Determining the optimal method of securely closing the base of the appendix during keyhole surgery after removal of the inflamed appendix

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Appendicitis is an Inflammation of the appendix. The conventional treatment for this condition involves an operation to remove the appendix, called an appendectomy. In recent years, this operation has been increasingly performed as keyhole surgery – laparoscopic appendectomy. For removal of the appendix during laparoscopic appendectomy, the best method of closing the remaining appendix stump to avoid leakage of bowel contents is unclear. Traditional approaches have involved ligatures and knots. However, in recent years, some surgeons have elected to use automated mechanical devices rather than ligatures, and it is unclear whether these devices reduce complications during laparoscopic appendectomy when compared with ligatures.

Study characteristics

We searched for all relevant randomised controlled trials up to 14 June 2017. This systematic review included eight randomised controlled trials involving a total of 850 participants. All trials compared mechanical devices versus ligatures for appendix stump closure. Five of the eight trials compared use of clips versus ligature, two trials compared an automated stapler versus ligature, and one trial compared all three methods.

Key results

Use of mechanical devices to close the appendix stump during laparoscopic appendectomy did not make a significant difference in the rate of overall complications when compared with use of a ligature, or in the rate of complications that happened during or after the appendectomy procedure. However, mechanical devices did make the operation nine minutes quicker when compared with ligatures. Mechanical devices did not make a substantial difference in overall hospital stay. We did not have enough information to reliably evaluate hospital costs, pain, or quality of life for either of these comparisons. As a result, we have not found enough evidence at present that would lead us to strongly recommend any particular method over another. More research should be undertaken to better compare available newer methods.

Quality of the evidence

The evidence used to derive our conclusions was generally of low quality. The studies we included for each analysis were vulnerable to different types of bias and contained inconsistencies and imprecision in their results due to small numbers of participants and events in each included study arm. It is likely that future research will substantially change our conclusions; further studies in this field are needed.