الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Acute appendicitis is the most common indication for emergent abdominal surgery with a life-time incidence between 7% and 9%. Appendectomy through McBurney’s incision become the standard technique for acute appendicitis, outstanding principally unchanged for 100 years because of its proven efficacy and safety [38]. Nowadays, the majority of appendectomies are undertaken laparoscopically, with evidence demonstrating reduced post-operative pain, a lower rate of wound infection, faster recovery and shorter hospital stay when compared with the open procedure. However, the laparoscopic approach is associated with longer procedure times, increased cost and a higher risk of post-operative intra-abdominal abscess formation [39]. Furthermore, appendiceal stump leakage secondary to inadequate stump closure is a recognized complication following laparoscopic appendectomy (LA). Multiple methods of laparoscopic closure of the appendiceal stump have previously been described, including; endoloops (EL), endoclips (both metallic and polymeric clips), linear stapler devices, suture ligation and endocoagulation [39-41]. However, there is no consensus as to the optimal method of appendiceal stump closure. Current literature suggests the relative advantages and disadvantages of such methods in securing the appendiceal stump[41]. The current study was conducted to compare between Non absorbable polymeric clips and endoloop ligatures in securing appendicular stump in laparoscopic appendicectomy The study enrolled 48 patients with clinical, laboratory and radiological evidences of acute appendicitis. Those patients were randomly subdivided into two groups based on method of appendiceal stump closure either non absorbable polymeric clips group or endoloop ligatures group. Our study revealed that both groups insignificant differences as regard baseline demographics and clinical and laboratory data. In line with the current study, Colak et al. (2013) found that there no significant differences in the sex and mean age of 2 groups. Preoperative co morbidities according to American Society of Anesthesiology class were also similar in both groups [42]. The main finding in the current results was that mean operative time was significantly longer among those patients who underwent endoloop ligatures (60.29 ± 4.42 vs. 54.62 ± 4.12 (minute); p< 0.001). This was in line with previously published mat analysis that revealed total operative time for endo-loop group was longer than the other group [43]. Also, Colak et al. (2013) found that the mean operation time were shorter in non-absorbable polymeric clips group than endoloop group (64.7±19.2 vs. 75.4±23, respectively); however, the difference was not significant (P=0.072) [42]. Also, Lasek et al. (2020) stated similar conclusion [44]. Our study found that both groups had insignificant difference as regard hospital stay (1.16 ± 0.38 vs. 1.08 ± 0.28 (day); p= 0.39). Wound infection occurred in three patients of group A(one patient had suprapubic port infection, one patient had infra umbilical port infection the third had two port site infection(suprapubic and infra umbilical) and two patients of group B(one patient had infra umbilical port infection and one patient had infraumbilical and left lower qudrant port infection). abdominal collection was found in only patient of group B. One patient in each group had port site bleeding and two patients in each group had paralytic ileus. All these complications showed no significant differences between both groups. Also, these complications were conservatively managed. In line with the current, Lasek et al. (2020) found that both groups had comparable hospital and major complication rates, postoperative intraabdominal abscess formation, reintervention rates and readmission rates were found [44]. Also, previous study Colak et al.(2013), found that no significant differences were found between 2 methods in clinical parameters including operation time, postoperative complication rate, and hospitalization time. The most significant postoperative complication was periappendicular abscess which developed in a single patient from the endoloop group. But, it is impossible to say whether it was caused by continuing local peritonitis or by leakage of the stump since the patient had perforated appendicitis [42]. Among the 277 patients included in previous study Pogorelic et al. (2017), there were no cases of intraoperative complications. There were 17 (6.1%) postoperative complications. There were 5 (1.8%) wound infections (3 in the polymeric clips group, 2 in the loop group), 5 (1.8%) intra-abdominal abscesses (2 in the polymeric clips group, 3 in the loop group) and 1 (0.3%) case of trocar site bleeding (in the polymeric clips group). There were no significant differences between the groups regarding the postoperative complications [45]. Sajid et al. (2009) found that there was statistically no difference in total hospital stay between both groups but patients who were underwent endoloop closure were associated with higher frequency of postoperative complications. But the authors concluded that incidence of intra-abdominal abscess formation in both groups is same based on this review, which may be an early evidence in favor of endo-loop to secure the appendicular stump [43]. Also, Knight et al. (2019) found that post-operative complication rates were similar across all stump closure methods. The incidence of post-operative peritonitis and intra-abdominal collection was low, with only 4 cases identified across 702 patients. It is likely that inadequate stump closure would manifest as either of these two complications. Furthermore, the degree of appendix inflammation and adequacy of laparoscopic washout was not adequately controlled for in the majority of included studies [38]. However, it is still unclear whether endo-loop is definitely effective, and for all stages and types of appendicitis and whether 1 or 2 endo-loops are required to secure stump effectively. In a randomized controlled trial, in patients with difficult preparation or advanced appendicitis endoloop has been found as a safe and effective technique [46]. In another randomized controlled trial, acute appendicitis with minimal inflamed appendix base can be safely divided using endo-loop [47]. Therefore, based on available evidence endo-loop cannot be recommended for every case of LA but an alternative to other techniques to secure the appendicular stump [44]. Regarding cost, the current study found that mean cost was significantly lower in endoloop group in comparison to other group (25.56 ± 5.32 vs. 110.45 ± 22.34 (LE); p < 0.001). Many studies pointed an advantage of nonabsorbable polymeric clips but higher cost than other products that are generally used for closure of appendiceal stump [42, 48, 49]. These study had several limitations as 1) relatively small sample size, 2) single center study, and 3) we didn’t compare between different surgical findings as regarding outcomes in form of operative time, complications and cost but here, the main aim our study was to compare between both techniques not surgical findings. At the same time, the patients in the current study were prospectively enrolled and randomly subgroups and hence, no selection bias could be predicted in our study. Laparoscopic appendectomy has gained increasing acceptance in the surgical community. Because this procedure has been proven to be safe and effective so it has been included in the guidelines for the treatment of acute appendicitis as first choice. Possible drawbacks of the laparoscopic technique are the increased treatment costs and a slightly increased rate of intra-abdominal abscesses. The technique of appendiceal stump closure is thought to influence the incidence of postoperative infectious complications
Closure of the appendiceal stump is a key step performed during laparoscopic appendicectomy. Inadequate management of the appendiceal stump has the potential to cause significant morbidity. Several methods of stump closure have been described, however high-level evidence is limited.
The current was conducted over two years’ duration and enrolled 48 patients with acute appendicitis. Those patients were randomly subdivided into two groups based on method of appendiceal stump closure either non
absorbable polymeric clips group or endoloop ligatures group. It was found that both groups had insignificant differences as regard different data of patients included age, sex, laboratory data, operative data and post-operative complication. But mean operative time was significantly longer among those patients who underwent endoloop ligatures (60.29 ± 4.42 vs. 54.62 ± 4.12 (minute); p< 0.001). Regarding cost, the current study found that mean cost was significantly higher in group non-absorbable polymeric clips in comparison to group endoloop ligatures. In conclusion based on the current although both procedures had a comparable result, but non-absorbable polymeric clips had shorter operative time but more cost. However, a major multicenter randomized controlled trial is required to produce reliable and high-quality evidence. Moreover, it would have been interesting to document the main criteria for the individual decision to use one or the other method on a case by case basis