Techniques for Mesoappendix Division and Appendiceal Stump Closure: A Comparative Review

Abstract

Acute appendicitis is a leading cause of emergency abdominal surgery, with laparoscopic appendectomy (LA) established as the gold standard treatment. Notwithstanding its extensive utilization, there is no agreement on the most effective method for closing the appendiceal stump and dividing the mesoappendix. This review sought to assess existing treatments in terms of surgical duration, hospital length of stay (LOS), complications, and cost-effectiveness. A comprehensive review of 53 studies was performed. Eligible studies included adult patients undergoing appendectomy and examined various procedures for appendiceal stump closure and mesoappendix division. The primary outcomes were surgical duration and LOS; the secondary objectives were postoperative complications and cost-effectiveness. For appendiceal stump closure, clips and staples were frequently linked to decreased surgical duration in comparison to ligatures or sutures, although outcomes varied. Clips were also associated with a reduced length of hospital stay. Cost-effectiveness analyses consistently found clips to be the most economical option for stump closure, with staples the most expensive. Complication rates were largely comparable, though loop ligatures were linked to more organ/space infections, and clips showed higher rates of surgical site infections in some studies. For mesoappendix division, electrocautery and energy devices generally shortened operative time compared with mechanical methods. Electrocautery was the least costly for mesoappendix division, while energy devices tended to increase costs. Division of the mesoappendix and appendiceal stump closure can be achieved with a wide range of techniques and tools. The optimal treatment strategy varies significantly based on the outcome investigated.

Keywords

appendicitis appendectomy general surgery appendiceal stump closure mesoappendix division

Introduction

Acute appendicitis is among the most prevalent abdominal emergencies, with an incidence of 233 cases per 100 000 annually and a lifetime risk of 6.7% in women and 8.6% in men.^1,2 Laparoscopic appendectomy is the gold standard treatment in high- and middle-income countries.³ Various techniques exist for appendiceal stump closure and mesoappendix division, including ligatures, clips, staples, electrocautery, and ultrasonic or energy-based approaches.⁴

While numerous publications have investigated individual procedures, there is a paucity of thorough comparisons among various methods for appendiceal stump closure and mesoappendix division.^5-7 This disparity underscores the necessity for a systematic examination. This review seeks to assess and compare different surgical procedures employed in appendectomy, concentrating on surgical duration, length of hospital stay, cost-effectiveness, and complications to inform intraoperative decision-making.

Methods

Eligibility Criteria

Out of the initial 529 articles found, 53 articles were deemed to meet the search criteria. Articles that met the following inclusion criteria were included in the review: (a) the study design was either a randomized controlled trial, meta-analysis, case-control, or an observational cohort study investigating the techniques for appendiceal stump closure or mesoappendix division transection in patients who underwent appendectomy for acute appendicitis; (b) patients were managed using laparoscopic or open appendectomy; (c) the experimental group and the control group received different treatments; (d) the study recorded data on median/mean surgical duration, mean/median hospital length of stay (LOS), surgical/anesthetic costs, or intra- and postoperative complications; and (e) the study included solely adult patients. Articles were excluded based on the following criteria: (a) duplicate articles; (b) irrelevant articles; (c) articles not accessible in English or lacking English translations; (d) data that is not accessible within the manuscript; (e) articles for which the full text was not accessible; (f) studies not indexed by PubMed; (g) previous systematic reviews (without a meta-analysis component), reviews, case reports, and letters; (h) studies present in one of the included meta-analyses; (i) low evidence papers; (j) conference abstracts; and (k) studies not comparing relevant techniques.

Search Methodology

The PubMed and MEDLINE databases were methodically searched from March 2024 to April 2024 for articles published between 2000 and 2024. The search terms were a combination of medical subject headings terms and the subsequent terms: appendicitis, appendix, mesoappendix, appendix resection, mesoappendix transection, stump closure, appendectomy, laparoscopic appendectomy, clips, loops, endoloop, ligatures, staples, sutures, electrocautery, energy device, ultrasonic and bipolar vessel-sealing systems (eg, LigaSure) (see Supplemental Table 1 for complete search strategy).⁸

Because this review focuses on a highly specialized surgical topic, a narrowed search strategy was employed. PubMed and MEDLINE were selected as they provide the most comprehensive and clinically relevant coverage of biomedical and surgical literature, particularly for operative techniques and outcomes related to appendectomy. Preliminary scoping indicated that expanding the search to additional databases produced predominantly duplicate citations or studies outside the scope of surgical technique evaluation, without improving yield or methodological completeness. Therefore, concentrating the search on these 2 platforms ensured both rigor and reproducibility while maintaining relevance to the clinical question.

Study Selection

The following information was retrieved: PubMed unique identifier, authors’ names, publication year, the country where the study was conducted, study design, study subjects, the number of participants, the number of male and female participants, the range of years covered by the study, case and control procedure, the number of patients who underwent the case and control procedure, the number of patients lost to further analysis, the number of patients with and without any complication for the case and control procedures, the number of patients with and without a specific complication for the case and control procedures, and mean and SD or median and IQR for surgical duration and hospital LOS.

Outcomes

The primary outcomes of interest were the surgical duration and total hospital LOS. The secondary outcomes of interest were complications as well as the cost of the procedures.

Terminology

In this review, terminology related to management of the appendix base has been standardized for consistency. Although the original studies variably described this step as appendix base division, appendix resection, transection of the appendix base, or appendiceal stump closure, these descriptions have been unified under the collective term “appendiceal stump closure.” This term is used to denote the operative management of the appendiceal base during appendectomy, irrespective of the specific technique employed. While there are technical differences in how appendiceal stump closure is achieved, such as single-step closure and division with staples vs sequential closure followed by sharp division when using loop ligatures or sutures, outcomes were analyzed according to the method used to manage the appendiceal base rather than the number of procedural steps.

Results

Appendiceal Stump Closure

Surgical Duration

Bass et al (2023) conducted a prospective multicenter cohort study including 3729 patients with acute appendicitis between November 2020 and May 2021 with 90-day follow-up.⁴ Appendiceal stump closure was achieved utilizing staples (38.1 %), looped ligatures (37.0 %), and clips (24.9 %). After adjustment for confounders, stapling was associated with significantly longer surgical duration [median surgical duration (95% CI): 5.75 min (3.35-8.15), P < 0.001] compared to loops, while clips and loops showed no difference (Table 1).

Table 1.

