Discussion
intra-abdominal, inflammation, 33,260
INFLAMMATION, COMPLICATED APPENDICITIS, COMPLICATIONS, POSTOPERATIVE COMPLICATIONS
In this study, we were unable to verify the superiority of the polymeric clip over the endoloop in laparoscopic appendectomy for uncomplicated appendicitis in terms of shortening the operative time. However, it was confirmed that the application time of the polymeric clip was shorter than that of the endoloop, and no difference in postoperative complications was observed.Several studies have compared the use of polymeric clips, endoloops, and endostaplers for appendiceal base ligation [The advantage of using polymeric clips is that they can be applied precisely to the desired area. The endoloop needs to be tightened for ligation, with the disadvantage that the surrounding tissue may be pinched during the tightening process. In our study, the pre-knotted area was tightened in two cases, and the surrounding tissues (sigmoid mesocolon and terminal ileal tissue) were pinched together. Although it did not cause complications, it made intra-abdominal handling challenging, with disadvantages for accurate targeting.One of the reasons for the failure to prove the superiority of the polymeric clip in reducing surgical time is that the overall time of laparoscopic appendectomy in our study was shorter than that in the study used as a reference for sample size calculation [The major limitation of the polymeric clip is that it can be difficult to apply to a thick appendiceal base or an appendiceal base with severe and friable inflammation [A limitation of our study is that it was not double-blinded because the researcher included in the clinical trial performed the surgery. However, we attempted to avoid bias as much as possible by having a person unrelated to the study check the time difference and divide the time required for surgery for each procedure. Second, the study lacked empirical evidence to quantify the extent of inflammation at the appendiceal base, making it challenging to determine when applying a polymeric clip would pose difficulty. Future studies should focus on preoperative CT findings of inflammation in the appendiceal base, for which polymeric clips are difficult to apply. Third, although there was no statistical difference in surgical fee, the actual price of two pieces of the polymeric clips is cheaper (Gems-clip Plus, ₩7,100 each) than that of one endoloop (Gemsloop-PGLA, ₩33,260). However, there are usually six pieces of polymeric clips (GEMS clips) in a bundle. Therefore, the price for one operation is ₩42,600. We certainly have to purchase a reusable clip applier (₩243,000), but if there is a smaller bundle of fewer than six pieces, the price competitiveness can be better.