Effectiveness of different appendiceal stump closure methods in laparoscopic appendectomy in children: A systematic review and network meta-analysis

Table 1 Summary of the studies included

Ref.	Study design	Setting	Population	Intervention	Comparison	Outcomes
Akbiyik et al[24]	Prospective cohort	Türkiye	Pediatric patients underwent laparoscopic appendectomy with appendiceal stump closure using either endoloop ligatures or nonabsorbable polymer clips	Nonabsorbable pre-tied endoloop ligature	Two Hem-o-lok® clips (nonabsorbable polymeric clips)	Nonabsorbable polymer clips are a safe, efficient, and cost-effective alternative to endoloop ligatures for pediatric laparoscopic appendectomy, offering shorter ligation time and lower cost without added complications
Akkoyun and Akbiyik[25]	Retrospective cohort	Türkiye	Pediatric patients underwent laparoscopic appendectomy with appendiceal stump closure using nonabsorbable polymeric clips (Hem-o-lok)	In all cases, the appendiceal stump was closed using nonabsorbable polymeric clips (Hem-o-lok): Either a double clip closure or a single clip closure		Polymeric clips demonstrated safety and effectiveness for pediatric laparoscopic appendectomy, with short operative and recovery times, minimal complications confined to perforated cases, and no long-term clip-related issues during 13 months of follow-up
Escolino et al[12]	Retrospective cohort	Multicenter	Pediatric patients underwent laparoscopic appendectomy with appendiceal stump closure using endoloop vs endostapler	Endoloop	Endo stapler	Compared with endoloop ligation, endostapler closure yielded fewer postoperative complications and lower overall costs despite higher supply expenses, with comparable operative and recovery outcomes, supporting its superior safety and cost-effectiveness
Juan et al[19]	Cross-sectional	Colombia	Pediatric patients underwent laparoscopic appendectomy with appendiceal stump closure using a bipolar sealing device (Ligasure)	The bipolar sealing device (LigaSure) closes the appendiceal stump by applying multiple consecutive seals with controlled energy delivery		The median operative time was 60 minutes with an average hospital stay of 2.8 days, and no stump leakage occurred; complications were rare (1% organ-space infection) and showed no association with stump closure method or appendix condition (P = 0.450)
Kocaman et al[23]	Retrospective cohort	Türkiye	Patients underwent laparoscopic appendectomy with appendiceal stump ligation using endoloop vs LigaSure	Endoloop	LigaSure	LigaSure significantly reduced operative time compared with endoloop (29.6 minutes vs 39.2 minutes, P < 0.001), with no stump leakage or intra-abdominal abscess in either group, though port site infection was slightly more frequent with endoloop (P = 0.043)
Martinez et al[14]	Retrospective cohort	United States	Pediatric patients underwent a laparoscopic appendectomy for acute, uncomplicated appendicitis, for which the appendiceal stump was managed with either a Surgical stapler or a polymeric clip	Polymeric clip	Surgical stapler	Both groups had comparable safety with no significant differences in complications, ED visits, reinterventions, or mortality; however, polymeric clips were associated with lower implant cost and longer operative time, while the stapler group involved slightly older patients and a nonsignificant increase in complications
Miyano et al[13]	Prospective cohort	Japan	Pediatric patients underwent a laparoscopic appendectomy for acute, uncomplicated appendicitis, for which the appendiceal stump was managed with either an endoloop or an endostapler	Endoloop	Endostapler	Loop and stapler techniques showed comparable safety and outcomes across demographic, clinical, and postoperative parameters, with low complication rates managed conservatively; stapling offered slightly shorter anesthesia time but at a significantly higher cost
Miyano et al[26]	Prospective cohort	Japan	Pediatric patients underwent a laparoscopic appendectomy for acute, complicated appendicitis, for which the appendiceal stump was managed with either an endoloop or an endostapler	Endoloop	Endostapler	Endostapler is more expensive, but there was no significant difference in morbidity for this technique, particularly with regard to the incidence of postoperative intra-abdominal abscess
Naiditch et al[20]	Retrospective cohort	United States	Pediatric patients underwent a laparoscopic appendectomy for acute appendicitis, for which the appendiceal stump was managed with either an endoloop or an endostapler	Endoloop	Endostapler	Endoloop and endostapler showed similar overall complication rates, though superficial wound infections were more frequent with endoloop in nonperforated cases (5.5% vs 0.9%, P = 0.007), while endoloop achieved shorter operative time in perforated appendicitis (52.2 minutes vs 58 minutes, P = 0.047)
Parikh et al[27]	Retrospective cohort	United States	Pediatric patients underwent a laparoscopic appendectomy for acute, for which the appendiceal stump was managed with either a looped suture or a stapler	Looped suture	Stapler	In pediatric laparoscopic appendectomy, looped suture and stapler techniques yielded comparable clinical outcomes, but looped suture was significantly more cost-effective, supporting its role as a safe and economical alternative
Pogorelić et al[22]	Prospective cohort	Egypt and Croatia	Pediatric patients underwent a laparoscopic appendectomy for acute appendicitis, for which the appendiceal stump was managed with either a polymeric clip or a harmonic stapler	Polymeric clip	Harmonic stapler	Compared with polymeric clips, the clipless technique in pediatric laparoscopic appendectomy was associated with fewer complications, shorter operative time and hospital stay, and less postoperative fever, suggesting a safer and more efficient alternative
Pogorelić et al[21]	Prospective cohort	Croatia	Pediatric patients underwent a laparoscopic appendectomy for acute appendicitis, for which the appendiceal stump was managed with either a polymeric clip or an endoloop	Polymeric clip	Endoloop	Polymeric clips provided comparable safety to endoloops in pediatric laparoscopic appendectomy, with similar complication rates but significantly shorter operative time and slightly reduced hospital stay, reflecting greater surgical efficiency
Safavi et al[10]	Retrospective cohort	Canada	Pediatric patients underwent a laparoscopic appendectomy for acute appendicitis, for which the appendiceal stump was managed with either an endoloop or an endostapler	Endoloop	Endostapler	In perforated appendicitis, endostapler use was linked to a higher rate of intra-abdominal abscess than endoloop (50% vs 12.7%) and was an independent predictor of abscess formation, while no significant differences were observed between techniques in non-perforated cases
Zeineddin et al[9]	Retrospective cohort	United States	Pediatric patients underwent a laparoscopic appendectomy	Endoloop	Stapler	Small bowel obstruction or reoperation after laparoscopic appendectomy is uncommon and mainly predicted by complicated appendicitis, with stapler use not significantly affecting these outcomes, leaving surgeon preference as the primary determinant of stump closure method

