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Cochrane Database of Systematic Reviews

Closure methods of the appendix stump for complications during laparoscopic appendectomy

Information

DOI:
https://doi.org/10.1002/14651858.CD006437.pub3Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 13 November 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:

  1. Cochrane Colorectal Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Gurdeep S Mannu

    Correspondence to: Nuffield Department of Population Health, University of Oxford, Oxford, UK

    [email protected]

  • Maria K Sudul

    Nuffield Department of Population Health, University of Oxford, Oxford, UK

  • Joao H Bettencourt‐Silva

    Department of Older People's Medicine, Norfolk & Norwich University Hospitals, Norwich, UK

  • Elspeth Cumber

    Department of General Medicine, John Radcliffe Hospital, Oxford, UK

  • Fangfang Li

    Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands

    Barcelona Institute for Global Health, Hospital Clínic‐University of Barcelona, Barcelona, Spain

  • Allan B Clark

    Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK

  • Yoon K Loke

    Norwich Medical School, University of East Anglia, Norwich, UK

Contributions of authors

Gurdeep S. Mannu coordinated all aspects of the review team and prepared the final manuscript.

Maria Sudul extracted data from published papers, entered data into Review Manager 5, helped carry out the analysis, and helped prepare the final review.

Joao H. Bettencourt‐Silva entered data into Review Manager 5 and helped carry out the analysis.

Elspeth Cumber and Fangfang Kate Li selected which trials were included/excluded and extracted data from included trials.

Allan B Clark provided statistical expertise.

Yoon K Loke helped interpret the analysis within the review and provided methodological expertise.

All review authors agreed on the final version of the manuscript for publication.

Sources of support

Internal sources

  • West China Hospital, Sichuan University, China.

External sources

  • No sources of support supplied

Declarations of interest

None known.

Acknowledgements

We would like to thank the Cochrane Colorectal Cancer Group, the CCCG Editorial Office, and Dr. Henning Keinke Andersen for assisting in development of the protocol, the review, and careful copy editing; Anne Sofie Christensen, who assisted in development of the protocol; Marija Barbateskovic, who developed the search strategies and ran the initial literature searches; and CCCG editors and peer referees Keith Chapple and Brett Doleman. We also would like to thank Nia Roberts, Outreach Librarian at the Bodliean Library, University of Oxford; and Sys Johnsen, Information Specialist at the Cochrane Colorectal Cancer Group; for updating the systematic search. We would like to acknowledge Stefan Sauerland and Geert Kazemier, who had the idea for the review; and Su Peng, Yao Chen, Jin Zhou, Yalin Zhang, Nansheng Cheng, Yun Liao, and Zong‐Guang Zhou, who drafted the review protocol. And finally Dolores Matheews from the Copy Edit Support team.

Version history

Published

Title

Stage

Authors

Version

2017 Nov 13

Closure methods of the appendix stump for complications during laparoscopic appendectomy

Review

Gurdeep S Mannu, Maria K Sudul, Joao H Bettencourt‐Silva, Elspeth Cumber, Fangfang Li, Allan B Clark, Yoon K Loke

https://doi.org/10.1002/14651858.CD006437.pub3

2012 Dec 12

Appendix stump closure during laparoscopic appendectomy

Protocol

Su Peng, Yao Cheng, Yalin Zhang, Jin Zhou, Yun Liao, Nansheng Cheng, Geert Kazemier, Stefan Sauerland, Zong‐Guang Zhou

https://doi.org/10.1002/14651858.CD006437.pub2

2007 Apr 18

Appendix stump closure during laparoscopic appendectomy

Protocol

Stefan Sauerland, Geert Kazemier

https://doi.org/10.1002/14651858.CD006437

Differences between protocol and review

We appropriately refined primary comparisons compared with those in the published protocol (Peng 2012) and followed results of the updated systematic search for 'mechanical devices compared to ligature devices' due to paucity of published research on different subtypes of mechanical devices, as discussed in Quality of the evidence and Implications for research. Furthermore, whereas the protocol specified the inclusion of all studies irrespective of length of publication, we decided that in cases when studies were reported solely in abstract form, we would include them in our quantitative synthesis only if full study data were made available to us. In preparation of this review, these refined inclusion criteria did not result in subsequent exclusion of any studies. In light of the type of outcome measures reported amongst included studies, we deemed Peto odds ratio (Peto OR) with 95% confidence intervals to be more appropriate for dichotomous outcomes when compared with relative risk estimates. However, we have presented the results of both in our sensitivity analysis.

Notes

None.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Data collection form (Microsoft Word).
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Figure 1

Data collection form (Microsoft Word).