Management of the Appendix Base—Surgical Duration

Study	Study type	Study size	Intervention	Control	Superior method	P-value
Bass et al, 2023⁴	Prospective cohort study	3729 patients	Staples	Loops	Loops	P < 0.001
Bass et al, 2023⁴	Prospective cohort study	3729 patients	Clips	Loops	No significant difference	P = 0.266
Galatioto et al, 2013⁴²	Retrospective cohort study	1084 patients	Staples	Loops	Loops	P < 0.050
Strzalka et al, 2016³⁶	Retrospective cohort study	307 patients	Staples	Clips	No significant difference	P = 1.00
Strzalka et al, 2016³⁶	Retrospective cohort study	307 patients	Staples	Sutures	Staples	P < 0.001
Strzalka et al, 2016³⁶	Retrospective cohort study	307 patients	Clips	Sutures	Clips	P < 0.001
Ates et al, 2012⁹	Randomized controlled trial	61 patients	Sutures	Clips	Clips	P = 0.001
Sadat-Safavi et al, 2016¹⁰	Randomized controlled trial	76 patients	Clips	Loops	Clips	P = 0.021
Ozdemir et al, 2022³⁸	Retrospective cohort study	310 patients	Clips	Sutures	Clips	P = 0.012^a
Ozdemir et al, 2022³⁸	Retrospective cohort study	310 patients	Clips	Loops	Clips	P = 0.012^a
Ozdemir et al, 2022³⁸	Retrospective cohort study	310 patients	Loops	Sutures	Loops	P = 0.012^a
Kim et al, 2022³⁹	Retrospective cohort study	332 patients	Clips	Loops	Clips	P = 0.027
Jenwitheesuk et al, 2012⁴⁰	Retrospective cohort study	91 patients	Clips	Loops	Clips	P < 0.001
Poon et al, 2023¹⁴	Meta-analysis	2585 patients	Clips	Loops	Clips	P = 0.001
Wilson et al, 2018²²	Retrospective cohort study	125 patients	Clips	Loops	Clips	P = 0.007
Kazemier et al, 2006⁶	Meta-analysis	427 patients	Loops	Staples	Staples	P = 0.040
Beldi et al, 2006²⁴	Retrospective cohort study	6486 patients	Loops	Staples	Staples	P = 0.001
Van Rossem et al, 2017³⁷	Prospective cohort study	7143 patients	Loops	Staples	No significant difference	P = 0.243
Colak et al, 2013¹⁵	Randomized controlled study	53 patients	Clips	Loops	No significant difference	P = 0.072
Lee et al, 2023¹⁶	Randomized controlled trial	207 patients	Clips	Loops	No significant difference	P = 0.426
Knight et al, 2019¹⁷	Meta-analysis	702 patients	Clips	Loops	No significant difference	P = 0.365
Knight et al, 2019¹⁷	Meta-analysis	702 patients	Clips	Staples	No significant difference	P = 0.365
Knight et al, 2019¹⁷	Meta-analysis	702 patients	Clips	Sutures	No significant difference	P = 0.365
Knight et al, 2019¹⁷	Meta-analysis	702 patients	Loops	Staples	No significant difference	P = 0.365
Knight et al, 2019¹⁷	Meta-analysis	702 patients	Loops	Sutures	No significant difference	P = 0.365
Knight et al, 2019¹⁷	Meta-analysis	702 patients	Staples	Sutures	No significant difference	P = 0.365
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Staples	Loops	No significant difference	Not available
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Staples	Clips	No significant difference	Not available
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Staples	Handmade loops	No significant difference	Not available
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Loops	Clips	No significant difference	Not available
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Loops	Handmade loops	No significant difference	Not available
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Clips	Handmade loops	No significant difference	Not available
Gupta et al, 2020⁴¹	Retrospective and prospective study	210 patients	Energy device	Loops	Energy device	P < 0.001
Yaron et al, 2023¹⁹	Retrospective cohort study	733 patients	One loop	Two loops	One loop	P < 0.010
Yaron et al, 2023¹⁹	Retrospective cohort study	733 patients	One loop	Two clips	Two clips	P < 0.010
Yaron et al, 2023¹⁹	Retrospective cohort study	733 patients	Two loops	Two clips	Two clips	P < 0.010
DeMare et al, 2020²⁶	Retrospective cohort study	846 patients	LigaSure vessel sealer, loops, and EndoBag retrieval device	Seven other combinations of disposable instruments	LigaSure vessel sealer, loops, and EndoBag retrieval device	P < 0.001
Yildirim et al, 2024¹⁸	Prospective cohort study	638 patients	Loops	Clips	Clips	P = 0.001
Najah et al, (2024)¹¹	Meta-analysis	3308 patients	Loops	Stapler	Stapler	Not available
Najah et al, (2024)¹¹	Meta-analysis	3308 patients	Loops	Sutures	Loops	Not available
Najah et al, (2024)¹¹	Meta-analysis	3308 patients	Stapler	Clips	Stapler	Not available
Najah et al, (2024)¹¹	Meta-analysis	3308 patients	Stapler	Sutures	Stapler	Not available
Najah et al, (2024)¹¹	Meta-analysis	3308 patients	Clips	Sutures	Clips	Not available
Farahani et al, (2024)¹³	Retrospective cohort	50 patients	Loops	Clips	Clips	P = 0.044
Almeida et al, (2025)¹²	Meta-analysis	344 patients	Clips	Loops	Clips	P < 0.001

^aP-value is based on an omnibus test rather than a pair-wise comparison.

In contrast, Kazemier et al (2006) analyzed 4 randomized controlled trials (n = 427) and found stapling reduced surgical time by 9 minutes vs loop ligatures (P = 0.040), though findings were heterogeneous (I2 = 73%).⁶ Ates et al (2012) reported that clips were significantly faster than sutures (41.27 ± 12.2 min vs 62.81 ± 15.4 min, P = 0.001).⁹ Similarly, Sadat-Safavi et al (2016) found clips faster than loop ligatures (21.5 vs 23.3 min, P = 0.021).¹⁰ Consistent with previous evidence, Farahani et al (2024), Almeida et al (2025), and Najah et al (2024) each reported faster procedures with clips compared with loops.^11-13 In addition, Najah found that suture closure was associated with a significantly longer surgical duration than clip application. A meta-analysis by Poon et al (2023) demonstrated appendiceal stump closure time reduced by 2 minutes and 7 seconds with clips compared to loops, and combined results from 6 RCTs showed an overall 5.15-minute decrease in surgical duration (95% CI −2.05 to −8.24 min, P = 0.001).¹⁴

However, Colak et al (2013) and Lee et al (2023) found no significant differences in mean surgical duration between clips and loops.^15,16 Knight et al (2019) reported similar mean surgical durations across clips (37 min; range 26-65), loops (39 min; 44-76), staples (51 min; 40-63), and sutures (33 min, no range) [F (2.17) = 1.078, P = 0.365].¹⁷ Yildirim et al (2024) demonstrated a shorter surgical duration for clips vs handmade loops (40.53 ± 11.63 min vs 48.76 ± 16.16 minutes; P = 0.001) without significant variations in other clinical parameters such as ASA scores, symptom duration, length of hospital or ICU stay, preoperative laboratory findings, histopathological outcomes, mortality, or morbidity (P > 0.05).¹⁸

Length of Stay

Bass et al (2023) found a longer LOS for stapling [median LOS (95% CI): 0.26 days (0.14-0.37), P < 0.001] and a shorter LOS for clips [median LOS (95% CI): −0.16 days (−0.08 to −0.25), P < 0.001] relative to loops after adjustment for confounding factors.⁴ Farahani et al (2024) observed that the ligature group had a longer hospital stay, though the difference did not reach statistical significance (P > 0.05).¹³ Furthermore, Sadat-Safavi et al (2016), Ates et al (2012), Kazemier et al (2006), and Colak et al (2013) found no statistically significant LOS differences among appendiceal stump closure techniques.^6,9,10,15 (Table 2)

Table 2.

Management of the Appendix Base - Length of Stay

Study	Study type	Study size	Intervention	Control	Superior method	P-value
Bass et al, 2023⁴	Prospective cohort study	3729 patients	Staples	Loops	Loops	P < 0.001
Bass et al, 2023⁴	Prospective cohort study	3729 patients	Clips	Loops	Clips	P < 0.001
Strzalka et al, 2016³⁶	Retrospective cohort study	307 patients	Staples	Clips	Clips	P = 0.005
Strzalka et al, 2016³⁶	Retrospective cohort study	307 patients	Sutures	Clips	Clips	P = 0.023
Kliuchanok et al, 2019²¹	Retrospective cohort study	618 patients	Staples	Clips	Clips	P = 0.0001
Jenwitheesuk et al, 2012⁴⁰	Retrospective cohort study	91 patients	Loops	Clips	Clips	P = 0.038
Bao et al, 2023⁴³	Retrospective cohort study	568 patients	Sutures	Clips	Sutures	P < 0.050
Colak et al, 2013¹⁵	Randomized controlled study	53 patients	Clips	Loops	No significant difference	P = 0.443
Marcinkeviciute et al, 2023²⁰	Retrospective cohort study	515 patients	Clips	Loops	No significant difference	P = 0.180
Sadat-Safavi et al, 2016¹⁰	Randomized controlled trial	76 patients	Clips	Loops	No significant difference	P > 0.050
Ates et al, 2012⁹	Randomized controlled trial	61 patients	Clips	Sutures	No significant difference	P = 0.994
Kazemier et al, 2006⁶	Meta-analysis	427 patients	Staples	Loops	No significant difference	P > 0.050
Singh et al, 2022⁵	Meta-analysis	802 patients	Electrocautery or energy device	Clips or loops	Electrocautery or energy device	P < 0.001
Farahani et al, 2024¹³	Retrospective cohort	50 patients	Loops	Clips	No significant difference	P > 0.05

