Handmade loop ligation versus Hem-o-lok clip closure for appendiceal stump management in laparoscopic appendectomy: a propensity score-matched study with direct material cost analysis.

backgroundLaparoscopic appendectomy is widely accepted as the standard surgical treatment for acute appendicitis. Several methods have been described for appendiceal stump closure, including handmade loop ligation and Hem-o-lok clip closure. Although Hem-o-lok clips are technically simple, their use increases direct material cost. The aim of this study was to compare perioperative outcomes, postoperative complications, and direct material costs between handmade loop ligation and Hem-o-lok clip closure during laparoscopic appendectomy.

methodsThis retrospective cohort study included adult patients who underwent laparoscopic appendectomy for acute appendicitis at a tertiary academic center. Patients were grouped according to appendiceal stump closure method. Propensity scores were estimated using age, sex, ASA class, previous abdominal surgery, preoperative white blood cell count, appendix diameter, periappendiceal fluid, and cecal edema. Histopathologic type was not included in the propensity model because it was unavailable at the time of intraoperative treatment allocation. BMI and preoperative temperature were excluded because of substantial missingness. One-to-one matching was performed using a caliper of 0.2 standard deviations of the logit of the propensity score, with exact matching for sex, ASA class, and cecal edema. Balance was evaluated using standardized mean differences. Direct material cost was calculated using institutional unit prices.

resultsThe raw dataset included 695 patients, comprising 652 patients in the handmade loop group and 43 in the Hem-o-lok group. BMI and preoperative temperature were missing in 609 (87.6%) and 614 (88.3%) patients, respectively. After the matching procedure, 35 well-defined pairs were obtained (n = 70). Operation time, length of hospital stay, time to first flatus, conversion to open surgery, postoperative complications, major complications, intra-abdominal abscess, and 30-day readmission did not differ significantly between groups. Drain placement was more frequent in the handmade loop group [6/35 (17.1%) vs. 0/35 (0.0%), p = 0.025; risk difference 17.1%, 95% CI 3.7 to 32.7]. Direct material cost per patient was 75 TL for handmade loop ligation and 570 TL for Hem-o-lok closure, corresponding to a 495 TL per-patient cost difference.

conclusionAfter propensity score matching, handmade loop ligation and Hem-o-lok clip closure showed no statistically significant differences in most short-term perioperative and postoperative outcomes, although drain placement was higher in the handmade loop group. Handmade loop ligation was associated with substantially lower direct material cost. Because of the retrospective design, small matched sample, residual imbalance in some covariates, and limited power for rare complications, these findings should be interpreted cautiously and should not be considered proof of equivalence.