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*Lange 1993 was not retrievable following a worldwide search because the journal was published and is going out of print (see Results section).
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Figure 2

*Lange 1993 was not retrievable following a worldwide search because the journal was published and is going out of print (see Results section).

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 1 Total complications.
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Analysis 1.1

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 1 Total complications.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.
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Analysis 1.2

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.
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Analysis 1.3

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between mechanical device and ligature.
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Analysis 1.4

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between mechanical device and ligature.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 5 Hospital stay (in days) between mechanical and ligature.
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Analysis 1.5

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 5 Hospital stay (in days) between mechanical and ligature.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.
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Analysis 1.6

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.
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Analysis 1.7

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.
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Analysis 1.8

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 1 Total complications.
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Analysis 2.1

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 1 Total complications.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.
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Analysis 2.2

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.
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Analysis 2.3

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between stapler and ligature.
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Analysis 2.4

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between stapler and ligature.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 5 Comparison of hospital stay between stapler and ligature.
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Analysis 2.5

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 5 Comparison of hospital stay between stapler and ligature.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.
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Analysis 2.6

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.
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Analysis 2.7

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.
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Analysis 2.8

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 1 Total complications.
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Analysis 3.1

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 1 Total complications.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.
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Analysis 3.2

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.
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Analysis 3.3

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between clips and ligatures.
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Analysis 3.4

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between clips and ligatures.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 5 Comparison of hospital stay between clips and ligature.
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Analysis 3.5

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 5 Comparison of hospital stay between clips and ligature.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.
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Analysis 3.6

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.
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Analysis 3.7

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.
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Analysis 3.8

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.

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Comparison 4 Endoscopic stapler versus clips, Outcome 1 Total complications.
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Analysis 4.1

Comparison 4 Endoscopic stapler versus clips, Outcome 1 Total complications.

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Comparison 4 Endoscopic stapler versus clips, Outcome 2 Intraoperative complications.
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Analysis 4.2

Comparison 4 Endoscopic stapler versus clips, Outcome 2 Intraoperative complications.

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Comparison 4 Endoscopic stapler versus clips, Outcome 3 Postoperative complications.
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Analysis 4.3

Comparison 4 Endoscopic stapler versus clips, Outcome 3 Postoperative complications.

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Comparison 4 Endoscopic stapler versus clips, Outcome 4 Comparison of operative time between stapler and clips.
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Analysis 4.4

Comparison 4 Endoscopic stapler versus clips, Outcome 4 Comparison of operative time between stapler and clips.

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Comparison 4 Endoscopic stapler versus clips, Outcome 5 Comparison of hospital stay between stapler and clips.
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Analysis 4.5

Comparison 4 Endoscopic stapler versus clips, Outcome 5 Comparison of hospital stay between stapler and clips.

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Comparison 4 Endoscopic stapler versus clips, Outcome 6 Postoperative superficial infections.
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Analysis 4.6

Comparison 4 Endoscopic stapler versus clips, Outcome 6 Postoperative superficial infections.

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Comparison 4 Endoscopic stapler versus clips, Outcome 7 Postoperative deep infections.
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Analysis 4.7

Comparison 4 Endoscopic stapler versus clips, Outcome 7 Postoperative deep infections.

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Comparison 4 Endoscopic stapler versus clips, Outcome 8 Postoperative ileus.
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Analysis 4.8

Comparison 4 Endoscopic stapler versus clips, Outcome 8 Postoperative ileus.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.
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Analysis 5.1

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.
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Analysis 5.2

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.
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Analysis 5.3

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between mechanical device and ligature.
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Analysis 5.4

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between mechanical device and ligature.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Hospital stay (in days) between mechanical device and ligature.
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Analysis 5.5

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Hospital stay (in days) between mechanical device and ligature.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.
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Analysis 5.6

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.
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Analysis 5.7

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.
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Analysis 5.8

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.
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Analysis 6.1

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.
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Analysis 6.2

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.
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Analysis 6.3

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between stapler and ligature.
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Analysis 6.4

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between stapler and ligature.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Comparison of hospital stay between stapler and ligature.
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Analysis 6.5

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Comparison of hospital stay between stapler and ligature.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.
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Analysis 6.6

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.
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Analysis 6.7

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.
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Analysis 6.8

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.
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Analysis 7.1

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.
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Analysis 7.2

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.
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Analysis 7.3

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between clips and ligature.
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Analysis 7.4

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between clips and ligature.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Comparison of hospital stay between clips and ligature.
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Analysis 7.5

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Comparison of hospital stay between clips and ligature.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.
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Analysis 7.6

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.
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Analysis 7.7

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.
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Analysis 7.8

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 1 Total complications.
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Analysis 8.1

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 1 Total complications.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 2 Intraoperative complications.
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Analysis 8.2

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 2 Intraoperative complications.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 3 Postoperative complications.
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Analysis 8.3

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 3 Postoperative complications.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 4 Comparison of operative time between stapler and clips.
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Analysis 8.4

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 4 Comparison of operative time between stapler and clips.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 5 Comparison of hospital stay between stapler and clips.
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Analysis 8.5

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 5 Comparison of hospital stay between stapler and clips.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 6 Postoperative superficial infections.
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Analysis 8.6

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 6 Postoperative superficial infections.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 7 Postoperative deep infections.
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Analysis 8.7

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 7 Postoperative deep infections.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 8 Postoperative ileus.
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Analysis 8.8

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 8 Postoperative ileus.

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Summary of findings for the main comparison. Mechanical devices versus ligature for appendix stump closure during laparoscopic appendectomy

Mechanical devices vs ligatures for appendix stump closure during laparoscopic appendectomy

Patient or population: patients undergoing appendix stump closure during laparoscopic appendectomy
Setting: hospital
Intervention: mechanical devices (endoscopic stapler/clips)
Comparison: ligature (intra/extracorporeal knot/Endoloop)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Risk with ligatures

Risk with mechanical devices

Total complications

205 per 1000

169 per 1000
(119 to 225)

OR 0.97

(0.27 to 3.50)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Intraoperative complications

76 per 1000

63 per 1000
(36 to 108)

OR 0.93

(0.34 to 2.55)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative complications

129 per 1000

109 per 1000
(71 to 154)

OR 0.80

(0.21 to 3.13)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative superficial infections

26 per 1000

13 per 1000
(5 to 33)

OR 0.58
(0.18 to 1.93)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative ileus

41 per 1000

20 per 1000
(8 to 46)

OR 0.47
(0.19 to 1.18)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative deep infections

14 per 1000

12 per 1000
(4 to 34)

OR 0.79
(0.24 to 2.53)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Operative time (minutes)

Mean operative time was

40.6 minutes.

Mean operative time

(minutes) in the intervention

group was 9.04 minutes

shorter (12.97 minutes shorter to 5.11 minutes shorter).

‐

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Hospital stay (days)

Mean hospital stay

was 1.4 days.

Mean hospital stay in the

intervention group was 0.02 days

longer (0.12 days shorter to 0.17 days longer).

‐

850
(8 RCTs)

⊕⊝⊝⊝
Very low1,2,3

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level for inconsistency (substantial heterogeneity).

bDowngraded one level for high risk of bias.

cDowngraded one level for imprecision (all included studies had few participants and events and thus wide confidence intervals, limiting the precision of estimates).

Figures and Tables -
Summary of findings for the main comparison. Mechanical devices versus ligature for appendix stump closure during laparoscopic appendectomy
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Summary of findings 2. Endoscopic stapler versus ligature for appendix stump closure during laparoscopic appendectomy

Endoscopic stapler vs ligature for appendix stump closure during laparoscopic appendectomy

Patient or population: patients undergoing appendix stump closure during laparoscopic appendectomy

Settings: hospital

Intervention: endoscopic stapler

Comparison: ligature

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Risk with ligature

Risk with endoscopic stapler

Total complications

421 per 1000

198 per 1000
(35 to 637)

OR 0.34 (0.05 to 2.41)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Intraoperative complications

182 per 1000

191 per 1000
(37 to 599)

OR 1.06 (0.17 to 6.70)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative complications

239 per 1000

250 per 1000
(51 to 678)

OR 0.20 (0.09 to 0.44)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative superficial infections

44 per 1000

47 per 1000
(8 to 236)

OR 0.10 (0.01 to 0.84)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative ileus

88 per 1000

93 per 1000
(16 to 393)

OR 0.37 (0.13 to 1.07)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative deep infections

31 per 1000

33 per 1000
(5 to 179)

OR 0.45 (0.10 to 2.08)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Operative time (minutes)

Mean operative time was 40.6 minutes.

Mean operative time

in the intervention

group was 8.52 minutes

lower (15.64 minutes shorter to 1.39 minutes shorter).

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Hospital stay (days)

Mean hospital stay

was 1.9 days.

Mean hospital stay in the

intervention group was 0.02 days

longer (0.38 days shorter to 0.34 days longer).

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aDowngraded one level for inconsistency (substantial heterogeneity).

bDowngraded one level for high risk of bias.

cDowngraded one level for imprecision (all included studies had few participants and events and thus wide confidence intervals, limiting the precision of estimates).

Figures and Tables -
Summary of findings 2. Endoscopic stapler versus ligature for appendix stump closure during laparoscopic appendectomy
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Summary of findings 3. Clips versus ligature for appendix stump closure during laparoscopic appendectomy

Clips vs ligatures for appendix stump closure during laparoscopic appendectomy

Patient or population: patients undergoing appendix stump closure during laparoscopic appendectomy

Settings: hospital

Intervention: clips

Comparison: ligature

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Risk with ligature

Risk with clips

Total complications

17 per 1000

18 per 1000
(3 to 105)

OR 2.03

(0.71 to 5.84)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Intraoperative complications

21 per 1000

22 per 1000
(4 to 124)

OR 1.74

(0.33 to 9.04)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative complications

17 per 1000

18 per 1000
(3 to 105)

OR 1.88

(0.63 to 5.64)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative superficial infections

14 per 1000

15 per 1000
(2 to 86)

OR 1.25

(0.32 to 4.90)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative ileus

10 per 1000

11 per 1000
(2 to 65)

OR 0.92

(0.15 to 5.64)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative deep infections

3 per 1000

4 per 1000
(1 to 23)

OR 1.75

(0.28 to 10.93)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Operative time (minutes)

Mean operative time was

40.0 minutes.

Mean operative time

in the intervention

group was 8.14 minutes

shorter (11.73 minutes shorter

to 4.55 minutes shorter).

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Hospital stay (days)

Mean hospital stay

was 1.5 days.

Mean hospital stay in the

intervention group was 0.03 days

shorter (0.16 days shorter to 0.11

days longer).

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aDowngraded one level for inconsistency (substantial heterogeneity).

bDowngraded one level for high risk of bias.

cDowngraded one level for imprecision (all included studies had few participants and events and thus wide confidence intervals, limiting the precision of estimates).

Figures and Tables -
Summary of findings 3. Clips versus ligature for appendix stump closure during laparoscopic appendectomy
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Summary of findings 4. Endoscopic stapler versus clips for appendix stump closure during laparoscopic appendectomy

Endoscopic stapler vs clips for appendix stump closure during laparoscopic appendectomy

Patient or population: patients undergoing appendix stump closure during laparoscopic appendectomy

Settings: hospital

Intervention: endoscopic stapler

Comparison: clips

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Risk with clips

Risk with endoscopic stapler

Total complications

67 per 1000

70 per 1000
(12 to 324)

OR 1.00

(0.13 to 7.60)

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Intraoperative complications

67 per 1000

70 per 1000
(12 to 324)

OR 1.00

(0.13 to 7.60)

[60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative complications

0 events in both treatment arms

NE

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative superficial infections

0 events in both treatment arms

NE

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative ileus

0 events in both treatment arms

NE

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative deep infections

0 events in both treatment arms

NE

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Operative time (minutes)

Mean operative time was

39.4 minutes.

Mean operative time

in the intervention

group was 3.46 minutes

shorter (6.94 minutes shorter

to 0.02 minutes longer).

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Hospital stay (days)

Mean hospital stay

was 2.0 days.

Mean hospital stay in the

intervention group was 0.04 days

shorter (0.28 days shorter to 0.20

days longer).

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; NE: not estimable; OR: odds ratio; RCT: randomised controlled trial.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aDowngraded one level for single study with limited sample size.

bDowngraded one level for high risk of bias.

cDowngraded one level for imprecision (the sole included studies had few participants and therefore few events, resulting in wide confidence intervals, which limited the precision of estimates).

Figures and Tables -
Summary of findings 4. Endoscopic stapler versus clips for appendix stump closure during laparoscopic appendectomy
Navigate to table in Review
Table 1. Primary outcomes in included studies

Study ID

Intervention arms

Total no. with complications

Total no. without complications

Intraoperative

Postoperative

Bleeding

Intraoperative rupture of appendix

Intraoperative organ injury/ faecal soiling

Access‐related visceral injury

Other

Total

Surgical site infection (superficial)

Deep infection

Bleeding

Paralytic ileus

Purulent peritonitis

Other

Total

Ortega 1995

Endoscopic linear stapler (LAS)

27

51

11

2

5

0

0

18

0

2

0

5

0

2a

9

2× catgut ligatures (Endoloops) (LAL)

62

27

14

4

11

0

0

29

4

4

0

14

0

11b

33

Open appendectomy (OA)

44

42

20

5

1

0

0

26

11

0

0

6

0

1c

18

Akbiyik 2011

Hem‐o‐lok clip (non‐absorbable polymeric clips)

0

28

0

0

0

0

0

0

0

0

0

0

0

0

0

Ligaure (Endoloop)

