A comparison of absorbable polymetric clips and metallic clips in laparoscopic appendectomy

Ting-Yuan Feng; Sheng-Chun Wang; Guo-Shiou Liao; Teng-Wei Chen; De-Chuan Chan; Kuo-Feng Hsu

doi:10.4103/jmedsci.jmedsci_372_21

ORIGINAL ARTICLE

Year : 2023 | Volume : 43 | Issue : 2 | Page : 63-66

A comparison of absorbable polymetric clips and metallic clips in laparoscopic appendectomy

Ting-Yuan Feng¹, Sheng-Chun Wang¹, Guo-Shiou Liao², Teng-Wei Chen², De-Chuan Chan², Kuo-Feng Hsu²
¹ Division of General Surgery, Department of Surgery, Cardinal Tien Hospital; Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
² Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Date of Submission	25-Dec-2021
Date of Decision	18-Mar-2022
Date of Acceptance	24-Mar-2022
Date of Web Publication	12-May-2022

Correspondence Address:
Dr. Kuo-Feng Hsu
Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist., Taipei 114
Taiwan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmedsci.jmedsci_372_21

Abstract

Background: Laparoscopic appendectomy is the most common emergent surgery, and various techniques were used for the closure of appendicular stump and appendiceal artery. Aim: This study aimed to compare the clinical impacts of absorbable polymeric clips and traditional metallic clips. Methods: We reviewed the laparoscopic appendectomies performed from June 2020 to May 2021 in a medical center. We analyzed the characteristics and intraoperative and postoperative data of patients receiving absorbable or metallic clips during laparoscopic appendectomy. Results: A total of 120 patients were enrolled in this study. Fifty-nine patients received lapro-clips for the ligation of appendicular stump and artery (Group A), whereas 61 patients received titanium clips (Group B). The operative time for both groups was 63.6 ± 18.9 min and 65.5 ± 19.2 min, respectively (P ɢ.586). There was no significant difference in postoperative complications (P = 0.958). The length of hospital stay for each group was 3.07 ± 1.14 days and 2.90 ± 1.18 days, respectively (P = 0.435). Conclusion: The application of absorbable polymetric clips is feasible and safe with the additional benefit of leaving no foreign body for the closure of appendicular stump and ligation of appendiceal artery for laparoscopic appendectomy.

Keywords: Acute appendicitis, appendiceal stump closure, ligation of artery, absorbable clip, metallic clip

How to cite this article:
Feng TY, Wang SC, Liao GS, Chen TW, Chan DC, Hsu KF. A comparison of absorbable polymetric clips and metallic clips in laparoscopic appendectomy. J Med Sci 2023;43:63-6

How to cite this URL:
Feng TY, Wang SC, Liao GS, Chen TW, Chan DC, Hsu KF. A comparison of absorbable polymetric clips and metallic clips in laparoscopic appendectomy. J Med Sci [serial online] 2023 [cited 2023 Dec 6];43:63-6. Available from: https://www.jmedscindmc.com/text.asp?2023/43/2/63/345199

Introduction

Appendicitis is the most common disease that requires urgent surgical intervention. It is estimated that 300,000 appendectomies were performed annually in the United States.^[1] Laparoscopic approach gradually becomes the gold standard method for acute appendicitis.^[2] In the past decades, many studies have proven that laparoscopic appendectomy (LA) is safer and more feasible compared to the traditional open surgery.^[3],[4],[5] LA reduces the surgical time, hospital stay, postoperative pain, and complication rates. Various techniques were used and investigated for the closure of the appendicular stumps because this is the most crucial step in LAs.^{[6],[7],[8],[9]} Absorbable polymetric clips were invented and used in various surgical fields in the past few years. Using polymetric clips for the closure of appendicular stump and ligation of appendiceal artery is a relatively new technique. Hence, a single-center, retrospective study was performed to evaluate the feasibility and safety of using absorbable clips for LA.

