We are doing appendectomies with excellent results, using single Endoloop with a titanium clip. Patients with appendicitis that compromise the appendix base we use Laparoscopic linear cutter stapler. Endo GIA™

There is No difference bury the stump or not . If you have experience ligation with 2 or 3/o silk is enaugh . Using endoloop and stapler is not cost effective except in perforate and eccessive inflame appendix which can not Ligate with suture

I recommend hand-made loop, It is simple and cheap method. "Laparoscopic appendectomy with hand-made loop.Videosurgery Miniinv 2014; 9 (2): 152–156"

Burhan, what is your trick for tightening the knot? Never tried the hand-made loop, but read your paper, sounds interesting and I might try it. Have never really found much usefulness for the endo GIA, I use laparosocpic suturing if base doesn't look good.  A single polypropelene or vicryl endoloop has worked for me. 

I agree. Vicryl or prolene are both acceptable.  There is no good evidence for single vs double Endoloop.  I do doubles because the cost difference is immaterial at my hospital and I feel happier with two.  If the base appears necrotic then I would use EndoGIA stapler taking a bit of adjacent caecum in the specimen.

What would be really interesting is if more people do some form of extracorporeal suturing to tie the base.  One option is a Roeder knot.  See link below.

The prepacked Endoloops are convenient but EC suturing is more cost effective.

http://youtu.be/cxobSQgdlDo?list=UUhWxkHBx8_NYLT4IaQM7t6A

nothing is ideal nor any consensus. catgut,silk or vicryl all can be used,infact all are used by different as their experience with similar result. single endo loop sufficient.

Fady Saleh, hand made look is similar endoloop, but you can make it yourself. It is cheaper than endoloop. You can make hand made loop with 2/0 vicryl. I think polipropilen is not appropriate, because it don't tighten sufficiently. Don't use silk for hand made loop, it doesn't slide. I never use endo GIA for lap appendectomy. Hand made loop is sufficient

I use a hand made loop with vicryl.

When the base of the appendix is inflammed it might cut through.

Then Stapler or intracorporeal suturing are the options available 

We are using a hand made loop done with polipropilene suture in laparoscopic approach with good outcomes. In our country the cost of mechanical suture difficult the use of staplers. When the base is too much compromised, we chose intracorporeal suturing. It's increasingly rare the laparotomic approach.

I do agree with dr Alfie J Kavalakat.The idea is to keep the costs down.We usually use a double loop technique at the base either catgut or vicryl.Catgut loops are cheaper.Also at times the stump can be secured using endosuturing  technique.In cases where the appendiular base  is friable and there is an impending risk of cutting through--we just apply the endoloop and avoid undue tightening and then place an endoclip over the loop tp secure the knot.

Dear Sanoop

catgut has been withdrawn from most of the world since the discovery of CJD and silk is known to cause extensive scarring and carries higher infection risk so is no longer used in the Western World. It is vicryl that is used commonly. Single Endoloop works well and I have not buried the stump for over 20 years I believe and have not regretted it to day. However although expensive I prefer Endo GIA particularly after having done a few stumpitis cases after appendectomy with use of loop 

sigle o double endoloop is inaf in most cases.Endo Gia is useful with local peritonitis

Dear Dr Bhutiani,

I totally  agree with your view.But i would like to mention that we work in a rural setup where cost of surgery is an important factor .For patients who are covered by insurance we do prefer vicryl. Moreover our technique is to apply one loop over the other at the same level and this leaves the appendicular stump almost flush with the caecum and might probably prevent stump appendicitis.Most of the times the stump is less than 0.5mm long.Well the use of endo GIA for appendectomy is almost out of question in our setup. A good majority  of our patients present late with local peritonitis /mass and most of the time we are able to  locate the base for loop placement. by meticulous dissection.

Nobody's talking ab

Good and practicle question.In Laparoscopic era in our part of the Globe ,double endoloops to the base of the appendix is the practice.It works well.Purse string with burrying the stump  with vicryl /catgut is the common practice.

Single endoloop in laparoscopy .purse string and stump in vicryl  in open surgery.

single loop vicryl. I have also used enodclips as well, with equal results.