0

21

0

0

0

0

0

0

0

0

0

0

0

0

0

Delibegovic 2012

45‐mm stapler

2

28

2

0

0

0

0

2

0

0

0

0

0

0

0

1 ligature (Endoloop)

0

30

0

0

0

0

0

0

0

0

0

0

0

0

0

1 Hem‐o‐lok clip (non‐absorbable polymeric clips)

2

28

2

0

0

0

0

2

0

0

0

0

0

0

0

Beldi 2004

1 ligature (Endoloop) only at appendix base (1 other at 6 to 12 mm distally)

5

104

0

0

0

0

0

0

0

3

0

0

0

2d

5

2 ligatures (Endoloops) at base of appendix (1 other at 6 to 12 mm distally)

5

94

0

0

0

0

0

0

0

4

0

0

0

1e

5

Sucullu 2009

Endodissector and endoclip

0

16

0

0

0

0

0

0

0

0

0

0

0

0

0

LigaSure 5 to 10 mm

0

16

0

0

0

0

0

0

0

0

0

0

0

0

0

Shalaby 2001

Endo GIA (Ethicon Endo‐Surgery, Cincinnati, Ohio, USA) stapler

0

60

0

0

0

0

0

0

0

0

0

0

0

0

0

Ligature (Endoloop)

5

35

0

0

0

0

0

0

3

1

0

0

0

1f

5

Extracorporeal laparoscopically assisted appendectomy

6

44

0

0

0

0

0

0

2

1

1

0

0

0

4

Colak 2013

Hem‐o‐lok (non‐absorbable polymeric clips)

3

23

0

0

0

0

0

0

2

0

0

0

0

1g

3

Ligature (Endoloop)

3

24

0

0

0

0

0

0

1

1

0

0

0

1g

3

Gonenc 2012

Titanium endoclip

4

57

1

0

0

0

0

1

1

1

0

1

0

0

3

Intracorporeal knotting

6

40

0

0

1

1

0

2

1

0

0

2

1

0

4

Ates 2012

Titanium endoclip

8

22

NS

NS

NS

NS

1h

7

0

1

0

0

0

0

1

Intracorporeal knotting

7

24

NS

NS

NS

NS

0

4

1

0

0

0

0

2i

3

Yang 2014

Intracorporeal knotting

5

125

0

NS

NS

NS

NS

0

NS

0

NS

NS

NS

5j

5

Titanium hem‐o‐lok

17

69

0

NS

NS

NS

NS

0

NS

0

NS

NS

NS

17k

17

Nadeem 2015

Extracorporeal knotting

5

31

1

NS

0

NS

NS

1

2

0

NS

1

NS

1

4

Metallic endoclip

10

22

2

NS

1

NS

NS

3

2

2

NS

2

NS

1l

7

NS: non‐significant.
aTwo cases of vomiting. bEleven cases of vomiting. cone case of vomiting. dOne case of pulmonary embolism (PE) and one case of persistent port site pain. eOne case of prolonged percutaneous drainage. fOne case of intestinal obstruction. gOne non‐surgical complication. ihTwo open endoclips dropped during procedure and discovered by abdominal X‐ray postoperatively. iOne case of abdominal pain and one case unknown. jThree cases of lower abdominal discomfort, one case of abdominal pain, and two cases of fever. kEight cases of lower abdominal discomfort, three cases of abdominal pain, five cases of fever, and one reoperation. lOne re‐admission occurred in each arm: The re‐admitted participant in the metallic endoclip arm required peritoneal lavage and drain placement.

Figures and Tables -
Table 1. Primary outcomes in included studies
Navigate to table in Review
Table 2. Sensitivity analyses

Mechanical appendix stump closure (with endoscopic stapler or clip(s)) vs ligation (with Endoloop or intra/extracorporeal knot)

Odds ratio (95% CI)

Risk ratio (95% CI)

Risk difference (95% CI)

Mean difference (95% CI)

Outcome

Fixed effect

Random effects

Fixed effect

Random effects

Fixed effect

Random effects

Fixed effect

Random effects

Total complications

0.77 (0.53 to 1.13)

0.97 (0.27 to 3.50)

0.83 (0.64 to 1.08)

1.09 (0.41 to 2.88)

‐0.03 (‐0.08 to 0.01)

‐0.02 (‐0.12 to 0.09)

‐

‐

Intraoperative complications

0.81 (0.45 to 1.46)

0.93 (0.34 to 2.55)

0.85 (0.53 to 1.35)

0.93 (0.40 to 2.18)

‐0.01 (‐0.04 to 0.02)

0.00 (‐0.02 to 0.02)

‐

‐

Postoperative complications

0.80 (0.52 to 1.24)

0.80 (0.21 to 3.13)

0.83 (0.57 to 1.19)

0.86 (0.27 to 2.74)

‐0.02 (‐0.06 to 0.02)

‐0.02 (‐0.10 to 0.06)

‐

‐

Operative time (minutes)

‐

‐

‐

‐

‐

‐

‐11.94 (‐13.04 to ‐10.84)

‐9.04 (‐12.97 to ‐5.11)

Hospital stay (days)

‐

‐

‐

‐

‐

‐

0.02 (‐0.12 to 0.16)

0.02 (‐0.12 to 0.17)

Postoperative superficial infections

0.47 (0.17 to 1.26)

0.58 (0.18 to 1.93)

0.48 (0.19 to 1.24)

0.61 (0.19 to 1.93)

‐0.02 (‐0.04 to 0.01)

‐0.01 (‐0.02 to 0.01)

‐

‐

Postoperative ileus

0.48 (0.20 to 1.15)

0.47 (0.19 to 1.18)

0.51 (0.23 to 1.14)

0.50 (0.22 to 1.17)

‐0.02 (‐0.04 to 0.01)

‐0.01 (‐0.03 to 0.02)

‐

‐

Postoperative deep infections

0.86 (0.31 to 2.41)

0.79 (0.24 to 2.53)

0.87 (0.32 to 2.35)

0.79 (0.25 to 2.47)

‐0.00 (‐0.02 to 0.02)

‐0.00 (‐0.02 to 0.01)

‐

‐

Endoscopic stapler vs ligature

Total complications

0.26 (0.14 to 0.46)

0.34 (0.05 to 2.41)

0.49 (0.35 to 0.68)

0.51 (0.09 to 2.84)

‐0.21 (‐0.29 to ‐0.12)

‐0.13 (‐0.40 to 0.14)

‐

‐

Intraoperative complications

0.72 (0.38 to 1.39)

1.06 (0.17 to 6.70)

0.79 (0.48 to 1.28)

1.07 (0.22 to 5.19)

‐0.04 (‐0.11 to 0.04)

‐0.00 (‐0.11 to 0.10)

‐

‐

Postoperative complications

0.19 (0.09 to 0.41)

0.20 (0.09 to 0.44)

0.27 (0.14 to 0.51)

0.25 (0.08 to 0.75)

‐0.17 (‐0.24 to ‐0.10)

‐0.12 (‐0.34 to 0.09)

‐

‐

Operative time (minutes)

‐

‐

‐

‐

‐

‐

‐12.94 (‐14.35 to ‐11.53)

‐8.36 (‐15.68 to ‐1.03)

Hospital stay (days)

‐

‐

‐

‐

‐

‐

0.03 (‐0.14 to 0.20)

‐0.02 (‐0.38 to 0.34)

Postoperative superficial infections

0.10 (0.01 to 0.86)

0.10 (0.01 to 0.84)

0.11 (0.01 to 0.88)

0.11 (0.01 to 0.87)

‐0.05 (‐0.08 to ‐0.01)

‐0.04 (‐0.08 to 0.00)

‐

‐

Postoperative ileus

0.37 (0.13 to 1.07)

0.37 (0.13 to 1.07)

0.41 (0.15 to 1.08)

0.41 (0.15 to 1.08)

‐0.05 (‐0.10 to 0.00)

‐0.02 ( ‐0.10 to 0.05)

‐

‐

Postoperative deep infections

0.45 (0.10 to 2.02)

0.45 (0.10 to 2.08)

0.46 (0.11 to 1.95)

0.47 (0.11 to 2.04)

‐0.02 (‐0.05 to 0.02)

‐0.02 (‐0.05 to 0.02)

‐

‐

Endoscopic stapler vs clips

Total complications

1.00 (0.13 to 7.60)

1.00 (0.13 to 7.60)

1.00 (0.15 to 6.64)

1.00 (0.15 to 6.64)

0.00 (‐0.13 to 0.13)

0.00 (‐0.13 to 0.13)

‐

‐

Intraoperative complications

1.00 (0.13 to 7.60)

1.00 (0.13 to 7.60)

1.00 (0.15 to 6.64)

1.00 (0.15 to 6.64)

0.00 (‐0.13 to 0.13)

0.00 (‐0.13 to 0.13)

‐

‐

Postoperative complications

NE

NE

NE

NE

0.00 (‐0.06 to 0.06)

0.00 (‐0.06 to 0.06)

‐

‐

Operative time (minutes)

‐

‐

‐

‐

‐

‐

‐3.46 (‐6.94 to 0.02)

‐3.46 (‐6.94 to 0.02)

Hospital stay (days)

‐

‐

‐

‐

‐

‐

‐0.04 (‐0.28 to 0.20)

‐0.04 [‐0.28, 0.20]

Postoperative superficial infections

NE

NE

NE

NE

0.00 (‐0.06 to 0.06)

0.00 (‐0.06 to 0.06)

‐

‐

Postoperative ileus

NE

NE

NE

NE

0.00 (‐0.06 to 0.06)

0.00 (‐0.06 to 0.06)

‐

‐

Postoperative deep infections

NE

NE

NE

NE

0.00 (‐0.06 to 0.06)

0.00 (‐0.06 to 0.06)

‐

‐

Clips vs ligature (Endoloop and intra/extracorporeal knot)

Total complications

2.33 (1.31 to 4.13)

2.03 (0.71 to 5.84)

2.11 (1.29 to 3.47)

1.84 (0.73 to 4.62)

0.08 (0.03 to 0.13)

0.05 (‐0.03 to 0.13)

‐

‐

Intraoperative complications

1.79 (0.49 to 6.56)

1.74 (0.33 to 9.04)

1.76 (0.51 to 6.01)

1.69 (0.35 to 8.19)

0.01 (‐0.02 to 0.04)

0.00 (‐0.02 to 0.02)

‐

‐

Postoperative complications

2.40 (1.28 to 4.48)

1.88 (0.63 to 5.64)

2.20 (1.27 to 3.82)

1.75 (0.66 to 4.61)

0.07 (0.02 to 0.12)

0.03 (‐0.04 to 0.11)

‐

‐

Operative time (minutes)

‐

‐

‐

‐

‐

‐

‐8.06 (‐9.85 to ‐6.26)

‐8.14 (‐11.73 to ‐4.55)

Hospital stay (days)

‐

‐

‐

‐

‐

‐

‐0.03 (‐0.16 to 0.11)

‐0.03 (‐0.16 to 0.11)

Postoperative superficial infections

1.27 (0.33 to 4.86)

1.25 (0.32 to 4.90)

1.25 (0.35 to 4.49)

1.24 (0.34 to 4.56)

0.00 (‐0.02 to 0.03)

0.00 (‐0.02 to 0.02)

‐

‐

Postoperative ileus

0.92 (0.19 to 4.56)

0.92 (0.15 to 5.64)

0.92 (0.20 to 4.21)

0.93 (0.16 to 5.33)

‐0.00 (‐0.02 to 0.02)

‐0.00 (‐0.02 to 0.02)

‐

‐

Postoperative deep infections

1.79 (0.37 to 8.58)

1.75 (0.28 to 10.93)

1.77 (0.38 to 8.16)

1.71 (0.28 to 10.28)

0.01 (‐0.02 to 0.03)

0.00 (‐0.01 to 0.02)

‐

‐

CI: confidence interval; NE: not estimable; "‐": not applicable.
Figures and Tables -
Table 2. Sensitivity analyses
Navigate to table in Review
Comparison 1. Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.97 [0.27, 3.50]

2 Intraoperative complications Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.93 [0.34, 2.55]

3 Postoperative complications Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.80 [0.21, 3.13]

4 Comparison of operative time between mechanical device and ligature Show forest plot

8

850

Mean Difference (IV, Random, 95% CI)

‐9.04 [‐12.97, ‐5.11]

5 Hospital stay (in days) between mechanical and ligature Show forest plot

8

850

Mean Difference (IV, Random, 95% CI)

0.02 [‐0.12, 0.17]

6 Postoperative superficial infections Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.58 [0.18, 1.93]

7 Postoperative deep infections Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.79 [0.24, 2.53]

8 Postoperative ileus Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.47 [0.19, 1.18]
Figures and Tables -
Comparison 1. Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot)
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Comparison 2. Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.34 [0.05, 2.41]

2 Intraoperative complications Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

1.06 [0.17, 6.70]

3 Postoperative complications Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.20 [0.09, 0.44]

4 Comparison of operative time between stapler and ligature Show forest plot

3

327

Mean Difference (IV, Random, 95% CI)

‐8.52 [‐15.64, ‐1.39]

5 Comparison of hospital stay between stapler and ligature Show forest plot

3

327

Mean Difference (IV, Random, 95% CI)

‐0.02 [‐0.38, 0.34]

6 Postoperative superficial infections Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.10 [0.01, 0.84]

7 Postoperative deep infections Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.45 [0.10, 2.08]

8 Postoperative ileus Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.37 [0.13, 1.07]
Figures and Tables -
Comparison 2. Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot)
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Comparison 3. Clips versus ligature (Endoloop or intracorporeal knot)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

2.03 [0.71, 5.84]

2 Intraoperative complications Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

1.74 [0.33, 9.04]

