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Effectiveness of different appendiceal stump closure methods in laparoscopic appendectomy in children: A systematic
Waleed A Elsayed1, Sayed Ahmed Elhadi2, Dalia Gad3
1Department of Pediatric Surgery, King Fahd Hospital of University, Imam Abdulrahman bin Faisal University, Khobar 34447, Saudi Arabia. wasayed@iau.edu.sa.
Insights
In pediatric laparoscopic appendectomy, all stump closure methods have similar safety. Harmonic scalpel (HS) significantly reduces operative time compared to endoloops (ELs).
Area of Science:
- Pediatric Surgery
- Surgical Techniques
- Evidence-Based Medicine
Background:
- Laparoscopic appendectomy (LA) is standard for pediatric acute appendicitis.
- Secure appendiceal stump closure is vital to prevent complications.
- Optimal closure technique lacks clear evidence.
Purpose of the Study:
- To systematically evaluate and rank pediatric LA stump closure techniques.
- To compare effectiveness and safety of various methods.
- To provide evidence for clinical decision-making.
Main Methods:
- Systematic review and network meta-analysis (PRISMA, Cochrane).
- Searched major databases up to May 2025.
- Included randomized and non-randomized studies; assessed bias (Newcastle-Ottawa Scale).
- Frequentist network meta-analysis (random-effects model) in R software.
- Analyzed total complications, operative time, and hospital stay; ranked using P-scores.
Main Results:
- Included 14 studies with over 50,000 pediatric patients.
- No significant differences in total complications or hospital stay across techniques (EL, stapler, clip, LigaSure, HS, sutures).
- Harmonic scalpel (HS) significantly reduced operative time vs. endoloops (EL) (-13.5 min).
- No technique showed increased/decreased complications or length of stay.
Conclusions:
- All appendiceal stump closure techniques demonstrate comparable safety profiles.
- Harmonic scalpel (HS) offers reduced operative time.
- Method selection can be based on efficiency and available resources.
Background:
Laparoscopic appendectomy (LA) is the standard treatment for acute appendicitis in children, offering reduced postoperative pain and quicker recovery compared to open surgery. A critical aspect of LA is the secure closure of the appendiceal stump to avoid complications such as leakage and abscess formation. Various closure techniques are employed, including endoloops (ELs), staplers, clips, and energy devices; however, the optimal method remains unclear due to inconsistent evidence.
Aim:
To systematically evaluate and rank the effectiveness and safety of different appendiceal stump closure techniques used in pediatric LA. By assessing outcomes such as postoperative complications, operative time, and length of hospital stay, this analysis seeks to provide evidence-based guidance to clarify clinical decision-making and optimize patient care.
Methods:
This systematic review and network meta-analysis, conducted according to PRISMA and Cochrane guidelines, compared the effectiveness and safety of stump closure methods in pediatric LA. Databases searched included PubMed, Cochrane Central, Web of Science, and Scopus up to May 1, 2025. Eligible studies included both randomized and non-randomized designs reporting surgical outcomes in pediatric patients. Two reviewers independently extracted data and assessed the risk of bias using the Newcastle-Ottawa Scale. A frequentist network meta-analysis with a random-effects model was conducted using R software to evaluate total complications (primary outcome), as well as operative time and hospital stay (secondary outcomes). P-scores were used to rank the effectiveness of treatments.
Results:
Fourteen studies comprising over 50000 pediatric patients were included in the network meta-analysis comparing appendiceal stump closure techniques in LA. No significant differences in total postoperative complications or hospital stay were observed among techniques, including EL, endostapler, polymer clip, LigaSure, harmonic scalpel (HS), and sutures. HS showed a statistically significant reduction in operative time compared to EL (mean difference: -13.5 minutes), while other methods did not demonstrate significant time savings. No technique was associated with a statistically significant increase or decrease in postoperative complications or length of stay. Publication bias was minimal, and the methodological quality of included studies was moderate to good.
Conclusion:
While all closure techniques show similar safety profiles, HS offers shorter operating times. These findings support tailoring stump closure method selection based on operative efficiency and resource availability.
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