Appendicitis is a common reason for surgical intervention and remains challenging for medical professionals due to its widespread occurrence and the high rates of complications when the diagnosis is delayed [1]. Acute appendicitis often leads to surgical emergencies requiring abdominal surgeries. Successfully treating patients depends largely on an early diagnosis and subsequent surgical intervention, usually through an appendectomy, before gangrene or perforation occurs [2]. Cases where typical signs and symptoms of appendicitis are absent present diagnostic challenges; in such situations, imaging studies are crucial for improving diagnostic accuracy [3]. Diagnostic techniques such as ultrasonography and computed tomography are frequently used, either independently or in combination, depending on the availability of resources [4]. Around 250,000 people are diagnosed with appendicitis in the United States each year, with a higher occurrence among younger individuals, particularly those in their twenties and thirties. Although the overall mortality rate is less than one per cent, the risk of death is higher if the appendix ruptures or if the patient is older [5].

Due to advancements in surgical methods and growing proficiency among surgeons, laparoscopic treatment has become increasingly popular. It has largely replaced open appendectomy as the preferred approach in different healthcare settings. The preference for laparoscopic appendectomy can be attributed to its association with reduced postoperative pain, quicker recovery, shorter hospital stays, and faster return to normal physical activities. As a result, this enhances patient productivity and quality of life [7].

Various surgical techniques are employed to secure the base of the appendix, such as extracorporeal knotting and intracorporeal knotting, endo-loops, endo-staplers, metallic endo-clips, and hemo-o-lok clips [8]. The use of metallic endo-clips for closing the base of the appendix, initially introduced by Cristalli et al. [9], is efficient and straightforward, making it an appealing choice for surgeons. This study aims to thoroughly assess and compare the effectiveness of two laparoscopic methods for closing the appendix stump: metallic endo-clips and extracorporeal knot-tying sutures. The main goal of the study is to identify any differences in outcomes, such as the incidence of leaks at the appendiceal base, the duration of the surgical procedure, rates of postoperative infections, and length of hospital stay, between these two techniques.

A comparative retrospective study was conducted at the Nishtar Medical University, Multan, to compare the efficacy of metallic endo-clips and extracorporeal knotting in appendectomy patients. Ethical approval from the institutional review board was obtained to ensure compliance with ethical principles for medical research involving human subjects, maintaining patient confidentiality and anonymity. The study involved 70 patients who had undergone appendectomy for acute appendicitis. Data was collected from surgical notes and discharge forms from the hospital's surgical unit. The patients were divided into two groups - Group A (received metallic endo-clips) and Group B (underwent extracorporeal knotting), with 35 patients in each group. The data was recorded in a Microsoft Excel spreadsheet and analysed using SPSS version 25. Categorical variables such as age, gender, and residential status were represented in percentages and frequencies. A sample t-test was used to compare the mean duration of surgery and postoperative hospital stay between the groups, while the chi-square test was employed to compare complications.

The study enrolled 70 patients, comprising 44 (62.9%) males and 26 (37.1%) females, as illustrated in Figure 1. The gender distribution highlights a male predominance, with a male-to-female ratio of approximately 2:1.

Regarding age distribution, the mean age of all patients was 30.24 ± 7.73 years, with ages ranging from 21 to 50. The mean age for male patients was 29.66 ± 8.38 years, while for female patients, it was 31.23 ± 6.52 years. Notably, most patients (81.4%) fell within the age group of up to 35, as shown in Figure 2, reflecting a higher incidence among younger individuals.

Regarding geographic distribution, 22 (31.4%) patients hailed from rural areas, while 48 (68.6%) came from urban areas, as shown in Figure 3. This distribution underscores the importance of considering diverse backgrounds and healthcare needs across different settings. Notably, urban areas contributed a more significant proportion of patients, suggesting potential differences in access to healthcare services and disease awareness between urban and rural populations.

The study revealed a significant difference in the mean duration of surgery between the two groups. Group A, which received metallic endo-clips, exhibited a mean surgery duration of 28.89 ± 2.42 minutes, while Group B, undergoing extracorporeal knotting, had a mean duration of 34.23 ± 1.68 minutes, as shown in Table 1. This disparity indicates that the use of metallic endo-clips was associated with shorter operative times, potentially attributable to the ease and efficiency of clip application compared to traditional knot-tying techniques.

However, the two groups had no substantial difference in the mean duration of hospital stay. Group A had a mean duration of 31.54 ± 6.54 hours, while Group B had a mean duration of 31.37 ± 5.49 hours, as shown in Table 2. This finding suggests that while metallic endo-clips may expedite surgical procedures, they do not significantly impact postoperative recovery time compared to extracorporeal knotting.

The study reported a low incidence of complications, with only 03 (4.3%) patients experiencing complications. Interestingly, 02 of the three complications occurred in Group B, as shown in Table 3, indicating a potentially higher risk associated with extracorporeal knotting.

