Comparison of three techniques for appendiceal stump closure during laparoscopy



acute appendicitis, laparoscopic appendectomy, laparoscopic purse string, Hem-o-lok clip


Aim: Laparoscopic appendectomy is the gold standard treatment of acute appendicitis. However, there is no consensus about the technique to apply when closing the appendix stump. This study compares three techniques to close the appendix stump: Laparoscopic purse-string suture (LPS), metal clips, and Hem-o-lok clips. The aim is to evaluate the advantages, safety, and costs of these three methods. Methods: We conducted a retrospective cohort study which included 220 patients who underwent laparoscopic appendectomy operations for acute appendicitis between May 2017 and December 2019. The cases were divided into three groups and evaluated. Group A received LPS, group B received metal clips, and group C received Hem-o-lok clips. The demographic features of the patients, American Society of Anesthesiology (ASA) scores, duration of surgery, postoperative complications, hospital stay, and cost were evaluated retrospectively from patient files. Results: There were 79 patients in group A, 91 patients in group B, and 50 patients in group C. There was no difference between the groups with respect to demographic features, ASA physiological state scores, and laboratuary values. The operation time and postoperative complication rates did not differ between groups (P>0.05). Group C had longer hospital stays (P=0.001), and group A had lower costs (P=0.001). Conclusion: In the laparoscopic appendectomy technique, the use of LPS for appendix stump closure is safe and effective. Furthermore, technical consumables and hospital treatment costs are significantly reduced.


Download data is not yet available.


Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2010;4;10:CD001546.

Pedersen AG, Petersen OB, Wara P, Rønning H, Qvist N, Laurberg S. Randomized clinical trial of laparoscopic versus open appendicectomy. Br J Surg. 2001;88:200-5.

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;22:226-31.

Sahm M, Kube R, Schmidt S, Ritter C, Pross M, Lippert H. Current analysis of endoloops in appendiceal stump closure. Surg Endosc. 2011;25:124-9.

Safavi A, Langer M, Skarsgard ED. Endoloop versus endostapler closure of appendiceal stump in pediatric laparoscopic appendectomy. Can J Surg. 2012;55:37-40.

Rickert A, Bönninghoff R, Post S, Walz M, Runkel N, Kienle P. Appendix stump closure with titanium clips in laparoscopic appendectomy. Langenbecks Arch Surg. 2012;397:327-31.

Delibegovic S, Matovic E. Hem-o-lok plastic clips in securing of the base of the appendix during laparoscopic appendectomy. Surg Endosc. 2009;23:2851-4.

Martín del Olmo JC, Blanco Alvarez JI, Carbajo Caballero MA, de la Cuesta de la Llave C, Vaquero Puerta C, Arenal J. Laparoscopic appendectomy by ultrasonically activated scalpel in acute appendicitis: preliminary report. J Laparoendosc Adv Surg Tech A. 2002;12:111-3.

Suttie SA, Seth S, Driver CP, Mahomed AA. Outcome after intra- and extra-corporeal laparoscopic appendectomy techniques. Surg Endosc. 2004;18:1123-5.

Knight SR, Ibrahim A, Makaram N, Patil P, Wilson MSJ. The use of polymeric clips in securing the appendiceal stump during laparoscopic appendicectomy: a systematic review. Eur J Trauma Emerg Surg. 2019;45:665-70.

Al-Temimi MH, Berglin MA, Kim EG, Tessier DJ, Johna SD. Endostapler versus Hem-O-Lok clip to secure the appendiceal stump and mesoappendix during laparoscopic appendectomy. Am J Surg. 2017;214:1143-8.

Colak E, Kement M, Ozlem N, Mutlu T, Yildirim K, Gurer A, et al. A comparison of nonabsorbable polymeric clips and endoloop ligatures for the closure of the appendicular stump in laparoscopic appendectomy: a prospective, randomized study. Surg Laparosc Endosc Percutan Tech. 2013;23:255-8.

