Clip Versus Ligature of The Appendicular Stump in Laparoscopic Appendectomy

DISCUSSION

Approximately 6% of the population develop appendicitis in their life time, with peak incidence between the ages of 10 and 30 years, thus making appendectomy the most frequently performed abdominal operation⁹

In our study total number of patients is forty (40) patients in which we use clips with 20 patients and ligature for 20 patients

Clipping and intracorporeal ligation are compared in this randomized, prospective trial for difficulty, safety, and operation time

For patients with acute appendicitis, laparoscopic appendectomy is now the standard treatment.¹⁰However, laparoscopic appendectomy is associated with a shorter hospital stay and probably with a quicker return to work, but the surgery duration for laparoscopic appendectomy is greater. ¹¹

Closing the appendix stump in laparoscopy should be as straightforward as possible from a technical standpoint, while also being safe, readily available, dependable, and requiring less time during procedure and lower money costs. ¹²

Laparoscopic appendectomy relies heavily on the proper closure of the appendicular stump. Techniques for laparoscopic appendix stump closure might vary widely. These include endostaplers, endoloops closure of the appendiceal stump by means of intracorporeal clipping and meta clip. Laparoscopic appendiceal stump closure is safe and rapid with the use of previously stated items, according to numerous researches. However, the use of endoloops and endostaplers necessitates an advanced degree of laparoscopic expertise that is not available in all facilities.⁸

A study was carried out by Gomes and his colleagues. A total of 131 patients who underwent laparoscopic appendectomy for severe acute appendicitis between January 2011 and January 2013 were studied. Metal endoclips were used to close 118 of those appendicular stumps. From the age of 12 to 75 (31.7±13.3), 52.7 percent of patients were men .¹³

An appendix that is gangrenous and/or perforated is considered to have complicated appendicitis. Abcesses and degrees of peritonitis can occur as a result. Evaluation of the procedure was based on its feasibility, operating time, infection, complication, and conversion rates.

Using a metal endoclip to close the appendicular stump was employed in 90% of the cases studied. It was necrosis of the appendix base that was the most significant element in the procedure's failure. These options included laparoscopic intra corporeal ligation (1.5 percent), laparoscopic knotting (3.8 percent), and video-assisted laparotomy (4.7 percent).

67.54 ±28.13 minutes was the average operating time. The wound infection rate was 2.54 percent, while the intra-abdominal infection rate was 5.08 percent. Only 0.85 percent of patients who underwent surgery experienced problems.

Clipping and intracorporeal ligation are compared in this randomized, prospective trial for difficulty, safety, and operation time.

In our study There was highly statistical significant (p-value < 0.001) decreased operative time in group A (43.2 ± 5.8, Range = 35 - 55 min) when compared with group B (54.3 ± 4.9, Range = 45 - 55 min). there was highly statistical significant (p-value < 0.001) decreased post-operative hospital stay in group A (12.3 ± 2.5, Range = 8 - 20 hours) when compared with group B (17.5 ± 3.1, Range = 10 - 25 hours).

In our study there is no statistically significant difference (p-value > 0.05) between the analyzed groups when it comes to baseline condition.

In our study Clinical (symptom duration and body temperature) and laboratory data (p-value > 0.05) demonstrate no statistically significant differences between the studied groups (TLC & neutrophils).

 In our study statistically significant difference (p-value 0.05) in post-operative complications between the tested groups. Ileus and port site infection occurred in only three cases (15 percent) in group B. n a study by Hansen and his colleagues, the incidence of port site infection was 2% which was lower than our study. Simply this can be attributed to endobags used in Hansen study. No doubt, the use of commercially available endobag will decrease the possibility of port site infection but its cost is the main obstacle for its routine use. The formation of endobag from sterilized glove is a good alternative with lower cost ¹⁴

According to a study by Kiudelis and colleagues, intracorporeal ligation is safe and less expensive than the endoloop approach. ¹⁵ Because end loops are six to twelve times less expensive than laparoscopic staplers, they have an advantage in our study since no major complications occurred during intra-corporeal ligation, and the cost of ligation is less because we only used one polyglactin ampoule, which might be used to close the port site as well in many cases, Furthermore, intra-corporeal ligation can be used in any situation¹⁶

In line with previous research by Ates et al.¹⁷, we found that metallic clips were effective in closing the appendicular stump.

ommercially available titanium and absorbable clip can sustain a high degree of intraluminal pressure and cannot be displaced by a pressure of 300mmHg, and are lower in cost, their use is acceptable for securing the appendicular stump like the cystic duct ¹⁸

all patients followed-up for 6 months postoperatively and were subjected to: History taking. Clinical examination including PR and PV. Laboratory investigations: CBC. Na and K in  markedly dehydrated patients.

In laparoscopic appendectomy, the two approaches of clip application and ligature are successful in securing the appendicular stump. We choose ligation over clipping in large, hard, and friable appendiceal stumps because of our growing expertise in ligation.

Clip application is associated with shorter operative times, easier application, and less difficulty for trainees than ligation procedures, that require a lot of experience.

CONCLUSION

The appendicular stump was held in place using ligation and clipping procedures, which were both safe, successful with low serious outcomes. The use of clips saves time during surgery, is quicker to apply, and is simpler for trainees to learn than ligation techniques, which necessitate previous expertise with a huge, hard, and friable appendiceal stump.