Cost-Effectiveness

Yaron et al (2023) compared 1021 appendectomies and found double-loop ligatures ($220) were costlier than clip closure ($180 for a cartridge of 4 clips, excluding reusable applier cost) and single-loop ligature ($110).¹⁹ Marcinkeviciute et al (2023) reported the lowest cost with clips (7.69€) followed by loops (91.35€) and staples (514.50€).²⁰ Kliuchanok et al (2019) similarly reported substantial cost savings with clips compared to staples (19.94€ vs 348.70€),²¹ while Wilson et al (2018) found polymeric clips to be less expensive than loop ligatures (£21 vs £49 per surgery).²² Moreover, Bozkurt et al (2014) found significant cost variation between clips types used, with titanium, metal, and polymeric clips costing $7, $10, and $50 per case, respectively.²³

While Beldi et al (2006) noted a 1.7-minute reduction in surgical duration with staples, the inclusion of other material costs led to an overall increase of $248 compared with loop closure.²⁴ Hilsden et al (2019) and DeMare et al (2020) confirmed lower total operative and disposable costs with loop ligatures.^25,26 Yildirim et al (2024) found clip closure 25.8 times costlier than loops ($31 vs $1.20).¹⁸

Of note, the cost analyses presented for appendiceal stump closure reflect the original reporting frameworks of the included studies, which vary in terms of currency, healthcare context, cost structure, and year of publication. Given this heterogeneity, absolute monetary values should not be compared between studies. Instead, the cost findings are intended to illustrate relative differences between appendiceal stump closure methods within the same study (Table 3).

Table 3.

Management of the Appendix Base—Cost-Effectiveness

Study	Study type	Study size	Intervention	Control	Superior method	P-value
Yaron et al, 2023¹⁹	Retrospective cohort study	1021 patients	One loop	Two loops	One loop	Not available
Yaron et al, 2023¹⁹	Retrospective cohort study	1021 patients	One loop	Two clips (cartridge contains 4 clips)	One loop	Not available
Yaron et al, 2023¹⁹	Retrospective cohort study	1021 patients	Two loops	Two clips (cartridge contains 4 clips)	Two clips (cartridge contains 4 clips)	Not available
Delibegovic et al, 2009⁴⁴	Prospective cohort study	52 patients	Loops	Clips	Clips	Not available
Al-Temimi et al, 2017⁴⁷	Prospective cohort study	92 patients	Clips	Staples	Clips	Not available
Marcinkeviciute et al, 2023²⁰	Retrospective cohort study	515 patients	Clips	Loops	Clips	Not available
Marcinkeviciute et al, 2023²⁰	Retrospective cohort study	515 patients	Staples	Loops	Loops	Not available
Marcinkeviciute et al, 2023²⁰	Retrospective cohort study	515 patients	Clips	Staples	Clips	Not available
Kliuchanok et al, 2019²¹	Retrospective cohort study	618 patients	Clips	Staples	Clips	Not available
Wilson et al, 2018²²	Retrospective cohort study	125 patients	Clips	Loops	Clips	Not available
Beldi et al, 2006²⁴	Retrospective cohort study	6486 patients	Staples	Loops	Loops	Not available
Hilsden et al, 2019²⁵	Retrospective cohort study	567 patients	Loops	Staples	Loops	P < 0.001
Matyja et al, 2015⁴⁸	Retrospective cohort study	60 patients	Sutures	Clips	Sutures	Not available
Matyja et al, 2015⁴⁸	Retrospective cohort study	60 patients	Clips	Staples	Clips	Not available
Matyja et al, 2015⁴⁸	Retrospective cohort study	60 patients	Sutures	Staples	Sutures	Not available
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Staples	Loops	No significant difference	Not available
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Staples	Clips	No significant difference	Not available
Yildiz et al, 2016³⁴	Retrospective cohort study	196 patients	Loops	Clips	No significant difference	Not available
Bozkurt et al, 2014²³	Retrospective cohort study	1849 patients	Metal clips	Polymeric clips	Metal clips	P < 0.001
DeMare et al, 2020²⁶	Retrospective cohort study	846 patients	LigaSure vessel sealer, loops, and EndoBag retrieval device	Seven other combinations of disposable instruments	LigaSure vessel sealer, loops, and EndoBag retrieval device	P < 0.001
Mehdorn et al, 2017⁴⁹	Retrospective cohort study	177 patients	Loops	Staples	Loops	P < 0.001
Lucchi et al, 2017⁴⁶	Retrospective cohort study	259 patients	Loops	Clips	Clips	P = 0.015
Yildirim et al, 2024¹⁸	Prospective cohort study	638 patients	Loops	Clips	Loops	Not available

Complications

Ureyen et al (2020) demonstrated no significant difference between clips and sutures in terms of peri- or postoperative complications (P > 0.050).²⁷ Bass et al (2023) reported that, compared with loops, the crude 30-day postoperative complication rate was slightly higher with staples (14.5% vs 13.3%, P < 0.001) and lower with clips (8.7% vs 13.3%, P < 0.001).⁴ However, the crude risk of serious adverse outcomes was greater with both clips and staples compared to loops (3.7% and 1.9% vs 1.2%, P < 0.001). Within 90 days postoperatively, no significant difference was observed in reoperation rates. After adjustment for confounders, the risk of any and severe complications did not differ significantly between methods. Similarly, Sadat-Safavi et al (2016) found no significant difference in complication rates between clips and loops (P > 0.05),¹⁰ consistent with findings by Ureyen et al (2020), Bass et al (2023), Farahani et al (2024), Almeida et al (2025), and Najah et al (2024)^4,11-13,27 (Table 4).

Table 4.