Varghese G. Feasibility and efficacy of using Hem-o-lok polymeric clips in appendicular stump closure in laparoscopic appendectomy. Cureus 2018;10(6):e2871.

Graham CW, Komidar L, Perger L. Comparison of polymeric clips and endoscopic staplers for laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A. 2019;29:240-2.

Kliuchanok K, Keßler W, Partecke I, Walschus U, Schulze T, Heidecke CD, et al. A comparison of non-absorbable polymeric clips and staplers for laparoscopic appendiceal stump closure: analysis of 618 adult patients. Langenbecks Arch Surg. 2019;404:711-6.

Gomes CA, Junior CS, de Peixoto RO, Netto JM, Gomes CC, Gomes FC. Appendiceal stump closure by metal endoclip in the management of complicated acute appendicitis. World J Emerg Surg. 2013;18;8:35.

Shadhu K, Ramlagun D, Wang Y, Ping X, Chen T, Zhu Y, et al. Re-evaluation of purse string suture in laparoscopic appendectomy. Surg Endosc. 2020;34:779-86.

Pokala N, Sadhasivam S, Kiran RP, Parithivel V. Complicated appendicitiseis the laparoscopic approach appropriate? A comparative study with the open approach: outcome in a community hospital setting. Am Surg. 2007;73;737-41.

Pirro N, Berdah SV. Appendicitis: yes or no to laparoscopic approach? J Chir (Paris). 2006;143:155-9.

Kouwenhoven EA, Repelaer van Driel OJ, van Erp WF. Fear for the intraabdominal abscess after laparoscopic appendectomy: not realistic. Surg. Endosc. 2005;19:923-6.

Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg. 2005;242:439-48.

Biondi A, Di Stefano C, Ferrara F, Bellia A, Vacante M, Piazza L. Laparoscopic versus open appendectomy: a retrospective cohort study assessing outcomes and cost-effectiveness. World J Emerg Surg. 2016;30;11:44.

Çalışkan Y. Original Alvarado scoring system in the diagnosis of acute appendicitis: A cohort study. J Surg Med. 2017;1:28-31.

Wagner M, Aronsky D, Tschudi J, Metzger A, Klaiber C. Laparoscopic stapler appendectomy. A prospective study of 267 consecutive cases. Surg Endosc. 1996;10:895-9.

van Rossem CC, van Geloven AA, Schreinemacher MH, Bemelman WA. Endoloops or endostapler use in laparoscopic appendectomy for acute uncomplicated and complicated appendicitis: No difference in infectious complications. Surg Endosc. 2017;3:178-84.

Gunes ME, Gemici E, Donmez T. Comparison of Laparoscopic Embedding Technique and Other Techniques for Appendiceal Stump Closure. Turk J Colorectal Dis. 2019;29:121-6.

Delibegović S, Mehmedovic Z. The influence of the different forms of appendix base closure on patient outcome in laparoscopic appendectomy: a randomized trial. Surg Endosc. 2018 ;32:2295-9.

Mannu GS, Sudul MK, Bettencourt-Silva JH, Cumber E, Li F, Clark AB, et al. Closure methods of the appendix stump for complications during laparoscopic appendectomy. Cochrane Database Syst Rev. 2017 Nov 13;11:CD006437.

Markides G, Subar D, Riyad K. Laparoscopic Versus Open Appendectomy in adults with Complicated Appendicitis: Systematic Review and Metaanalysis. World J Surg. 2010;34:2026-40.

Śmigielski J, Piskorz Ł, Koptas W. Comparison of treatment costs of laparoscopic and open surgery. Videosurgery and Other Miniinvasive Techniques 2015;10:437-41.






Research Article

How to Cite

Gemici E, Dönmez T, Sürek A, Abdullayev S, Aydın H, Bozkurt MA, Karabulut M. Comparison of three techniques for appendiceal stump closure during laparoscopy. J Surg Med [Internet]. 2020 Aug. 1 [cited 2024 Jun. 23];4(8):618-22. Available from: