Abstract
Background: Laparoscopic appendectomy is a commonly performed procedure, with surgeons having a choice of instruments to close the appendiceal stump. Recent studies have shown slight variability in operating room time by device, with similar clinical outcomes. The purpose of this study is to examine differences in selection of closure technique between hospitals and individuals, surgical time by device, cost differences, and the effect on time and cost when an energy device is added.
Methods: A patient database was created to examine the choice of technique for appendiceal stump closure, specifically endoscopic stapler, polymer locking clip, or a ligating loop. The use of energy devices was also examined. Acquisition costs of different disposable devices were determined. The study included 56 surgeons at four hospitals over a seven-year period.
Results: A total of 7,042 cases were included in the complete-case multivariable analysis. The most common technique in the adjusted cohort to close the appendiceal stump was with a stapler (70.4%), followed by endoloops (15.3%) and then polymer locking clips (Hem-o-Lok) (14.3%). Energy devices were used in 37.1% of cases, most commonly with a stapler. Choice of closure device and inclusion of an energy device varied by hospital and by surgeon. The study found that cases performed with an endoscopic stapler took the longest at 34.1 minutes, followed by polymer locking clips at 27.2 minutes and loops at 25.0 minutes. Closure-device use was associated with operative time overall after multivariable adjustment (Wald χ²[2]= 6.24, p = 0.044). Stapler use was associated with additional time compared to polymer locking clips (p = 0.030). However after Holm adjustment, pairwise comparisons were not statistically significant. The use of an energy device did not result in a decrease in operating time (adjusted difference = +0.94 minutes, p = 0.60). Financial cost of disposable instruments between closure techniques varied from $37 to over $1,500.
Conclusions: In this study, staplers were the most popular method to close the appendiceal stump, although they were more expensive than loops and polymer locking clips and did not result in shorter OR times. Addition of an energy device did not decrease OR times. Significant cost savings could be realized if surgeons switched to a more economical method of stump closure such as polymer locking clips.
Keywords
Appendectomy, Practice variation, Value-based care