Management of the Appendix Base—Complications

Study	Study type	Study size	Intervention	Control	Superior method	P-value	Type of complication
Strzalka et al, 2016³⁶	Retrospective cohort study	307 patients	Staples	Clips	No significant difference	P = 0.319^a	Any postoperative complication
Strzalka et al, 2016³⁶	Retrospective cohort study	307 patients	Staples	Sutures	No significant difference	P = 0.319^a	Any postoperative complication
Strzalka et al, 2016³⁶	Retrospective cohort study	307 patients	Sutures	Clips	No significant difference	P = 0.319^a	Any postoperative complication
Arer et al, 2019⁵²	Retrospective cohort study	287 patients	Sutures	Clips	No significant difference	P = 0.111	Any complication
Shadhu et al, 2020⁵³	Retrospective cohort study	882 patients	Sutures	Clips	No significant difference	P = 0.387	Any complication
Ureyen et al, 2020²⁷	Randomized controlled trial	41 patients	Sutures	Clips	No significant difference	P > 0.050	Any perioperative complication
Okamoto et al, 2021⁵⁴	Retrospective cohort study	231 patients	Loops	Purse-string sutures	No significant difference	P = 0.73	Any postoperative complication
Okamoto et al, 2021⁵⁴	Retrospective cohort study	231 patients	Loops	Purse-string sutures	No significant difference	P = 0.42	Intra-abdominal abscess
Okamoto et al. 2021⁵⁴	Retrospective cohort study	231 patients	Loops	Purse-string sutures	No significant difference	P = 1.00	Ileus
Okamoto et al, 2021⁵⁴	Retrospective cohort study	231 patients	Loops	Purse-string sutures	No significant difference	P = 1.00	Surgical site infection
Yaron et al, 2023¹⁹	Retrospective cohort study	733 patients	One loop	Two loops	No significant difference	P = 0.150^a	Any complication
Yaron et al. 2023¹⁹	Retrospective cohort study	733 patients	One loop	Two clips	No significant difference	P = 0.150^a	Any complication
Yaron et al, 2023¹⁹	Retrospective cohort study	733 patients	Two loops	Two clips	No significant difference	P = 0.150^a	Any complication
Delibegovic et al, 2009⁴⁴	Prospective cohort study	52 patients	Loops	Clips	No significant difference	Not available	Any intra- or postoperative complication
Ozdemir et al, 2022³⁸	Retrospective cohort study	310 patients	Clips	Sutures	No significant difference	P = 0.763^a	Surgical site infection
Ozdemir et al, 2022³⁸	Retrospective cohort study	310 patients	Clips	Loops	No significant difference	P = 0.763^a	Surgical site infection
Ozdemir et al, 2022³⁸	Retrospective cohort study	310 patients	Sutures	Loops	No significant difference	P = 0.763^a	Surgical site infection
Bass et al, 2023⁴	Prospective cohort study	3729 patients	Staples	Loops	No significant difference	P = 0.139	Any complication
Bass et al, 2023⁴	Prospective cohort study	3729 patients	Clips	Loops	No significant difference	P = 0.142	Any complication
Bass et al, 2023⁴	Prospective cohort study	3729 patients	Staples	Loops	No significant difference	P = 0.067	Severe complication
Bass et al, 2023⁴	Prospective cohort study	3729 patients	Clips	Loops	No significant difference	P = 0.842	Severe complication
Swank et al, 2014⁵⁵	Retrospective cohort study	1036 patients	Staples	Loops	No significant difference	Not available	Any intra- and postoperative complication
Vuille-Dit-Bille et al, 2019⁵⁰	Retrospective cohort study	673 patients	Clips	Staples	No significant difference	P = 0.277^b	Intra-abdominal abscess
Vuille-Dit-Bille et al, 2019⁵⁰	Retrospective cohort study	673 patients	Clips	Staples	No significant difference	P = 1.000^b	Readmission
Vuille-Dit-Bille et al, 2019⁵⁰	Retrospective cohort study	673 patients	Clips	Staples	No significant difference	P = 1.000^b	Reoperation
Marcinkeviciute et al, 2023²⁰	Retrospective cohort study	515 patients	Clips	Loops	No significant difference	P > 0.99	Any postoperative complication
Hue et al, 2013⁵⁸	Prospective cohort study	105 patients	Clips	Loops	No significant difference	Not available	Any intra- and postoperative complication
Sadat-Safavi et al, 2016¹⁰	Randomized controlled trial	76 patients	Clips	Loops	No significant difference	P = 0.5	Wound infection
Sadat-Safavi et al, 2016¹⁰	Randomized controlled trial	76 patients	Clips	Loops	No significant difference	P = 0.238	Surgical site pain
Sadat-Safavi et al, 2016¹⁰	Randomized controlled trial	76 patients	Clips	Loops	No significant difference	P = 0.5	Technical complication
Sahm et al, 2011⁵⁶	Prospective cohort study	1790 patients	Loops	Staples	No significant difference	P = 0.765	Seroma
Sahm et al, 2011⁵⁶	Prospective cohort study	1790 patients	Loops	Staples	No significant difference	P = 0.652	Abscess
Sahm et al, 2011⁵⁶	Prospective cohort study	1790 patients	Loops	Staples	No significant difference	P = 0.881	Insufficient stump closure, postoperative bleeding, postoperative peritonitis
Sahm et al, 2011⁵⁶	Prospective cohort study	1790 patients	Loops	Staples	No significant difference	P = 0.795	Small-bowel obstruction (mechanical)
Sahm et al, 2011⁵⁶	Prospective cohort study	1790 patients	Loops	Staples	No significant difference	P = 0.765	Small-bowel obstruction (paralytic)
Sohn et al, 2013⁵⁷	Retrospective cohort study	430 patients	Loops	Staples	No significant difference	P = 0.254	Surgical site infection
Sohn et al, 2013⁵⁷	Retrospective cohort study	430 patients	Loops	Staples	No significant difference	P = 0.499	Intra-abdominal abscess
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Clips	Loops	Clips	P = 0.038^c	Organ/space infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Clips	Staples	No significant difference	P = 0.570^c	Organ/space infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Clips	Suture	No significant difference	P = 0.437^c	Organ/space infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Loops	Staples	No significant difference	P = 0.394^c	Organ/space infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Loops	Suture	No significant difference	P = 0.108^c	Organ/space infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Staples	Suture	No significant difference	P = 0.329^c	Organ/space infection
Antoniou et al. 2017⁷	Meta-analysis	5171 patients	Clips	Loops	Loops	P < 0.001^c	Surgical site infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Clips	Staples	No significant difference	P = 0.083^c	Surgical site infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Clips	Suture	Suture	P = 0.001^c	Surgical site infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Loops	Staples	No significant difference	P = 0.412^c	Surgical site infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Loops	Suture	No significant difference	P = 0.131^c	Surgical site infection
Antoniou et al, 2017⁷	Meta-analysis	5171 patients	Staples	Suture	No significant difference	P = 0.062^c	Surgical site infection
Kazemier et al, 2006⁶	Meta-analysis	427 patients	Loops	Staples	Staples	P = 0.010	Surgical site infection
Kazemier et al, 2006⁶	Meta-analysis	427 patients	Loops	Staples	Staples	P = 0.030	Ileus
Kazemier et al, 2006⁶	Meta-analysis	427 patients	Loops	Staples	No significant difference	P = 0.46	Rupture of the appendix
Ceresoli et al, 2019²⁸	Meta-analysis	12 538 patients	Staples	Loops	Staples	Not available	Surgical site infection
Ceresoli et al, 2019²⁸	Meta-analysis	12 538 patients	Staples	Loops	No significant difference	Not available	Intra-abdominal abscess
Lasek et al, 2020⁵⁹	Prospective cohort study	1269 patients	Clips	Staples	No significant difference	P = 0.078^a	Intra-abdominal abscess
Lasek et al, 2020⁵⁹	Prospective cohort study	1269 patients	Clips	Loops	No significant difference	P = 0.078^a	Intra-abdominal abscess
Lasek et al, 2020⁵⁹	Prospective cohort study	1269 patients	Clips	Staples	Staples	P = 0.017^a	Any perioperative complication
Lasek et al, 2020⁵⁹	Prospective cohort study	1269 patients	Staples	Loops	Staples	P = 0.017^a	Any perioperative complication
Lasek et al, 2020⁵⁹	Prospective cohort study	1269 patients	Clips	Loops	Loops	P = 0.017^a	Any perioperative complication
Soll et al, 2016⁶⁰	Retrospective cohort study	813 patients	Clips	Loops	Clips	P < 0.008	Intra-abdominal abscess
Beldi et al, 2006²⁴	Retrospective cohort study	6486 patients	Loops	Staples	No significant difference	P = 0.470	Any intraoperative complication
Beldi et al, 2006²⁴	Retrospective cohort study	6486 patients	Loops	Staples	No significant difference	P = 0.343	Any postoperative complication
Beldi et al, 2006²⁴	Retrospective cohort study	6486 patients	Loops	Staples	Staples	P = 0.002	Readmission
Farahani et al, (2024)¹³	Retrospective cohort	50 patients	Loops	Clips	No significant difference	P > 0.05	Any intra- and postoperative complication
Almeida et al, (2025)¹²	Meta-analysis	344 patients	Clips	Loops	No significant difference	P = 0.83	Wound infection

^aP-value is based on an omnibus test rather than a pair-wise comparison.