Is there a need to bury the stump? Is there any evidence or just we follow, as we were told or demonstrated to do. Its definitely good for practice as one can appreciate how to handle bowel at both open and laparoscopic surgery

We apply a single endoloop while grasping the distal cut end of the appendix to avoid contamination and quickly inserting it in a cheap retrieving bag or the thumb of a nr 8 glove which we take out by the (only) 10mm port used for the laparoscope at the end of the operation). In the rare cases where we have a thick inflamed appendicular base we use an endo GIA because we fear that the endoloop would cut through the wall of the appendix. We don't bury the stump nor burn the protruding mucosa. This is what we do both in lap and in open surgery, and also if we have diffuse purulent peritonitis

single endoloop

We used vicryl No. 0 to ligate the appendex base through extracorporal pretied ligature during minilaparoscopic appendectomy by using new spiral needle.

lasheen ae. et al surgical endoscopy journal 2014

Reasonable option, however I feel 0 suture is too thick. One can easily use 00 or even 000. The basis is every suture material (more so the braided ones like Vicryl) is a foreign body and carries a risk of infection and scarring particularly in an already infected field. So the least amount of material used the better. Just an opinion, there is no hard and fast rule.

I have used hand made loop with 2#0 Prolene or Vicryl , double ties at the base.

and intracoporeal  suturing with 2#0 Vicryl or silk  were used if the base was lot of inflammation 

I usually do the same as Ahmed, unless necrosis at the apendix base is presente, then I prefer to use linear staplers.

Base healthy: Laparoscopy-Single Endoloop to the base; Open: You can use whatever suture available. Base not healthy, laparoscopy or open-after securing the stump, I do a purse string  and bury the stump. I would not say mine is ideal but so far so good.

Most methods and materials work, albeit som are very expensive (eg linear stapler).

For laparoscopic as well as for open appendicectomy, I personally prefer hand-sewn suture ligation, using a monofilament absorbable material , caliber 2-0.

Tissue-friendly, secure (won't slip), leaves no residue material.

Although Trained in delhi, I am spoiled in the West. In my cases in majority I use endo GIA Vascular stapling gun for both the base of the appendix and the vascular pedicle. A bit expensive but very quick and I feel (although no studies to show) the cost equalises when compared to the time, length of anaesthesia, nurses time, the heating, lighting in theatres etc.

In routine practice we cauterize the vascular pedicle with Ultrasicson and place two or one endoloops to the base.Time taken is not more than firing two endo staplers.I agree time differs from the pathology and the surgeon.

I think double endoloop suture ( Hand made preferable )  is enough. Also Harmonic Scalpel can be used following suturing. 

I usually use Double endoloop! (hand made sometimes)

Never used to secure the base as I use Endo GIA. May be I am just lazy.

Double endo loop handmade or commercially availkable.If the base is diseased two of three interrupted sutures with omental patch .

If the base of appendix is thick due to inflammation, I prefer to put my ligation on the caecum proximal to the inflammed base by hand made chromic catgut #1 material, double ligation. Have never regreted thus far.

double endoloop suture is enough.

I think the the type of suture material is important but the most important is the more close to the base the more risk of post appendectomy caecal fistula. Thanks

I have never changed my suture material to other than chromic catgut despite so much fuss that may have several reasons than scientific ones. If the endoloop is put on healthy area of the tissue, and in this context, on the adjacent healthy wall of caecum, and I have always done so without any regret. Cause of fecal fistula from caecum is difficult to understand if the loop is put over healthy tissue and not too tight to cut through, fistula should not occur, as I can view it and have, fortunately not come accross it.

Never seen or heard from my colleagues about caecal fistula after appendectomy. May be i have not done enough>

I agree with you Om regarding putting suture on a healthy tissue. I recall my Prof of Surgery Prof S K Nair from MAMC in Delhi asking where would you put sutures if the base of appendix was gangrenous as well. The answer he taught was go further back on to caecum where the tissue is healthy.

A great teacher I must add.

It depends. Single endoloop, double endoloop, stapler...

During laparoscopy I’ve used endoloops and hemolok clips if the base is healthy and a stapler if the base is gangrenous in which case I will staple across healthy tissue on the caecum