Use of hem-o-lok clips for laparoscopic appendectomy in children: retrospective analysis and comparison to ligature loop and endoscopic surgical stapler

Background: There are multiple techniques used for laparoscopic appendectomy (LA): ligature loop (LL), surgical stapler (SS) (Endopath Ets-Flex-Endoscopic Articulating Linear Cutter 33 mm Standard Ref Atb 35. Ethicon, Somerville, New Jersey, US), and hem-o-lok clips (HOL) (Weck Closure System. Triangle Park, NC, USA). The application of the LL usually demands dexterity and training, whilst using HOL may be more advantageous due to its simplicity in terms of application and its low cost in contrast with the SS. The objective of this study is to determine safety and efficacy of the different devices that can be used in the surgical procedure.

Methods: From June 2016 to December 2019, 253 consecutive children aged to 1 to 18 years were retrospectively reviewed. They were divided into three groups depending on the device used to secure the appendix: (I) in the first group, the base of the appendix was secured by double LL, (II) in the second group the base of the appendix was secured with SS, and (III) in the third group the base of the appendix was secured with two non-absorbable HOL. The data collected includes age, gender, operative time, device used to ligate the base of the appendix, previous tests (blood analysis, imaging), antibiotic prophylaxis administered, length of hospital stay, intraoperative and postoperative complications, shoulder pain and histological study of the specimen.

Results: There were 253 patients that underwent laparoscopic appendectomy during the study time, with a mean age of 10.3±4.1 in the LL group, 9.4±2.7 in the SS group and 10.4±3.3 in the HOL group, P=0.165. Distribution by gender was 77.8% for males in the LL group, 65.2% in the SS group and 61.3% in the HOL group, P=0.559. The mean surgical time with IQR in brackets was 60.0 (10.0) minutes (min), in the first group in which the base of the appendix was secured with LL, in the second group in which the base of the appendix was secured with SS 60.0 (15.0) min and finally in the third in which the base of the appendix was secured with HOL 40.0 (30.0) min, P<0.001. HOL clips have a significantly lower cost than their analogues. Specifically, 5 HOL clips have a cost of EUR 26.75, while three LL have a cost of EUR 53.70 and a single SS has a cost of EUR 276.58. Postoperative complications were found in 14.3% of the LL group, 9.8% in the SS group and 4.6% in the HOL group, P=0.137. Efficacy and safety in controlling the base of appendix were the same in all groups.

Conclusions: The HOL are safe and reduce surgical costs during laparoscopic appendectomy in children.