Table 1: Mean duration of surgery

Table 2: Mean duration of hospital stay

Table 3: Stratification of complications

Acute appendicitis is a serious health issue that demands urgent care and treatment. It is a primary cause of abdominal pain, often necessitating surgery, accounting for more than 20% of hospital visits for this type of discomfort. The condition is more prevalent among teenagers, with a slightly higher occurrence in males. Research indicates that younger patients are at a greater risk of complications, with up to 66% of those under five experiencing appendix perforation. Typical symptoms of acute appendicitis include sudden and intense abdominal pain starting around the belly button and migrating to the lower right side. Other accompanying symptoms may include nausea, vomiting, and loss of appetite. In some instances, patients may also present with fever, diarrhoea, constipation, and bloating. Seeking medical attention promptly is crucial. If left untreated, a perforated appendix can lead to serious complications such as peritonitis or abscess formation, which can be life-threatening [10].

Our study involved 70 patients, with 44 males (62.9%) and 26 females (37.1%). Our findings revealed that male patients were more susceptible with a male-to-female ratio of 2:1. This finding aligns with Khattak et al.'s study in Dera Ismail Khan, which reported a similar male-to-female ratio [11]. Additionally, Ahmed et al., Jamali et al., and Zia et al. 12-14 support our conclusion that male gender predominance exists. Ahmed et al. reported a 58.75% male gender predominance [12], consistent with our results. Jamali et al. found that 76% of the affected patients were male [13]. Zia et al. (2015) reported a 57% male gender predominance in their Karachi study [14], which aligns with our findings. These results provide valuable insights into the gender distribution of patients affected. Further research can build on these results to explore the reasons for the higher incidence of the condition in male patients, which can lead to more effective treatment and management. The mean age of our study cases was 30.24 ± 7.73 years, with the minimum age being 21 and the maximum age being 50. The mean age of the male patients was 29.66 ± 8.38 years, while that of the female patients was 31.23 ± 6.52 years. Our study results have reported that most cases, i.e., 57 (81.4%), were aged up to 35 years. In their study, Khattak et al. reported that most patients were from the second and third decades of life [11]. Research conducted by Ahmed et al. also stated a mean age of 24.25 ± 5 years [12]. Research conducted by Jamali et al. also reported a mean age of 22.46 ± 9.38 years [13], similar to our study results. Another research conducted by Zia et al. from Karachi also reported similar results [14].

Regarding demographic distribution, 22 (31.4%) belonged to rural areas, and 48 (68.6%) belonged to urban areas. Complications were noted only in 03 (4.3%) of our study cases, with 01 cases reported in Group A and 02 from Group B. The low incidence of complications is an encouraging outcome that validates the safety and effectiveness of using endo-clips. Nonetheless, further research is necessary to validate the results and to investigate the factors underlying the positive outcomes.

The study found that the mean surgery duration in group A was 28.89 ± 2.42 minutes, while in group B, it was 34.23 ± 1.68 minutes. The statistical significance of the difference in duration indicates that the surgical procedure used in group A was more efficient than in group B. Notably, our findings align with the research conducted by Nadeem et al., which showed that extracorporeal knotting had a mean duration of 48.3 ± 8.45 minutes, while metallic endo-clips took 42.1 ± 7.40 minutes [15]. This suggests metallic endo-clips could lead to a shorter surgery duration than extracorporeal knotting. These results support the use of metallic endo-clips as an efficient alternative to extracorporeal knotting, which is consistent with previous research.

Group A had a mean hospital stay duration of 31.54 ± 6.54 hours, while Group B had a mean duration of 31.37 ± 5.49 hours. Our study aimed to establish if there was a considerable difference between the two groups in terms of hospital stay duration. Our results revealed no substantial difference between the durations of hospital stay of Group A and Group B. Our findings differ from those of Nadeem et al., who documented a considerable difference between the two groups. According to their study, the mean hospital stay duration for metallic endo-clips was 21.6 ± 13.6 hours, while for extracorporeal knotting, it was 29.0 ± 29.5 hours [15].

The aim of our current research was to assess the advantages of utilising metallic endo-clips in laparoscopic appendiceal stump closure. Our findings indicate that this method presents several benefits over conventional approaches. The application of metallic endo-clips led to reduced operative times, likely attributed to the ease and swiftness of clip application, thereby minimising the duration of anaesthesia and surgery. Shorter operative times could enhance surgical efficiency and lower the potential for complications associated with prolonged anaesthesia and surgery. We observed that implementing metallic endo-clips resulted in lower complication rates compared to traditional methods, possibly due to the more secure closure provided by the clips, reducing the risk of postoperative issues like stump leakage and infection. Future research should involve larger, multicentre populations to establish the accuracy and applicability of our results. It is imperative to assess metallic endo-clips' long-term safety and effectiveness to ensure their viability for long-term patient use. Our study was confined to a single tertiary care hospital, which might impact the generalizability of our findings. Our limited sample size may have constrained our ability to detect small yet potentially significant differences between the two surgical techniques. In summary, our study proposes that the use of metallic endo-clips in laparoscopic appendiceal stump closure offers potential benefits with respect to operative time and intraoperative complications. Additional research is required to validate these findings and appraise the long-term outcomes of incorporating this technique.

DECLARATIONS

Acknowledgement

None to Declare

Funding

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical Approval

An Institutional Ethical Review Board of Nishtar Medical University vide No.23843/NMU & H gave ethical approval for the study.

