Page 19 - World Journal of Laparoscopic Surgery

Appendicular Stump Closure by Polymer Clip vs Endoloop in Laparoscopic Appendectomy
Operative Technique the mesoappendix. However, only appendices up to 16 mm in
Pneumoperitoneum was established using a Veress needle inserted diameter can be clipped, a disadvantage not shared with the loop. 4
from the infraumbical region. The first 10 mm trocar was introduced Ease of application for endoloop and polymer clips was decided
in the abdomen just below the umbilicus. by the surgeon’s opinion that was obtained by giving surgeon
The second 5 mm trocar was placed just above the pubic opinion form having options mentioned below
symphysis and the third trocar of 5 mm in the left lower abdomen • Poor
below the level of the umbilicus in the line of the anterior axillary • Good
fold. From 10 mm scope, 30° telescope was inserted and from 5 mm • Excellent.
port dissection was performed.
After viewing the abdominal organs and confirming the Ease of Application
diagnosis of acute appendicitis, the appendix was mobilized
and skeletenized by cutting its mesoappendix using a harmonic It was feasibility to close appendicular stump by polymer clip and
scalpel or cautery. Further procedure to apply clips or endoloop endoloop, which was decided by the surgeon.
was decided by the operating surgeon. Ease of application measures feasibility for the surgeon that
includes the time taken for closing appendicular stump, the proper
For Polymer Clip Application closure of appendicular stump, and handling of endoloop and
A 30° telescope was inserted from 5 mm scope, and from 10 mm polymer clip intraoperative, which was decided by the surgeon; and
trocar polymer clip applicator was inserted. The appendicular base he gives opinion accordingly. Time taken for closure of appendicular
was seen intraoperatively and an idea about diameter was made by stump was time taken after skeletonization of appendix up to
the surgeon. If the diameter of the appendicular base was less than the closure of appendicular stump. After all this, considering the
or equal to 10 mm approximately than it is easily closed by polymer surgeon had given his opinion regarding “ease of application” in
clips. First clip was applied at the base of the appendix using clip this study.
applicator (Fig. 1), and a second clip was applied above the first clip
using clip applicator. Then the appendix was cut with a harmonic Postoperative Care and Follow-up
scalpel or scissor above the second clip, and it was removed from Intravenous antibiotic (injection ceftriaxone 1 g 12 hourly) was given
10 mm port. Ethicon HEM-O-LOK clip (polymer clip, Fig. 2) was for 1 day than patients shifted on an oral antibiotics (tablet cefixime
used in this study. Polymer clip which was slipped or not covering 200 mg 1BD). The first dressing was done after 48 hours, and further
appendicular stump was considered as a wasted clip. dressing was done only when there was soakage.
Discharge from the wound was sent for culture and sensitivity
For Endoloop Application test and then patients treated accordingly. Temperature more than
Three endoloops were applied on appendicular base (Fig. 3) and 98.6°F was considered as fever in this study. If a patient had a fever or
the appendix was cut between the second and third loop by wound discharge, then the total count was done. Ultrasonography
harmonic scalpel or scissors. The appendix was removed by a 10 (USG) was done in all cases after 48 hours. If the total count was
3
mm port. Endoloop was made outside from chromic catgut and more than 11,000/mm , then it was considered as wound infection.
introduced by knot pusher from the trocar. Endoloop which was Patients having no complaint of fever or wound discharge, then
slipped and not covering appendicular stump was considered as they were discharged after 48 hours with 5 days of oral antibiotic
wasted endoloop. In both groups, 10 mm port incision was closed (tablet cefixime 200 mg 1BD); the same for both groups. The patient
with port vicryl and other port incisions were closed by ethilon 2-0. was not discharged when there were complaints, such as fever and
After the appendectomy appendix was sent for histopathologic wound discharge. Patients having fever given oral paracetamol (500
examination in both groups. mg) as and when required.
Endoloop and clips are equally cost-effective, but the clip Patients having wound discharge were given antibiotics
appears to be simpler in handling than the endo-loop and, like the according to culture and sensitivity report and sutures were
stapler, offers closing, and cutting the appendix before dissecting removed after control of infection. If a patient had no complications,

Fig. 1: Polymer clip applicator Fig. 2: Polymer clips

World Journal of Laparoscopic Surgery, Volume 12 Issue 2 (May–August 2019) 65