. laparoscopic appendectomy]. Chirurg. 2002;73(8):791-8. German.
10. Ates M, Dirican A, Ince V, Ara C, Isik B, Yilmaz S. Comparison of intracorporeal knot-tying suture (polyglactin) and titanium endoclips in laparoscopic appendiceal stump closure: a prospective randomized study. Surg Laparosc Endosc Percutan Tech. 2012;22(3):226-31.
11. Gonenc M, Gemici E, Kalayci MU, Karabulut M, Turhan AN, Alis H. Intracorporeal knotting versus metal endoclip application for the closure of the appendiceal stump during laparoscopic appendectomy in uncomplicated appendicitis. J Laparoendosc Adv Surg Tech A. 2012;22(3):231-5.
12. Bali İ, Karateke F, Özyazıcı S, Kuvvetli A, Oruç C, Menekşe E, et al. Comparison of intracorporeal knotting and endoloop for stump closure in laparoscopic appendectomy. Ulus Travma Acil Cerrahi Derg. 2015;21(6):446-9.