ED: Emergency department.

Table 2 Baseline characteristics of the included studies

Ref.	Intervention	Number	Number of boys	Age (years)	Cost	Follow-up
Akbiyik et al[24]	Polymeric clip	28	18	From 1 to 15	40 USD per two clips	1 week to 1 year
	Endoloop	21	14	From 3 to 15	121.5 USD per two endoloop
Akkoyun and Akbiyik[25]	Polymeric clip	121	67	From 3 to 15	10 USD for one clip	1-23 months
Escolino et al[12]	Endostapler	334	267	8.9	57.836 EUR for supplies	NA
	Endoloop	374	196	10.8	91.56 EUR for supplies
Juan et al[19]	LigaSure	209	116	9.7	NA	30 days
Kocaman et al[23]	LigaSure	94	51	12.5	NA	NA
	Endoloop	39	18	11.4
Martinez et al[14]	Polymeric Clip	17	10	10.06	35.36 USD total closure cost	30 days
	Surgical Stapler	90	50	11.95	375.67 USD total closure cost
Miyano et al[13]	Endostapler	81	48	10.8	1296 USD (anesthesia and one stapling set)	NA
	Endoloop	75	49	10.5	891 USD (anesthesia and 3 Loops)
Miyano et al[26]	Endostapler	31	13	9.7	Endostaple set at 550 USD	NA
	Endoloop	37	15	9.1	Endoloop at 48 USD
Naiditch et al[20]	Endostapler	391	223	9.92	NA	Median follow-up 15.5 days (range 0–51) for non-perforated; 19.3 days (range 0–135) for perforated
	Endoloop	388	233	9.69
Parikh et al[27]	Stapler	128	80	12	254.58 USD/stapler device	30 days
	Looped Suture	110	57	12.1	40.77 USD/unit
Pogorelić et al[22]	Polymeric Clip	197	119	11	NA	30 days
	Harmonic Scalpel	115	72	11
Pogorelić et al[21]	Polymeric clip	101	63	13	17.64 EUR	1-4 weeks
	Endoloop	176	84	13.5	34.16 EUR
Safavi et al[10]	Endostapler	24	NA	10.58	251.68 per ndostapler per case (in Canadian dollars)	NA
	Endoloop	208		11.55	57.57 per Endoloop per case (in Canadian dollars)
Zeineddin et al[9]	Stapler	35788	21677	10.7	10329.3 USD for all cases	30 days
	Endoloop	13403	8056	10.2	9569.2 USD for all cases