Materials and Methods

Study design

This study was approved by the Ethics Committee (TSGHIRB No.: B202105118). Patients diagnosed with acute appendicitis were enrolled. Interval appendectomy, pelvic inflammatory disease-related appendicitis, and appendiceal neoplasm were excluded in this study. The patients were divided into two groups. Group A received 12-mm absorbable polymetric clips (Lapro-Clip^™, Medtronic, Minneapolis, Minnesota, US) for appendicular stump and 8-mm ones for appendiceal artery. Group B received titanium clips (Endo Clip^™, Medtronic, Minneapolis, Minnesota, US). The primary outcome measures were operative time, intraoperative complications, postoperative complications, pathological diagnosis, and hospital stay length. Intraoperative complications were defined as injury to adjacent organs and severe bleeding. Postoperative complications included surgical site infections, postoperative bleeding that requires a second operation, and postoperative ileus that requires prolonged hospital stay, conservative treatment, and intra-abdominal abscess formation. All complications were further categorized using the Clavien‒Dindo classification. The final pathology diagnosis was divided into three subgroups: acute appendicitis, acute suppurative appendicitis, and acute gangrenous appendicitis. All clinical data were collected from a physician who did not participate in the surgery or care of the patients.

Statistical analysis

Statistical analyses were performed using the SPSS version 22.0 software (IBM, Armonk, NY, USA) by a statistical expert who was not in contact with the patients. The variables between the two groups were compared using unpaired t -test, Fisher's exact test, and Mann–Whitney U test. Continuous variables are presented as mean ± standard deviation. A two-tailed P < 0.05 was considered statistically significant.

Results

A total of 120 LAs were performed. Fifty-nine patients received absorbable clips (Group A), whereas 61 patients received metallic clips (Group B). The patient's characteristics were similar with regard to their age, gender, body mass index, and the American Society of Anesthesiologists classification [Table 1]. The severity of the disease was accessed by the initial laboratory data of white blood count (WBC) and C-reactive protein (CRP). The mean WBC was 12.53 ± 4.15 × 10³/μL for Group A and 12.43 ± 3.90 × 10³/μL for Group B (P = 0.886). The CRP level in Group A was 2.67 ± 4.41 mg/dL, whereas that in Group B was 3.68 ± 6.12 mg/dL (P = 0.311). Both data showed no significant difference in patient selections.

Table 1: Clinical features of patients undergoing laparoscopic appendectomy (Group A: Lapro-clip; Group B: Titanium clip)

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The operative time for both groups was similar (63.6 ± 18.9 min and 65.5 ± 19.2 min, respectively; P = 0.586). None of the patients had severe intraoperative complications. However, three patients from Group A and four patients from Group B had postoperative complications. Two patients developed intra-abdominal abscesses that required prolonged drainage and longer hospital stay. One patient from Group A and two patients from Group B developed postoperative ileus and required prolonged fasting and parenteral nutrition. One patient from each group developed surgical site infection and required further wound care during outpatient follow-up. None of these patients were rehospitalized for severe postoperative adverse effects. The overall postoperative complication rates were not significantly different (P = 0.958). The final pathology results discovered 62 acute appendicitis (34 in Group A vs. 28 in Group B), 47 acute suppurative appendicitis (19 in Group A vs. 28 in Group B), and 11 acute gangrenous appendicitis (six in Group A vs. five in Group B) (P = 0.307). It revealed that the severity in each group was comparable. The length of hospital stay for each group was 3.07 ± 1.14 days and 2.90 ± 1.18 days, respectively (P = 0.435), which demonstrated no significant difference. The perioperative and postoperative data are shown in [Table 2].

Table 2: Intraoperative and postoperative data of undergoing laparoscopic appendectomy (Group A: Lapro-clip; Group B: Titanium clip)

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Discussion

The closure of appendicular stump and ligation of appendiceal artery are the most important steps in LAs. Various techniques for mesoappendix dissection and appendiceal artery ligation were purposed. These include endoclip, electrocautery, Harmonic scalpel, and LigaSure energy device.^[10] Harmonic scalpel and LigaSure energy devices ensure vessel sealing when used for vessels under 7 mm in diameter.^[11],[12] It is fast and feasible in the dissection of mesoappendix; however, the expenses needed to use energy devices for a relatively simple surgical procedure are not accepted by most patients. Different methods for the closure of appendicular stump were compared.^{[6],[7],[8],[9]} Studies showed no significant differences in intra-abdominal abscess or operative time. Rare cases of migration of endoclips or polymetric clips were reported.^{[13],[14],[15]} Despite their relatively low incidence, the complications can be lethal.