Competing Interest

There is nothing to declare.

1. Orban, Y.A., Algazar, M., Farag, A., and Elalfy, T.R. "Do We Still Encounter Non-appendicitis Pathologies during Laparoscopic Appendectomy?" World, vol. 14, no. 1, 2021, p. 11. doi:10.3390/world14010011.
2. Abd ElFatah, M.S., Khattab, M.H., Ibrahim, M.I.I., Desoukey, S.H., Hanna, A., and Grace, M.N. "The Role of Ultrasound and CT in Diagnosis of Acute Appendicitis & Its Impact on The Surgical Outcome." The Egyptian Journal of Hospital Medicine, vol. 89, no. 2, 2022, pp. 6859-6866. doi:10.21608/ejhm.2022.118698.
3. Khan, S., Usama, M., Basir, Y., Muhammad, S., Jawad, M., Khan, T., et al. "Evaluation of Modified Alvarado, Ripasa and Lintula Scoring System as Diagnostic Tools for Acute Appendicitis." Journal of Ayub Medical College Abbottabad, vol. 32, no. 1, 2020, pp. 46-50. doi:10.5552/jamc.v32i1.851.
4. Frountzas, M., Stergios, K., Kopsini, D., Schizas, D., Kontzoglou, K., and Toutouzas, K. "Alvarado or RIPASA Score for Diagnosis of Acute Appendicitis? A Meta-Analysis of Randomized Trials." International Journal of Surgery, vol. 56, 2018, pp. 307-314. doi:10.1016/j.ijsu.2018.06.014.
5. Ferris, M., Quan, S., Kaplan, B.S., Molodecky, N., Ball, C.G., Chernoff, G.W., et al. "The Global Incidence of Appendicitis: A Systematic Review of Population-Based Studies." Annals of Surgery, vol. 266, no. 2, 2017, pp. 237-241. doi:10.1097/SLA.0000000000002025.
6. Ihnát, P., Tesař, M., Tulinský, L., and Vávra, P. "Technical Modifications of Appendiceal Transection During Laparoscopic Appendectomy." Rozhledy v Chirurgii: Mesicnik Ceskoslovenske Chirurgicke Spolecnosti, vol. 99, no. 12, 2020, pp. 534-538. doi:10.33690/00203399/99/12/534.
7. Mannu, G.S., Sudul, M.K., Bettencourt‐Silva, J.H., Cumber, E., Li, F., Clark, A.B., et al. "Closure Methods of the Appendix Stump for Complications During Laparoscopic Appendectomy." Cochrane Database of Systematic Reviews, no. 11, 2017. doi:10.1002/14651858.CD011357.pub2.
8. Omari, A.H., Khammash, M.R., Qasaimeh, G.R., Shammari, A.K., Yaseen, M.K.B., and Hammori, S.K. "Acute Appendicitis in the Elderly: Risk Factors for Perforation." World Journal of Emergency Surgery, vol. 9, no. 1, 2014, p. 1-6. doi:10.1186/1749-7922-9-1.
9. Cristalli, B.G., Izard, V., Jacob, D., and Levardon, M. "Laparoscopic Appendectomy Using a Clip Applier." Surgical Endoscopy, vol. 5, 1991, pp. 176-178. doi:10.1007/BF02264659.
10. Oh, J. "Acute Perforated Appendicitis Complicated by Necrotizing Fasciitis and Bladder Perforation." Cureus, vol. 13, no. 1, 2021. doi:10.7759/cureus.12464.
11. Khattak, S., Aslam, S., and Kamal, A. "Acute Appendicitis: An Audit of 663 Cases." Gomal Journal of Medical Sciences, vol. 8, no. 2, 2010. doi:10.5455/gjms.11237.
12. Ahmed, W., Akhtar, M.S., and Khan, S. "Seasonal Variation of Acute Appendicitis." Pakistan Journal of Medical Sciences, vol. 34, no. 3, 2018, pp. 564-568. doi:10.12669/pjms.343.14463.
13. Jamali, K.S., Ahmed, H., Jawed, M., and Shaikh, U. "Acute Appendicitis: Efficacy of Complete Clinical Evaluation and Modified Alvarado Scoring System in Diagnosis." The Professional Medical Journal, vol. 22, no. 12, 2015, pp. 1601-1605. doi:10.17957/TPMJ/15.2996.
14. Zia, M.K., Usmani, M.S., Saad, A., and Uzma, K. "Delayed Postoperative Recovery in Patients of Acute Appendicitis with Hyperbilirubinemia." Pak J Surg, vol. 31, no. 3, 2015. doi:10.21699/pjs.v31i3.628.
15. Nadeem, M., Khan, S., Ali, S., Shafiq, M., Elahi, M., Abdullah, F., et al. "Comparison of Extra-Corporeal Knot-Tying Suture and Metallic Endo-Clips in Laparoscopic Appendiceal Stump Closure in Uncomplicated Acute Appendicitis." International Journal of Surgery Open, vol. 2, 2016, pp. 11-14. doi:10.1016/j.ijso.2016.06.001.