^bP-value is for uncomplicated appendicitis.

^cP-value calculated based on confidence interval⁶⁹.

Antoniou et al (2017) (meta-analysis of 43 RCTs) identified suture ligation as most effective, with lower risk of superficial and organ/space infections.⁷ Sutures were associated with fewer operative site infections than clips [OR (95% CI): 0.20 (0.08-0.55)], while clips carried a higher infection risk than loops [OR (95% CI): 2.22 (1.56-3.13)]. Conversely, clips were linked to a lower risk of organ/space infection compared to loops [OR (95% CI): 0.56 (0.32-0.96)]. Kazemier et al (2006) and Ceresoli et al (2019) demonstrated lower infection rates with staples than loops.^6,28

Mesoappendix Division

Surgical Duration

Bass et al (2023) included 2252 patients in their prospective multicenter cohort analysis of mesoappendix division methods.⁴ Electrocautery was used in 1564 (60.4 %) and energy devices in 688 (30.5 %) cases. Procedures using energy devices were longer (65 min vs 57 min, P < 0.001), though this difference lost statistical significance after adjustment for confounders. Sucullu et al (2009) conducted a randomized controlled trial comparing electrocautery alone (LigaSure 5 to 10 mm) with electrocautery (endodissector) in combination with clips.²⁹ Surgical duration was significantly shorter with electrocautery only (49.06 ± 14.73 mins vs 59.69 ± 12.54 mins, P = 0.036). In an RCT, Qaiser et al (2021) compared harmonic scalpel and suture ligation for mesoappendix division and showed that the harmonic scalpel substantially shortened surgical duration (1.56 ± 0.68 min vs 21.07 ± 2.84 min, P < 0.001)³⁰ (Table 5).

Table 5.

Management of the Mesoappendix—Surgical Duration

Study	Study type	Study size	Intervention	Control	Superior method	P-value
Bass et al, 2023⁴	Prospective cohort study	2252 patients	Energy device	Electrocautery	No significant difference	P = 0.976
Qaiser et al, 2021³⁰	Randomized controlled trial	110 patients	Energy device	Sutures	Energy device	P < 0.001
Sucullu et al, 2009²⁹	Randomized controlled trial	32 patients	Electrocautery (LigaSure 5 to 10 mm)	Electrocautery (endodissector) in combination with clips	Electrocautery	P = 0.036

Length of Stay

Bass et al (2023) demonstrated a longer crude LOS with energy devices (2.1 days vs 1.8 days, P < 0.001),⁴ though the difference was not significant after adjustment for confounders. Similarly, Doepker et al (2014) found no significant difference in mean LOS between electrocautery and energy devices compared to non-energy methods, such as staples, loop ligatures, or clips (P = 0.618)³¹ (Table 6).

Table 6.

Management of the Mesoappendix—Length of Stay

Study	Study type	Study size	Intervention	Control	Superior method	P-value
Singh et al, 2022⁵	Meta-analysis	2223 patients	Energy source (electrocautery or energy device)	Non-energy source (clips or ligatures)	No significant difference	P = 0.880
Doepker et al, 2014³¹	Retrospective cohort study	838 patients	Energy source (electrocautery or energy device)	Non-energy source (staples, loops, or clips)	No significant difference	P = 0.618
Bass et al, 2023⁴	Prospective cohort study	2252 patients	Energy device	Electrocautery	No significant difference	P = 0.111

Cost-Effectiveness

Doepker et al (2014) identified a significant cost disparity between energy sources (electrocautery and energy devices) and non-energy techniques (staples, loop ligatures, or clips), with energy devices adding approximately $700-1000 per case due to device expenses.³¹ Lee et al (2023) found mean costs of $959 for the energy devices, $571 for clips, and $452 for electrocautery.¹⁶ Chu et al (2011) also showed wide cost variation depending on surgeon’s choice of technique: the most economical surgeon used 1 multi-use endoscopic clip applier for mesoappendix division, 2 loops for managing the appendiceal stump, and three 5 millimeter trocars, equivalent to $299, whereas the least economical relied on 2 staple firings for mesoappendix division, 1 staple firing for management of the appendiceal stump, and 12/5/10-mm trocars, corresponding to $552.³²

Worth mentioning, the studies assessing the cost implications of mesoappendix division techniques span nearly 2 decades and employ heterogeneous economic reporting methods, including differences in currencies, costing frameworks, and included resource components. As a result, absolute cost figures are not directly comparable across studies. Cost data should therefore be interpreted as relative, within-study comparisons rather than as generalizable or directly transferable economic estimates (Table 7).

Table 7.

Management of the Mesoappendix - Cost-Effectiveness

Study	Study type	Study size	Intervention	Control	Superior method	P-value
Doepker et al, 2014³¹	Retrospective cohort study	838 patients	Energy source (electrocautery or energy device)	Non-energy source (staples, loops, or clips)	Non-energy source	Not available
Lee et al, 2023¹⁶	Randomized controlled trial	207 patients	Energy device	Clips	Clips	Not available
Lee et al, 2023¹⁶	Randomized controlled trial	207 patients	Energy device	Electrocautery	Electrocautery	Not available
Lee et al, 2023¹⁶	Randomized controlled trial	207 patients	Electrocautery	Clips	Electrocautery	Not available
Chu et al, 2010³²	Retrospective cohort study	89 patients	One multi-use endoscopic clip applier for mesoappendix division, two loops for managing the appendiceal stump, and three 5 millimeter trocars	Two staple firings for mesoappendix division, one staple firing for management of the appendiceal stump, and 12/5/10-mm trocars	One multi-use endoscopic clip applier for mesoappendix division, two loops for managing the appendiceal stump, and three 5 millimeter trocars	Not available

Complications

Bass et al (2023) observed no significant crude differences in overall and severe complications or reoperation rates between energy devices and electrocautery.⁴ However, after adjustment, energy devices were correlated with fewer overall [adjusted IRR (95% CI): 0.58 (0.41-0.82), P = 0.002] and severe complications [adjusted IRR (95% CI): 0.33 (0.11-0.96), P = 0.045]. Tartaglia et al (2020) in a retrospective cohort of 2076 cases, found higher rates of postoperative intra-abdominal abscesses with clips compared to electrocautery (P < 0.001).³³ Conversely, Sucullu et al (2009) reported no significant differences in complication rates between electrocautery alone and electrocautery in combination with clips.²⁹ Doepker et al (2014) also reported no significant differences in bleeding (5.1 % vs 3.1 %, P = 0.548), transfusion requirements (P = 0.653), or postoperative anemia rates (P = 0.345) between energy and non-energy sources³¹ (Table 8).

Table 8.

Management of the Mesoappendix—Complications

Study	Study type	Study size	Intervention	Control	Superior method	P-value	Complication type
Bass et al, 2023⁴	Prospective cohort study	2252 patients	Energy device	Electrocautery	Energy device	P = 0.002	Any complication
Bass et al, 2023⁴	Prospective cohort study	2252 patients	Energy device	Electrocautery	Energy device	P = 0.045	Any severe complication
Sucullu et al, 2009²⁹	Randomized controlled trial	32 patients	Electrocautery	Electrocautery in combination with clips	No significant difference	Missing	Any complication
Doepker et al, 2014³¹	Retrospective cohort study	838 patients	Energy source (electrocautery or energy device)	Non-energy source (staples, loops, or clips)	No significant difference	P = 0.548	Bleeding event
Doepker et al, 2014³¹	Retrospective cohort study	838 patients	Energy source	Non-energy source	No significant difference	P = 0.653	Postoperative transfusion
Doepker et al, 2014³¹	Retrospective cohort study	838 patients	Energy source	Non-energy source	No significant difference	P = 0.345	Postoperative anemia
Tartaglia et al, 2020³³	Retrospective cohort study	2076 patients	Electrocautery	Clips	Electrocautery	P < 0.001	Intra-abdominal abscess

Discussion

Evidence regarding the effect of appendiceal stump closure technique on surgical duration remains inconsistent. Several studies, including randomized controlled trials (RCTs) and meta-analyses,^15,17 found no significant difference between clips and loops,^{4,15-17,19,34} clips and staples,^17,35,36 loop ligatures and staples,^22,34,37 sutures and loop ligatures,¹⁷ sutures and clips,¹⁷ or sutures and staples.¹⁷ Conversely, other investigations, including a randomized controlled trial and 2 meta-analyses,^6,10,14 demonstrated that loop ligatures were slower than clips,^{10,12-14,38-40} staples,^6,24 and energy devices⁴¹; sutures exhibited similar delays.^9,36,38 Bass et al (2023) and Galatioto et al (2013), however, reported the opposite trend, with loop ligatures being faster than staples.^4,42 This discrepancy may be attributable to study design, as the observational nature of these studies and lack of case-selection data suggest potential bias. Staples may have also been reserved for more complex cases.