Postoperative leakage or bleeding is a major concern for most surgeons. In this study, no patient was readmitted after an initial operation. The absorbable clip group showed noninferior surgical time and other related postoperative complications compared to the traditionally used metallic clip group. In addition, imaging studies play an important role in the current medical practice. Metallic clips from previous surgeries sometimes interfere with the interpretation of the imaging studies, including X-ray, computerized tomography, and magnetic resonance imaging. In contrast, absorbable polymetric clips are efficacious in closing the appendicular stump and artery, with the benefits of no foreign body after being fully degraded.

This study has some limitations. First, absorbable clips are relatively new to our center, and the sample size was relatively small. Second, this is a retrospective single-center study, so the results might have clinicopathological biases. Furthermore, all absorbable clips were used by a single surgeon, whereas metallic clips were used by other surgeons. There may be some differences in surgical techniques used by the surgeons that may influence the results.

Conclusion

LA is well-established for treating acute appendicitis. The use of absorbable polymetric clips in the closure of appendicular stump and ligation of appendiceal artery showed similar postoperative complications and hospital stay length. With the benefits of leaving no foreign body, LA may reduce long-term foreign body-related complications. Absorbable clips seem to have the potential as the optimal tool to secure the base of the appendix and appendiceal artery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Wray CJ, Kao LS, Millas SG, Tsao K, Ko TC. Acute appendicitis: Controversies in diagnosis and management. Curr Probl Surg 2013;50:54-86.
2.	Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: Modern understanding of pathogenesis, diagnosis, and management. Lancet 2015;386:1278-87.
3.	Jaschinski T, Mosch CG, Eikermann M, Neugebauer EA, Sauerland S. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2018;11:CD001546.
4.	Poprom N, Wilasrusmee C, Attia J, McEvoy M, Thakkinstian A, Rattanasiri S. Comparison of postoperative complications between open and laparoscopic appendectomy: An umbrella review of systematic reviews and meta-analyses. J Trauma Acute Care Surg 2020;89:813-20.
5.	Talha A, El-Haddad H, Ghazal AE, Shehata G. Laparoscopic versus open appendectomy for perforated appendicitis in adults: Randomized clinical trial. Surg Endosc 2020;34:907-14.
6.	Lv B, Zhang X, Li J, Leng S, Li S, Zeng Y, et al. Absorbable polymeric surgical clips for appendicular stump closure: A randomized control trial of laparoscopic appendectomy with lapro-clips. Oncotarget 2016;7:41265-73.
7.	Soll C, Wyss P, Gelpke H, Raptis DA, Breitenstein S. Appendiceal stump closure using polymeric clips reduces intra-abdominal abscesses. Langenbecks Arch Surg 2016;401:661-6.
8.	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.
9.	Vuille-Dit-Bille R, Soll C, Mazel P, Staerkle RF, Breitenstein S. Appendiceal stump closure with polymeric clips is a reliable alternative to endostaplers. J Int Med Res 2020;48:300060519856154.
10.	Lee JS, Hong TH. Comparison of various methods of mesoappendix dissection in laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A 2014;24:28-31.
11.	Janssen PF, Brölmann HA, Huirne JA. Effectiveness of electrothermal bipolar vessel-sealing devices versus other electrothermal and ultrasonic devices for abdominal surgical hemostasis: A systematic review. Surg Endosc 2012;26:2892-901.
12.	Dutta DK, Dutta I. The harmonic scalpel. J Obstet Gynaecol India 2016;66:209-10.
13.	Sato T, Denno R, Yuyama Y, Matsuura T, Kanisawa Y, Hirata K. Unusual complications caused by endo-clip migration following a laparoscopic cholecystectomy: Report of a case. Surg Today 1994;24:360-2.
14.	Yao CC, Wong HH, Chen CC, Wang CC, Yang CC, Lin CS. Migration of endoclip into duodenum. A rare complication after laparoscopic cholecystectomy. Surg Endosc 2001;15:217.
15.	Dolay K, Alis H, Soylu A, Altaca G, Aygun E. Migrated endoclip and stone formation after cholecystectomy: A new danger of acute pancreatitis. World J Gastroenterol 2007;13:6446-8.