Use of Polymeric Clip (Hem-O-Lock) for Appendiceal Stump Ligation as a Favorable Technique in Laparoscopic Appendectomy


Mohammad Kermansaravi 1 , Sattar Darabi 1 , Foolad Eghbali 1 , Samaneh Rokhgireh 2 , Abdolreza Pazouki 3 , *

1 MD, Fellowship of Advanced Minimally Invasive Surgery, Minimally Invasive Research Center, Iran University of Medical Sciences, Tehran, IR Iran

2 MD, Fellowship of MIS in Gynecology, Endometriosis and Gynecologic Research Center, Iran University of Medical Sciences, Tehran, IR Iran

3 MD, Associate Professor of Minimally Invasive Surgery, Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Head, Center of Excellence For Minimally Invasive Surgery Training, Iran University of Medical Sciences, IR Iran

How to Cite: Kermansaravi M, Darabi S, Eghbali F, Rokhgireh S, Pazouki A. Use of Polymeric Clip (Hem-O-Lock) for Appendiceal Stump Ligation as a Favorable Technique in Laparoscopic Appendectomy, J Minim Invasive Surg Sci. 2017 ; 6(1):e44086. doi: 10.5812/minsurgery.44086.


Journal of Minimally Invasive Surgical Sciences: 6 (1); e44086
Published Online: February 11, 2017
Article Type: Research Article
Received: November 19, 2016
Revised: January 6, 2017
Accepted: January 15, 2017


Background: Laparoscopic appendectomy (LA) has become the standard choice for acute appendicitis. Several techniques to close the appendiceal stump were investigated, and use of polymeric clips, are shown safe and cost effective.

Objectives: Evaluation of the efficacy and safety of appendiceal stump closure with polymeric clips in LA.

Methods: This is a retrospective cohort study included 35 patients who underwent LA, between April 2013 and August 2016 in Rasool-e-Akram university hospital. appendiceal stumps ligation were performed by polymeric clips. One month follow up after surgery was performed for all patients. Demographic information of patinets, surgery, complications, readmission and pathological reports, were collected from medical records and data base.

Results: Thirty-five patients were included in this retrospective study. Nineteen patients were male and 16 patients were female (54.3% vs 45.7%). The mean age was 28.49 ± 9.56 years, mean operative time was 59.6 ± 11.8 minutes and mean hospitalization was 2.54 ± 0.7 days. There was no intraoperative complication and intraabdominal abscess formation. Also no readmission and no perioperative death were recorded in documents. In pathologic reports, there were 15 (42.8%) suppurative and one gangrenous (2.8%) appendicitis.

Conclusions: Application of polymeric clips for stump ligation is safe, cost effective and time saving, and could be used as favorable technique in LA.

1. Background

Laparoscopic procedures are performed for elective and urgent intraabdominal operations, such as acute appendicitis (1). Laparoscopic appendectomy (LA) was done by Semm in 1983 for the first time and nowadays, it is the choice and maybe the gold standard procedure in the presence of an experienced surgeon (2-6) LA especially is preferred in female, obese and old patients (2-7).

Advantages of LA, include, shorter hospitalization, faster recovery, less postoperative pain, less analgesic necessity, less surgical site infection and better cosmetic results (2, 3, 5, 7-12).

But, it has some disadvantages, such as longer duration of operation, increased cost and more incidence of intraabdominal abscess (2, 5, 11).

The most important stage of LA, maybe is stump closure, because, incomplete ligation may lead to serious complications such as intraabdominal infections, colonic fistula, postoperative peritonitis and even sepsis (13-17).

There is no standard method for appendiceal stump closure and the selected method remains controversial (5, 12, 18, 19).

The ideal method must be safe, economic, accessible, easily operated and often is selected based on the surgeon’s experience and appendiceal stump situation during laparoscopy, such as its diameter and degree of its base inflammation (4, 18, 20-22).

There are some methods for appendiceal stump closure, that all are safe, such as metallic clips (1, 6, 11, 14, 16, 18, 20, 22), polymeric clips (Hem-o-lock) (4, 8, 10, 14, 18, 22, 23), endo loop (2, 5, 7, 13, 14, 16-19, 21-25), endo stapler (5, 8, 11, 13, 19-22, 24), intra corporeal knot (3, 7, 11, 20, 22) and bipolar and vessel sealing devices (15, 22, 26).