3 Postoperative complications Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

1.88 [0.63, 5.64]

4 Comparison of operative time between clips and ligatures Show forest plot

6

553

Mean Difference (IV, Random, 95% CI)

‐8.14 [‐11.73, ‐4.55]

5 Comparison of hospital stay between clips and ligature Show forest plot

6

553

Mean Difference (IV, Random, 95% CI)

‐0.03 [‐0.16, 0.11]

6 Postoperative superficial infections Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

1.25 [0.32, 4.90]

7 Postoperative deep infections Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

1.75 [0.28, 10.93]

8 Postoperative ileus Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

0.92 [0.15, 5.64]
Figures and Tables -
Comparison 3. Clips versus ligature (Endoloop or intracorporeal knot)
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Comparison 4. Endoscopic stapler versus clips

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

1.0 [0.13, 7.60]

2 Intraoperative complications Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

1.0 [0.13, 7.60]

3 Postoperative complications Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

4 Comparison of operative time between stapler and clips Show forest plot

1

60

Mean Difference (IV, Random, 95% CI)

‐3.46 [‐6.94, 0.02]

5 Comparison of hospital stay between stapler and clips Show forest plot

1

60

Mean Difference (IV, Random, 95% CI)

‐0.04 [‐0.28, 0.20]

6 Postoperative superficial infections Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

7 Postoperative deep infections Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

8 Postoperative ileus Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]
Figures and Tables -
Comparison 4. Endoscopic stapler versus clips
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Comparison 5. Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.77 [0.53, 1.13]

2 Intraoperative complications Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.81 [0.45, 1.46]

3 Postoperative complications Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.80 [0.52, 1.24]

4 Comparison of operative time between mechanical device and ligature Show forest plot

8

850

Mean Difference (IV, Fixed, 95% CI)

‐11.94 [‐13.04, ‐10.84]

5 Hospital stay (in days) between mechanical device and ligature Show forest plot

8

850

Mean Difference (IV, Fixed, 95% CI)

0.02 [‐0.12, 0.16]

6 Postoperative superficial infections Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.47 [0.17, 1.26]

7 Postoperative deep infections Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.86 [0.31, 2.41]

8 Postoperative ileus Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.48 [0.20, 1.15]
Figures and Tables -
Comparison 5. Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model
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Comparison 6. Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.26 [0.14, 0.46]

2 Intraoperative complications Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.72 [0.38, 1.39]

3 Postoperative complications Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.19 [0.09, 0.41]

4 Comparison of operative time between stapler and ligature Show forest plot

3

327

Mean Difference (IV, Fixed, 95% CI)

‐12.99 [‐14.39, ‐11.58]

5 Comparison of hospital stay between stapler and ligature Show forest plot

3

327

Mean Difference (IV, Fixed, 95% CI)

0.03 [‐0.14, 0.20]

6 Postoperative superficial infections Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.10 [0.01, 0.86]

7 Postoperative deep infections Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.45 [0.10, 2.02]

8 Postoperative ileus Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.37 [0.13, 1.07]
Figures and Tables -
Comparison 6. Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model
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Comparison 7. Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

2.33 [1.31, 4.13]

2 Intraoperative complications Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

1.79 [0.49, 6.56]

3 Postoperative complications Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

2.40 [1.28, 4.48]

4 Comparison of operative time between clips and ligature Show forest plot

6

553

Mean Difference (IV, Fixed, 95% CI)

‐8.06 [‐9.85, ‐6.26]

5 Comparison of hospital stay between clips and ligature Show forest plot

6

553

Mean Difference (IV, Fixed, 95% CI)

‐0.03 [‐0.16, 0.11]

6 Postoperative superficial infections Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

1.27 [0.33, 4.86]

7 Postoperative deep infections Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

1.79 [0.37, 8.58]

8 Postoperative ileus Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

0.92 [0.19, 4.56]
Figures and Tables -
Comparison 7. Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model
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Comparison 8. Sensitivity analysis: endoscopic stapler versus clips using fixed effect model

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

1.0 [0.13, 7.60]

2 Intraoperative complications Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

1.0 [0.13, 7.60]

3 Postoperative complications Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Comparison of operative time between stapler and clips Show forest plot

1

60

Mean Difference (IV, Fixed, 95% CI)

‐3.46 [‐6.94, 0.02]

5 Comparison of hospital stay between stapler and clips Show forest plot

1

60

Mean Difference (IV, Fixed, 95% CI)

‐0.04 [‐0.28, 0.20]

6 Postoperative superficial infections Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

7 Postoperative deep infections Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8 Postoperative ileus Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figures and Tables -
Comparison 8. Sensitivity analysis: endoscopic stapler versus clips using fixed effect model
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