For mesoappendix division, electrocautery and energy devices appear superior to clips, loops, and sutures, with respect to surgical duration, as supported by 2 RCTs and 1 meta-analysis.^29,30 However, Bass et al (2023) observed no significant difference between electrocautery and energy devices after adjusting for confounders.⁴ Future research should prioritize patients with complicated appendicitis, since most current evidence, derived primarily from uncomplicated cases, demonstrates minimal differences in key outcomes across devices. Trials focusing on complicated cases are more likely to determine whether specific techniques provide meaningful clinical advantages in settings where inflammation, contamination, and anatomical challenges may affect device performance.

Findings regarding the correlation between appendiceal stump closure technique and total hospital stay are similarly heterogeneous. Several studies detected no association between closure technique and hospital LOS.^6,9,10,15,20 Among studies reporting differences, clips were generally associated with the shortest LOS,^4,21,36,40 whereas staples were associated with longer LOS compared with clips and loops.^4,21 Comparative evidence regarding sutures, electrocautery, and energy devices remains limited.⁴³ For mesoappendix division, no significant differences in LOS were identified among any techniques.^4,31

Most studies identified clips as the most cost-effective method for appendiceal stump closure,^20-22,44-47 while staples consistently represented the most expensive option.^{20,21,24,25,44,47-49} The cost of loop ligatures typically fell between these choices.^{20,22,25,26,46} For mesoappendix division, electrocautery was the least expensive technique, followed by staples or clips, with energy devices representing the most expensive option.^16,31,32 However, several limitations affect the interpretation of these findings. Some comparisons in the source studies are inconsistently reported, a limitation that cannot be fully resolved without access to the underlying data. Cost-effectiveness results are also difficult to interpret across studies due to multiple currencies and nearly 2 decades of economic change. Converting all costs to a single standardized currency and year was not feasible, which inherently limits comparability and precision. Additionally, familiarity bias may have influenced outcomes, whereby results tend to favor operative techniques most routinely performed by the surgeons in each study. This well-recognized phenomenon in procedural research may further limit the generalizability of comparative findings.

Overall intra- and postoperative complication rates appear broadly comparable across most closure techniques.^{4,19,24,27,36,38,44,45,50-58} Among studies reporting differences, loop ligatures were associated with higher overall complication rates than staples.^6,24,28,59 In a meta-analysis of RCTs, Antoniou et al (2017) found that clips were linked to a greater incidence of surgical site infections compared with loops and sutures.⁷ Additionally, 2 studies showed an increased risk of organ/space infections and intra-abdominal abscesses with loops compared to clips.^7,60

For mesoappendix division, most studies reported no significant differences in bleeding, transfusion requirement, postoperative anemia, infection rate, or reoperation frequency across techniques.^4,29,31 Nevertheless, Bass et al (2023) found electrocautery to be associated with higher rates of overall and severe complications compared to energy devices after adjustment for confounders.⁴ Tartaglia et al (2020) reported that clips were more frequently correlated with intra-abdominal abscesses compared to electrocautery.³³

Recent innovations in appendiceal stump closure, minimally invasive access, and digital integration are advancing appendectomy toward greater efficiency, safety, and patient-centered care. A 2025 meta-analysis comparing single-incision (SILA) and conventional laparoscopic appendectomy (CLA) found no significant differences in hospital stay, surgical duration, or complication rates, confirming both as viable options.⁶¹ Another randomized trial comparing a modified single-port approach using needle-type grasping forceps (mSLAN) with conventional three-port laparoscopic appendectomy demonstrated comparable short-term outcomes and surgical duration but superior cosmetic results, supporting its potential for wider clinical use.⁶²

Indocyanine green (ICG) fluorescence angiography (FA) provides real-time visualization of tissue perfusion, improving intraoperative assessment and surgical decision-making.⁶³ Zorzetti et al (2023) showed that ICG-FA reliably evaluates appendiceal stump vascularization, allowing perfusion-guided adjustments that may reduce postoperative complications.⁶³ Moreover, robotic-assisted appendectomy has emerged as a feasible alternative to conventional laparoscopy. Comparative studies report equivalent safety and efficacy, though robotic procedures may offer shorter hospital stays and faster recovery at higher cost and with longer surgical duration.^64,65

Digital technologies further enhance perioperative care. Artificial intelligence models now outperform traditional methods in predicting postoperative complications, mortality, and wound-related events, as highlighted in a 2025 BJS abstract.⁶⁶ Deep learning–based approaches for surgical instrument annotation also show promise in improving intraoperative precision, surgical training, and overall patient outcomes.⁶⁷

As value-based healthcare gains focus, comprehensive cost evaluation has become integral to surgical innovation. While clips remain the most economical option for appendiceal stump closure and staples the most expensive, such comparisons overlook total procedural costs. Time-Driven Activity-Based Costing (TDABC) provides a more complete framework, encompassing surgical duration, personnel, anesthesia, and instrument reprocessing. A pediatric TDABC study reported a mean total cost of $2753.39 per case, primarily driven by personnel and operating room expenses.⁶⁸ Efficiency improvements were linked to triage-based delegation, advanced practice provider integration, and same-day discharge. No comparable adult analyses exist, but similar evaluations could identify opportunities for cost and resource optimization through standardization, scheduling, and staffing strategies. Incorporating sustainability metrics, such as carbon footprint, waste reduction, and device reusability, will further align appendectomy practices with economic and environmental efficiency.

Conclusion

Appendiceal stump closure and mesoappendix division can be performed using various techniques, and instruments, each offering distinct advantages depending on the outcome assessed. While this review outlines important differences in specific perioperative and postoperative outcomes, the available evidence does not allow for firm recommendations at this stage. No single technique emerges as universally superior. Consequently, decisions should be individualized, with surgeons, and institutions weighing operative efficiency, cost, and complication risk in the context of their own experience, patient characteristics, and local resources.

Supplemental Material

Supplemental material - Techniques for Mesoappendix Division and Appendix Resection: A Comparative Review

Supplemental material for Techniques for Mesoappendix Division and Appendix Resection: A Comparative Review by Lovisa Ekestubbe, MD, Maximilian P. Forssten, MD, Sebastian P. Forssten, MD, Gary A. Bass, MD, MSc, MBA, PhD, Yousef AlHussaini, MD and Shahin Mohseni, MD, PhD in The American Surgeon

Footnotes

ORCID iDs

Maximilian P. Forssten

Shahin Mohseni

Author Contributions

Conception and Study Design: Lovisa Ekestubbe, Maximilian P. Forssten, Gary A. Bass, Shahin Mohseni; Literature Review: Lovisa Ekestubbe, Maximilian P. Forssten, and Yousef AlHussaini; Data Acquisition: Lovisa Ekestubbe and Maximilian P. Forssten; Data Analysis and Interpretation: Lovisa Ekestubbe, Maximilian P. Forssten, and Sebastian P. Forssten; Drafting of the Manuscript: Lovisa Ekestubbe, Maximilian P. Forssten, and Gary A. Bass; Critical Revision: Sebastian P. Forssten, Yousef AlHussaini, and Shahin Mohseni.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material is available online.

