SMJ Current Issue

The handmade endoloop technique. A simple and cheap technique for laparoscopic appendectomy
  Fahrettin  Yildiz,  Alpaslan  Terzi,  Sacid  Coban,  Nazif  Zeybek,  Ali  Uzunkoy

Objectives: To compare 2 laparoscopic appendectomy techniques.
Methods: We describe a modified technique, the handmade endoloop technique, for closing the base of the appendix. This prospective study was carried out at Harran University Medical Faculty, Sanliurfa, and Gulhane Military Medical Academy, Ankara, Turkey from September 2006 to February 2008. We evaluated the safety and efficacy of the procedure in 98 acute appendicitis cases: 57 patients handmade endoloop patients, and 41 endoloop technique patients. Operative time, postoperative complications, need for analgesics, and procedure cost were measured for both groups. The endoloops and sutures used to manage appendectomy were listed at current prices, summarized as number consumed per case, and compared. Data were analyzed by appropriate test.
Results: The average price of material used for closing the base of appendix was 81 American Dollars (USD) for laparoscopic appendectomy with endoloop, and 8 USD for the technique described by this article. Overall, postoperative complications, operative time, and the need for analgesia did not show a statistical difference in comparing both groups.
Conclusions: This procedure is simple, safe, and cheap.

Saudi Medical Journal 2009; Vol. 30 (2): 224-227 doi:


Laparoscopic appendectomy is preferred by many surgeons due to numerous documented advantages of this approach. Studies have shown advantages of laparoscopic appendectomy to include precise operative diagnosis, lower morbidity, decreased intra-abdominal scarring, shortened length of stay, and fewer intraoperative and postoperative complications.1-3sup> However, increased cost often is cited against the general use of laparoscopic appendectomy.4sup> The most important reason that contributes largely to the elevated cost of laparoscopic appendectomy is the disposable equipment used during the procedure. The use of the endoloop or endostapler, as disposable equipment, in laparoscopic appendectomy for closing the base of appendix is more common. To diminish the cost of laparoscopic appendectomy, several methods have been essayed, such as the one- or 2-trocar techniques,5sup> instrument-assisted knotting,6sup> and closure of the stump by clip applier7sup> rather than endoloop suture or endostaplers. The objectives of the present study were to establish the feasibility of the closure of the appendicular stump by using a handmade Vicryl loop; to establish whether differences exist in the postoperative course, in comparison with those patients whose appendicular stump was closed with endoloop; and to compare the cost of both techniques and evaluate whether the use of a handmade Vicryl loop is a safe alternative for laparoscopic appendectomies. We carried out the following prospective study, because we believe that using the handmade loop knot, which has been used in many open procedures, is a safe method for closure of the appendiceal stump during laparoscopic appendectomy.

Methods.b>span>span> This prospective study was carried out at Harran University Medical Faculty, Sanliurfa and Gulhane Military Medical Academy, Ankara, Turkey from September 2006 to February 2008; and 98 consecutive laparoscopic appendectomies were performed. We consulted with the Chair of the local Research Ethics Committee of Harran University Medical Faculty on the procedures. The patients were verbally informed about the details, risks, and benefits of the technique, and consents were obtained under the supervision of Bioethics consultant in some cases. The choice of the approach was made by the operating surgeon with the approval of the patients. Patients in the study included one group of 57 patients (group I) who underwent laparoscopic appendectomy with a handmade endoloop technique for closing the base of the appendix. A second group included 41 patients (group II) who underwent laparoscopic appendectomy technique by using endoloop. All of the patients received the same preoperative antibiotics according to the institutional protocol. In both techniques, access to the peritoneum was carried out and the peritoneum was opened in direct vision, than the 10-mm, reusable first trocar was placed in the subumbilical position. Two reusable 5-mm ports were placed in the left iliac fossa position and median suprapubic position. After the initial laparoscopic evaluation of the abdominal cavity, the appendicular mesentery was dissected meticulously by unipolar forceps. Ligation of the appendicular base was carried out using 3 endoloops (Ethicon Endosurgery,Cincinnati, Ohio, USA), placing 2 of them in the proxim


From the Department of General Surgery (Yildiz, Terzi, Uzunkoy), Harran University Medical Faculty, Sanliurfa, and the Department of General Surgery (Coban), Gaziantep University Medical Faculty, Gaziantep, and the Department of General Surgery (Zeybek), Gulhane Military Medical Faculty, Ankara, Turkey.

Received 28th October 2008. Accepted 5th January 2009.

Address correspondence and reprint request to: Dr. Fahrettin Yildiz, Department of General Surgery, Harran University Medical Faculty, Sanliurfa 63300, Turkey. E-mail:




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 span> span>2.  span>Schick KS, Hüttl TP, Fertmann JM, Hornung HM, Jauch KW, Hoffmann JN. A critical analysis of laparoscopic appendectomy: how experience with 1,400 appendectomies allowed innovative treatment to become standard in a university hospital. span>World J Surgspan>span> 2008; 32: 1406-1413.

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