Polymeric clip is a safe, available, cost-effective and easy to apply instrument for ligation of appendiceal stump and can decrease the operating time, but it is not suitable for gangrenous or wide appendiceal stump > 10 mm, because the maximum of its XL size is 9.4 mm (4, 10, 14, 22, 27). There is no difference in safety, between one or two clips application for stump closure (10).

The aim of this retrospective study was to evaluate the efficacy and safety of appendiceal stump closure with polymeric clips in LA at the Rasool-e -akram university hospital.

2. Methods

This is a retrospective cohort study and the patients with primary diagnosis of acute appendicitis that underwent laparoscopic appendectomy between April 2013 and August 2016, in Rasool-e-Akram hospital of Iran University of Medical Science, were entered to this study.

Totally, 35 patients underwent LA under general anesthesia in operating room by Minimally invasive surgery (MIS) fellows or MIS expert general surgeons, in supine position, that the surgeon and camera-surgeon was standing on patient’s left side, with standard 3 ports procedure, or 4 ports in complicated cases, and all stumps were closed by XL (Gold) polymeric clips (Hem-o-lock).

All patients had follow up after surgery for one month and were visited by MIS fellows. Demographic information of patients were ageand sex, also information of surgery, complications, readmission and pathological reports, were collected from medical records and data base.

3. Results

Thirty five patients were included in this retrospective study. Nineteen patients were male and 16 patients were female (54.3% vs 45.7%). The mean age was 28.49 ± 9.56 years (14 - 55 years), mean operative time was 59.6 ± 11.8 minutes and mean hospitalization time was 2.54 ± 0.7 days (1 - 5 days). There was no conversion to open approach and no use of other techniques for ligation of appendiceal stump. One case (2.86%) had gangrenous appendicitis, but the base of appendix was gangrene free. There was no intraoperative complication, such as bleeding or bowel perforation, and no important complication such as stump leak and intra-abdominal abscess formation.

There are no readmission due to complications or perioperative death. Additional data are listed in Table 1.

Table 1. Demographic, Complications and Pathological Findings of Patients
No. (%)
Male Gender19 (54.3)
Female Gender16 (45.7)
DM2 (5.7)
Simple19 (54.2)
Suppurative15 (42.8)
Gangrenous1 (2.8)
Postoperative Complications
Stump Leakage0
Ileus2 (5.7)

Abbreviations: DM, Diabetes mellitus; I.A.A, intra-abdominal abscess.

4. Discussion

LA is a safe procedure and could be considered as a gold standard for acute appendicitis even in complicated cases (9). In our academic hospital, most of appendectomies are performed by residents in open technique, and only few cases are operated by MIS fellows in laparoscopic technique.

The stump closure may be most important and more difficult step in LA (14, 16, 17, 27).

Advantages of polymeric clips are facility of application. Therefore using of polymeric clips is an efficient and safe way of securing the stump of appendix, compared with intra or extra-corporeal suturing especially for residents and low experienced surgeons.

In our study, our mean operation time was 59.6 ± 11.8 minutes that was near to other studies that used metallic clips, endostapler and endoloop (5, 14).

Cost-effectiveness of the method is one of the selection criteria, in our country, such as many other countries, polymeric clips are available and are more cost effective in comparison with other instruments such as endostapler and endoloop, this feature adds to the choice of this method. (Table 2), and it was confirmed in two previous studies (4, 22).

Table 2. The Approximate Price Comparison Between Appendiceal Stump Closure Devices in Iran
DeviceApproximate Cost, $
Endostapler200 - 300
Endoloop20 - 40
Polymeric clips10 - 20
Metallic clips5 - 20
Vessel sealing handle250 - 500

There was no stump leak or abdominal abscess, even in diabetic patients and in suppurative or gangrenous appendicitis that gangrene doesn’t involve it’s base or cecum, that confirm other similar studies that use of polymeric clips for stump closure has been safe and time saving (4, 14, 18, 22, 23).

There is no difference in polymeric clips safety and complications in comparison with other techniques such as endo stapler, endo loop or suture knot (4, 7, 10, 14, 18, 22). But it should be avoided in gangrened appendiceal base or wide base more than 10 mm.

4.1. Study Limitations

Our study is a retrospective study with small sample size, because most of appendectomies were performed by residents in open technique and urgent manner. Further studies are recommended in larger sample size, longer follow up and in clinical trial fashion.

4.2. Conclusions

Our study confirmed the previous findings of similar studies, and as accessibility, safety, feasibility and cost effectiveness of polymeric clips (Hem-o-lock).Alsowe consider that it can be a favorable technique for appendiceal stump closure and could simplify this step of LA specially for low experienced or in training surgeons.




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