COMBINATION OF ULTRASONIC ENERGY DEVICE WITH SIMPLE INTERRUPTED INTRACORPOREAL SUTURE VERSUS ENDO-LOOP IN CLOSURE OF APPENDIX STUMP

Introduction: Appendicitis is a commonly encountered abdominal inflammatory disease in surgical practice that affects patients of varying ages, but more commonly in those aged 11-20 years old. The mainstay of treatment is the surgical removal of the appendix. In 1894, McBurney introduced the technique of open appendectomy to perform surgical removal of the appendix. This then became the standard for many years until the advancement of technology paved the way for a laparoscopic approach which is shown to bring about better objectively measurable outcomes and has now become the norm. The surgical technique of laparoscopic appendectomy (LA) is well established, but controversy exists regarding the closure of the stump. Commonly used techniques to close the stump during LA are intracorporeal knotting, purse string sutures and Hem-o-lock polymeric clips. These techniques do not demonstrate any significant differences in outcomes such as surgery time, pre-operative and postoperative complication rates and length of hospital stay. The use of endo-loop for stump closure is theoretically associated with higher risk of surgical-site infections due to fecal contamination. Endoloop also requires more manipulation of the appendix which can cause it to dislodge from the appendiceal stump. It is also not the best option when the base of the appendix is inflamed. On the other hand, use of the intracorporeal suture knot requires more experience. This study aims to compare intracorporeal suture knotting with endo-loop as a method of stump closure in LA by conducting a retrospective analysis to assess the outcomes achieved through both methods within the period of this study in Melaka General Hospital. Materials & Methods: For the purpose of this retrospective cohort study, we collected data from patient records between February 2021 till May 2021 for LA cases that used either the combination of ultrasonic energy device and simple interrupted intracorporeal suture knotting or endo-loop as a method of stump closure. We excluded patients who were below 16 years old, patients with a history of major abdominal surgery as well as pregnant patients. All LA were performed using 3 conventional laparoscopic trocars—one 10mm trocar placed via infraumbilical, one 5mm trocar each via suprapubic and left lower quadrant mid-clavicular. For intracorporeal suture knotting, the stump was transected using an ultrasonic energy device and secured via intracorporeal suture knotting using a polyglactin based 2/0 suture. As for endo-loop, 2 knots (surgitie chromic gut 4/0) were applied at the base and cut using cutting scissors. Results: The demographic data of patients were described in Table 1 and divided into two arms: endo-loop (Group 1) VS intracorporeal suture (Group 2). Out of a total of 68 patients, 50 (73.5%) were females and 18 (26.5%) were males. The mean age was 25.2 (min. 12, max. 65). Group 1 consisted of a total of 42 patients, whilst the Group 2 had 26 patients. In both categories, the majority of the patients fell within normal BMI and had an ASA of 1, however when compared between the two arms, this was found to have no statistical difference. Intraoperatively, 39 patients (92.9%) in Group 1 were diagnosed with acute appendicitis versus 17 (64.5%) in Group 2. The use of endo-loop was not recorded in any case of macerated or perforated appendicitis. When both arms were compared, there was a statistically significant difference (p=0.004) in intra-operative findings and therefore the decision to use either endo-loop or intracorporeal sutures for closure. Table 2 outlines the measurable outcomes. In both arms of this study, neither the length of surgery (p=0.218) nor the length of hospital stay (p=0.639) demonstrated a clinically significant difference. In Melaka General Hospital, it was found that there were no records of morbidity in all cases analysed within the study period. Discussion: A wide array of evidence has proven laparoscopic methods for surgery to be associated with more desirable clinical outcomes. For LA, the method of stump closure is the main technical step in determining its success. There are many studies that cite the multiple different techniques of stump closure in LA and compare them to each other, but stump closure via endo-loop is by far the most frequently used method. One prospective study that compared the use of intracorporeal suture knotting versus the use of endo-loops in stump closure concluded that there were no significant differences in outcome even when an invaginating suture was used to sink the stump (2). Our study also demonstrated a similar outcome; however, we can only speculate that with a larger sample size and collection of data over a longer period, the results may differ. Although outcomes were no different, it is worth noting that the use of endo-loop for closure is deemed unsuitable for cases where intraoperatively, the appendix is found to be macerated or perforated as endo-loop usage will require more manipulation of the stump which is already inflamed, and this can precipitate stump leakage. In another study, Del Olmo et al demonstrated in their case report that the use of ultrasonic energy devices alone to dissect and resect the appendix resulted in no clinically undesirable outcomes (3). In all the cases in this study, the patients who have had intracorporeal sutures applied for stump closure had the appendix first resected using an ultrasonic energy device before securing with a suture. Based on the literature search, there are few to none that study the use of an ultrasonic device in combination with intracorporeal suture knotting versus other methods. Therefore, we hope to use this study as a stepping-stone to conducting a randomized controlled trial to study the efficacy and outcomes of routinely applying the use of ultrasonic energy devices when using intracorporeal sutures.