References

Bhangu

Søreide

Di Saverio

Assarsson

Drake

. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278-1287.

Guan

Liu

Pan

, et al. The global, regional, and national burden of appendicitis in 204 countries and territories, 1990–2019: a systematic analysis from the global burden of disease study 2019. BMC Gastroenterol. 2023;23:44.

Köhler

Hendricks

Kastner

, et al. Laparoscopic appendectomy versus antibiotic treatment for acute appendicitis-a systematic review. Int J Colorectal Dis. 2021;36(10):2283-2286.

Bass

Kaplan

Forssten

Walsh

Cao

Mohseni

ESTES SnapAppy Group . Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study. Eur J Trauma Emerg Surg. 2023;49(1):17-32.

Singh

Anand

Pakkasjärvi

Verma

Bajpai

. Energy devices for clipless-sutureless laparoscopic appendectomy: a systematic review and meta-analysis on utility and safety. Medicina. 2022;58(11):1535.

Kazemier

in’t Hof

Saad

Bonjer

Sauerland

. Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling? Surg Endosc. 2006;20(9):1473-1476.

Antoniou

Mavridis

Hajibandeh

, et al. Optimal stump management in laparoscopic appendectomy: a network meta-analysis by the minimally invasive surgery synthesis of interventions and outcomes network. Surgery. 2017;162(5):994-1005.

Meneses

Ferreira De Castro

Tomé

Ferreira

. Applications of different energy devices in laparoscopic and robotic gynecological surgery: a systematic review. Arch Gynecol Obstet. 2025;312(3):691-719.

Ates

Dirican

Ince

Ara

Isik

Yilmaz

. Comparison of intracorporeal knot-tying suture (Polyglactin) and titanium endoclips in laparoscopic appendiceal stump closure: a prospective randomized study. Surg Laparosc Endosc Percutaneous Tech. 2012;22(3):226-231.

10.

Sadat-Safavi

Nasiri

Shojaiefard

, et al. Comparison the effect of stump closure by endoclips versus endoloop on the duration of surgery and complications in patients under laparoscopic appendectomy: a randomized clinical trial. J Res Med Sci. 2016;21:87.

11.

Najah

Makhlouf

Abusalah

, et al. Effectiveness of different appendiceal stump closure methods in laparoscopic appendectomy a network meta-analysis. Langenbecks Arch Surg. 2024;409(1):270.

12.

Almeida

Medina

LHA

Coelho

, et al. Endoloop versus metallic clip for stump closure in laparoscopic appendectomy: a systematic review and meta-analysis. Cureus. 2025;17(1):e77471.

13.

Farahani

Safaei

. Comparison of two methods: clipping and suturing in laparoscopic appendectomy. Surg Open Sci. 2024;19:162-165.

14.

Poon

SHT

Law

Lai

ATY

. Clips closure versus endoloop ligation in laparoscopic appendectomy: a systematic review and meta-analysis of comparative studies. Ann Med Surg. 2023;85(10):5011-5021.

15.

Colak

Kement

Ozlem

, et al. A comparison of nonabsorbable polymeric clips and endoloop ligatures for the closure of the appendicular stump in laparoscopic appendectomy: a prospective, randomized study. Surg Laparosc Endosc Percutaneous Tech. 2013;23(3):255-258.

16.

Lee

Park

. Advantages of using a polymeric clip versus an endoloop during laparoscopic appendectomy in uncomplicated appendicitis: a randomized controlled study. World J Emerg Surg. 2023;18(1):39.

17.

Knight

Ibrahim

Makaram

Patil

Wilson

MSJ

. The use of polymeric clips in securing the appendiceal stump during laparoscopic appendicectomy: a systematic review. Eur J Trauma Emerg Surg. 2019;45(4):665-670.

18.

Yildirim

Koca

Tufekci

Saglam

Ozkan

. Handmade loop versus Hem-o-Lok clip in closure of appendiceal stump during laparoscopic appendectomy: limited setting in a peripheral university hospital. J Laparoendosc Adv Surg Tech. 2024;34(9):822-828.

19.

Yaron

Hagai

Nayyera

Nili

Shai

Shmuel

. Appendiceal stump closure in laparoscopic appendectomy: one endoloop vs. two endoloops vs. two endoclips-does it matter? Langenbecks Arch Surg. 2023;408(1):270.

20.

Marcinkeviciute

Luksaite-Lukste

Jasiunas

Poskus

. Self-locking polymeric clips are safe for the closure of appendiceal stump in laparoscopic appendectomy. Medicina. 2023;59(3):533.

21.

Kliuchanok

Keßler

Partecke

, 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(6):711-716.

22.

Wilson

Maniam

Ibrahim

Makaram

Knight

Patil

. Polymeric clips are a quicker and cheaper alternative to endoscopic ligatures for securing the appendiceal stump during laparoscopic appendicectomy. Ann R Coll Surg Engl. 2018;100(6):454-458.

23.

Bozkurt

Ünsal

Kapan

Kankaya

Kalaycı

Alış

. Two different methods for appendiceal stump closure: metal clip and Hem-o-lok clip. J Laparoendosc Adv Surg Tech. 2014;24(8):571-573.

24.

Beldi

Vorburger

Bruegger

Kocher

Inderbitzin

Candinas

. Analysis of stapling versus endoloops in appendiceal stump closure. Br J Surg. 2006;93(11):1390-1393.

25.

Hilsden

Khan

Vogt

Schlachta

. Staplers vs. loop-ligature: a cost analysis from the hospital payer perspective. Surg Endosc. 2019;33(10):3419-3424.

26.

DeMare

Luehmann

Kawak

, et al. Cost-effective approach to the laparoscopic appendectomy: balancing disposable instrument cost with operative time. Am Surg. 2020;86(6):715-720.

27.

Ureyen

Tan

Dadalı

Yıldırım

İlhan

. Hem-o-lok clips versus intracorporeal knotting for the closure of the appendix stump in laparoscopic appendectomy: a prospective randomized study. Ulus Travma Acil Cerrahi Derg. 2020;26(3):384-388.

28.

Ceresoli

Tamini

Gianotti

Braga

Nespoli

. Are endoscopic loop ties safe Even in complicated acute appendicitis? A systematic review and meta-analysis. Int J Surg. 2019;68:40-47.

29.

Sucullu

Filiz

Kurt

Yilmaz

Yildiz

. The effects of LigaSure on the laparoscopic management of acute appendicitis: “LigaSure assisted laparoscopic appendectomy.”. Surg Laparosc Endosc Percutaneous Tech. 2009;19(4):333-335.

30.

Qaiser

Nazir

Khan

Butt

Anwar

. Comparison of ultrasonic dissection and suture ligation for mesoappendix in laparoscopic appendectomy. Cureus. 2021;13(4):e14316.

31.

Doepker

Gregg

Meeker

Ellis

Grannan

. Does the use of newer technology to divide the mesoappendix result in less bleeding? A retrospective analysis. Journal of Current Surgery. 2014;4(1):6-9.

32.

Chu

Chandhoke

Smith

Schwaitzberg

. The impact of surgeon choice on the cost of performing laparoscopic appendectomy. Surg Endosc. 2011;25(4):1187-1191.

33.

Tartaglia

Fatucchi

Mazzoni

, et al. Risk factors for intra-abdominal abscess following laparoscopic appendectomy for acute appendicitis: a retrospective cohort study on 2076 patients. Updates Surg. 2020;72(4):1175-1180.

34.

Yıldız

Koca

. Is there an ideal stump closure technique in laparoscopic appendectomy? Surg Technol Int. 2016;28:117-120.