Table 3 Quality assessment of the included studies according to the Newcastle-Ottawa Scale

Ref.	Selection (stars; max 4)	Comparability (stars; max 2)	Outcome/exposure (stars; max 3)	Total score (stars; max 9)	Quality rating
Akbiyik et al[24]	4	2	3	9	Good quality
Akkoyun and Akbiyik[25]	3		3	6	Moderate quality
Escolino et al[12]	4	2	3	9	Good quality
Juan et al[19]	2	1 star	3	6	Moderate quality
Kocaman et al[23]	3		2	5	Moderate quality
Martinez et al[14]	3		2	5	Moderate quality
Miyano et al[13]	3		3	6	Moderate quality
Miyano et al[26]	3		3	6	Moderate quality
Naiditch et al[20]	3		3	6	Moderate quality
Parikh et al[27]	3		3	6	Moderate quality
Pogorelić et al[22]	3		3	6	Moderate quality
Pogorelić et al[21]	3		3	6	Moderate quality
Safavi et al[10]	3	2	3	8	Good quality
Zeineddin et al[9]	4	2	3	9	Good quality

Table 4 League table comparing the overall complications, length of hospital stays, and operative time among the different appendiceal stump closure methods

		Endoloop	Endostapler	Harmonic Scalpel	LigaSure	Polymeric clip
The overall complications (risk ratios)	Endoloop	-	1.0397 (0.6691; 1.6153)	8.8503 (0.3772; 207.6631)	7.2308 (0.6721; 77.7929)	0.7207 (0.2305; 2.2532)
	Endostapler	-	-	8.5127 (0.3549; 204.1865)	6.9550 (0.6208; 77.9199)	0.6932 (0.2089; 2.3003)
	Harmonic scalpel	-	-	-	0.8170 (0.0157; 42.4231)	0.0814 (0.0043; 1.5439)
	LigaSure	-	-	-	-	0.0997 (0.0071; 1.3897)
	Polymeric clip	-	-	-	-	-
Length of hospital stays (mean difference)	Endoloop	-	-0.0025 (-0.5263; 0.5212)	0.8590 (-0.3280; 2.0460)	0.0000 (-0.9859; 0.9859)	0.1590 (-0.5422; 0.8603)
	Endostapler	-	-	0.8616 (-0.3413; 2.0645)	0.0025 (-1.1138; 1.1189)	0.1616 (-0.5663; 0.8895)
	Harmonic scalpel	-	-	-	-0.8590 (-2.4020; 0.6840)	-0.7000 (-1.6577; 0.2577)
	LigaSure	-	-	-	-	0.1590 (-1.0508; 1.3689)
	Polymeric clip	-	-	-	-	-
Operative time (mean difference)	Endoloop	-	2.7732 ( -1.9506; 7.4970)	13.5030 (1.4045; 25.6016)	9.6000 ( -0.4075; 19.6075)	4.1630 ( -2.3568; 10.6828)
	Endostapler	-	-	10.7299 ( -1.7110; 23.1707)	6.8268 ( -4.2395; 17.8932)	1.3899 (-5.7451; 8.5248)
	Harmonic scalpel	-	-	-	-3.9030 (-19.6041; 11.7981)	-9.3400 (-19.5315; 0.8515)
	LigaSure	-	-	-	-	-5.437 (-17.3809; 6.5070)
	Polymeric clip	-	-	-	-	-