35.

Zaninotto

Rossi

Anselmino

, et al. Laparoscopic versus conventional surgery for suspected appendicitis in women. Surg Endosc. 1995;9(3):337-340.

36.

Strzałka

Matyja

Rembiasz

. Comparison of the results of laparoscopic appendectomies with application of different techniques for closure of the appendicular stump. World J Emerg Surg. 2016;11:4.

37.

van Rossem

van Geloven

AAW

Schreinemacher

MHF

Bemelman

snapshot appendicitis collaborative study group . Endoloops or endostapler use in laparoscopic appendectomy for acute uncomplicated and complicated appendicitis: no difference in infectious complications. Surg Endosc. 2017;31(1):178-184.

38.

Ozdemir

Sunamak

. Comparison of the non-absorbable polymer clips, knot-tying, and loop ligature appendiceal stump closure methods in laparoscopic appendectomy. Cir Cir. 2022;90(2):193-196.

39.

Kim

Jeon

Cho

Shin

Moon

. Clinical outcomes of locking polymeric clip for laparoscopic appendectomy in patients with appendicitis: a retrospective comparison with loop ligature. Ann Coloproctol. 2022;38(2):160-165.

40.

Jenwitheesuk

Chotikawanich

Saeseow

Thanapaisal

Punchai

Paonariang

. Laparoscopic appendectomy: results of a new technique for stump management. J Med Assoc Thail. 2012;95(Suppl 11):S7-S10.

41.

Gupta

Singh

Bansal

Pandey

. Sutureless appendectomy by using harmonic scalpel: is it possible? J Laparoendosc Adv Surg Tech. 2020;30(4):429-432.

42.

Galatioto

Guadagni

Zocco

, et al. Mesoappendix and appendix stump treatment in laparoscopic appendectomy: a retrospective study in 1084 patients. Ann Ital Chir. 2013;84(3):269-274.

43.

Bao

Wang

Tang

Meng

. Application and curative effect of laparoscopic purse-string sutures in the treatment of adult acute complicated appendicitis. BMC Surg. 2023;23(1):1.

44.

Delibegović

Matović

. Hem-o-lok plastic clips in securing of the base of the appendix during laparoscopic appendectomy. Surg Endosc. 2009;23(12):2851-2854.

45.

Delibegović

Mehmedovic

. The influence of the different forms of appendix base closure on patient outcome in laparoscopic appendectomy: a randomized trial. Surg Endosc. 2018;32(5):2295-2299.

46.

Lucchi

Berti

Grassia

Siani

Gabbianelli

Garulli

. Laparoscopic appendectomy: hem-O-Lok versus endoloop in stump closure. Updates Surg. 2017;69(1):61-65.

47.

Al-Temimi

Berglin

Kim

Tessier

Johna

. Endostapler versus Hem-O-Lok clip to secure the appendiceal stump and mesoappendix during laparoscopic appendectomy. Am J Surg. 2017;214(6):1143-1148.

48.

Matyja

Strzałka

Rembiasz

. Laparosocopic appendectomy, cost-effectiveness of three different techniques used to close the appendix stump. Pol Przegl Chir. 2015;87(12):634-637.

49.

Mehdorn

Schürmann

Mehdorn

Gockel

. Intended cost reduction in laparoscopic appendectomy by introducing the endoloop: a single center experience. BMC Surg. 2017;17(1):80.

50.

Vuille-Dit-Bille

Soll

Mazel

Staerkle

Breitenstein

. Appendiceal stump closure with polymeric clips is a reliable alternative to endostaplers. J Int Med Res. 2020;48(1):300060519856154.

51.

Strzałka

Matyja

Rembiasz

. Results of laparoscopic appendectomies performed with the use of titanium clips for closure of the appendicular stump. Pol Przegl Chir. 2014;86(9):418-421.

52.

Arer

Avci

Yabanoglu

. Hand-made extracorporeal knotting versus Hem-o-Lok clip for stump closure in laparoscopic appendectomy. J Coll Physician Surg Pak. 2019;29(12):1203-1206.

53.

Shadhu

Ramlagun

Wang

, et al. Re-evaluation of purse string suture in laparoscopic appendectomy. Surg Endosc. 2020;34(2):779-786.

54.

Okamoto

Otowa

Fujinaka

, et al. Purse-string suture after ligating by endoloop for closing of the appendiceal stump is an alternative for endostapler in selected cases: a propensity score-matched study. Asian J Endosc Surg. 2021;14(4):775-781.

55.

Swank

van Rossem

van Geloven

Aa. W

, et al. Endostapler or endoloops for securing the appendiceal stump in laparoscopic appendectomy: a retrospective cohort study. Surg Endosc. 2014;28(2):576-583.

56.

Sahm

Kube

Schmidt

Ritter

Pross

Lippert

. Current analysis of endoloops in appendiceal stump closure. Surg Endosc. 2011;25(1):124-129.

57.

Sohn

Hoffmann

Pohlen

, et al. [stump closure in laparoscopic appendectomy. Influence of endoloop or linear stapler on patient outcome]. Chirurgia (Buchar). 2014;85(1):46-50.

58.

Hue

Kim

Nam

Kim

. The usefulness and safety of Hem-o-lok clips for the closure of appendicular stump during laparoscopic appendectomy. J Korean Surg Soc. 2013;84(1):27-32.

59.

Lasek

Wysocki

Mavrikis

, et al. Pol-LA Polish Laparoscopic Appendectomy Collaborative Study Group. Comparison of stump closure techniques during laparoscopic appendectomies for complicated appendicitis - results from Pol-LA (Polish laparoscopic appendectomy) multicenter large cohort study. Acta Chir Belg. 2020;120(2):116-123.

60.

Soll

Wyss

Gelpke

Raptis

Breitenstein

. Appendiceal stump closure using polymeric clips reduces intra-abdominal abscesses. Langenbecks Arch Surg. 2016;401(5):661-666.

61.

Kossenas

Kouzeiha

Moutzouri

Georgopoulos

. Single-incision versus conventional laparoscopic appendectomy in adults: a systematic review and meta-analysis of randomized controlled trials. Updates Surg. 2025;77(2):287-296.

62.

Chen

Guo

, et al. Modified single-port laparoscopic appendectomy using needle-type grasping forceps vs conventional three-port laparoscopic appendectomy for acute uncomplicated appendicitis. World J Gastrointest Surg. 2025;17(4):102607.

63.

Zorzetti

Lauro

Cuoghi

, et al. A hypothetical new challenging use for indocyanine green fluorescence during laparoscopic appendectomy: a mini-series of our experience and literary review. J Clin Med. 2023;12(16):5173.

64.

Reddy

Tote

Zade

, et al. Comparative analysis of robotic-assisted versus laparoscopic appendectomy: a review. Cureus. 2024;16(6):e63488.

65.

Becker

DeLeon

Rao

Pei

. A comparison of outcomes between laparoscopic and robotic appendectomy among ACS-NSQIP hospitals. Laparoscopic, Endoscopic and Robotic Surgery. 2023;6(2):39-42.

66.

Shaikh

Saunders

Khalifa

. eP115 ‘use of artificial intelligence in predicting outcomes of emergency surgical procedures. Br J Surg. 2025;112(Supplement_1):318.090.

67.

Ahmed

Yousef

Ahmed

, et al. Deep learning for surgical instrument recognition and segmentation in robotic-assisted surgeries: a systematic review. Artif Intell Rev. 2024;58(1):1.

68.

Abbas

Smith

, et al. Time-driven activity-based costing to identify opportunities for cost reduction in pediatric appendectomy. J Pediatr Surg. 2016;51(12):1962-1966.

69.

Altman

Bland

, et al. How to obtain the P value from a confidence interval. BMJ. 2011. Aug 8;343:d2304. https://www.bmj.com/content/343/bmj.d2304.long.