Background: Because it causes less postoperative pain, shorter hospital stay and faster recovery, laparoscopic appendectomy is the preferred surgical treatment of acute and recurrent appendicitis. The most important step to prevent postoperative complications is the secure closure of the stump of the appendix. Hem-o-lok polymer clips are a feasible, cost-effective and technically convenient alternative for the closure of the appendiceal stump.
Aims: To assess the effectiveness and safety of Hem-o-lok clips in laparoscopic appendectomy for appendiceal stump closure.
Materials and Methods: This was a prospective observational study done in the Department of Minimal Access and General Surgery, Government Medical College Srinagar. The study was conducted for a period of 18 months from March 2024 to September 2025. We enrolled a total of 36 patients who underwent laparoscopic appendectomy and closure of appendiceal stump with Hem-o-lok clips. Demographic profile, operative time, length of hospital stay and postoperative complications were analyzed using statistical methods.
Results and discussion: Mean age of patients was 30.14 ± 13.47 years with female predominance (72.2%). The most common presentation was recurrent appendicitis (58.3%). Mean operative time was 53.5 ± 21.5 minutes . Most procedures were performed in 41–60 minutes. Postoperative recovery was good with few complications in most of the cases. There was no stump leak, intra-abdominal abscess, or mortality.
Conclusion: The use of hem-o-lok clips is a safe, reliable and technically feasible technique for appendiceal stump closure in laparoscopic appendectomy. They are related to acceptable operative time, low complication rates and favorable postoperative results.
Acute appendicitis is one of the most common causes of acute abdomen worldwide requiring emergency surgical intervention . The disease is caused by obstruction of the appendiceal lumen by lymphoid hyperplasia, fecoliths, tumors or parasites, which causes inflammation, ischemia, and bacterial overgrowth, which can ultimately lead to necrosis if left untreated [1]. Appendicitis is most common in young adults with peak incidence in the 2nd and 3rd decades of life [2].
For over a century the gold standard procedure has been the open appendectomy. However, since the first laparoscopic appendectomy by Semm in 1982 [3], minimally invasive surgery has revolutionized the management of appendicitis. Laparoscopic appendectomy has many advantages such as decreased postoperative pain, shorter hospital stay, faster recovery, better cosmetic outcome and lower wound infection rates [4].
One of the most important steps in laparoscopic appendectomy is the safe closure of the appendiceal stump. Inadequate stump closure can lead to severe postoperative complications such as fecal fistula, stump leak, intra-abdominal abscess and peritonitis [5]. Endoloops, intracorporeal sutures, staplers, metallic clips, and polymeric clips are some of the techniques that have been used for appendiceal stump closure [6] .
Endoscopic staplers are reliable for closure but increase the cost of the procedure markedly [7]. Endoloops are less expensive but technically difficult and time-consuming (8). Hem-o-lok clips are nonabsorbable polymer clips with locking mechanisms that are designed to provide secure tissue ligation. The clips are radiolucent and inert, easy to apply, and associated with shorter operative time. [9]
There are many studies that demonstrate the safety and efficacy of Hem-o-lok clips in laparoscopic appendectomy. Clips offer adequate compression at the base of the appendix and decrease operative complexity with low complication rates [10–12]. These have gained popularity over the years due to ease of application and cost-effectiveness.
There is increasing evidence on the efficacy of Hem-o-lok clips in laparoscopic appendectomy, but there is limited prospective observational data from tertiary care hospitals in the Indian subcontinent. Therefore, the present study was carried out to evaluate operative outcomes, postoperative recovery and complications with the use of Hem-o-lok clips for closure of appendiceal stump.
Aim & Objectives
Aims
To assess the efficacy of Hem-o-lok clips for appendiceal stump ligation in laparoscopic appendectomy.
Objective
MATERIALS AND METHODS
Study Design
Hospital-based prospective observational study.
Study Setting
Department of Minimal Access and General Surgery, Government Medical College Srinagar.
Study Duration
March 2024 to September 2025.
Study Population
Thirty-six patients undergoing laparoscopic appendectomy with Hem-o-lok clip application for appendiceal stump closure.
Inclusion Criteria
Exclusion Criteria
Surgical Technique
Under general anesthesia, patients were positioned supine with Trendelenburg tilt and right side elevated. Pneumoperitoneum was established using carbon dioxide through a supraumbilical port. Additional 5-mm working ports were inserted in the right iliac fossa and suprapubic region.
The appendix was identified and mesoappendix dissected using harmonic scalpel. Hem-o-lok clips were applied at the appendiceal base using a clip applicator. Two clips were applied proximally and one distally, followed by division of the appendix between clips.
Follow-Up
Patients were followed on postoperative day 7 and day 30.
Statistical Analysis
Continuous variables were expressed as mean ± SD. Categorical variables were represented as frequency and percentages. Statistical significance was considered at p < 0.05.
RESULTS
Table 1: Age Distribution of Study Population
|
Age Group (Years) |
Frequency |
Percentage |
|
<20 |
12 |
33.3% |
|
20–30 |
10 |
27.8% |
|
31–40 |
7 |
19.4% |
|
41–50 |
4 |
11.1% |
|
51–60 |
2 |
5.6% |
|
>60 |
1 |
2.8% |
Mean age: 30.14 ± 13.47 years
The majority of patients belonged to younger age groups, reflecting the classical epidemiological pattern of appendicitis occurring predominantly in young adults.
Fig 1: Age Distribution of Study Population
Table 2: Gender Distribution
|
Gender |
Frequency |
Percentage |
|
Female |
26 |
72.2% |
|
Male |
10 |
27.8% |
Female patients constituted the majority of the study population with a female-to-male ratio of approximately 2.6:1.
Fig 2: Gender Distribution
Table 3: Distribution of Comorbidities
|
Comorbidity |
Frequency |
Percentage |
|
No Comorbidity |
30 |
83.3% |
|
Hypothyroidism |
4 |
11.1% |
|
HTN + T2DM |
1 |
2.8% |
|
HTN + T2DM + Hypothyroidism |
1 |
2.8% |
Most patients had no associated medical comorbidity. Hypothyroidism was the commonest associated illness.
Table 4: Clinical Presentation
|
Presentation |
Frequency |
Percentage |
|
Recurrent Appendicitis |
21 |
58.3% |
|
Acute Appendicitis |
6 |
16.7% |
|
Follow-up Acute Appendicitis |
6 |
16.7% |
|
Recurrent Pain Abdomen |
3 |
8.3% |
Recurrent appendicitis represented the predominant clinical presentation, emphasizing the increasing recognition of recurrent inflammatory appendiceal disease.
Fig 3: Clinical Presentation of Patients
Table 5: Operative Time Distribution
|
Operative Time |
Frequency |
Percentage |
|
<20 min |
1 |
2.8% |
|
20–40 min |
10 |
27.8% |
|
41–60 min |
18 |
50.0% |
|
61–80 min |
3 |
8.3% |
|
>80 min |
4 |
11.1% |
Mean operative time: 53.5 ± 21.5 minutes
The majority of surgeries were completed within 41–60 minutes. Longer operative durations were generally associated with dense adhesions, recurrent inflammation, or difficult anatomy.
Interpretation of the Results
The results achieved in the present study demonstrate that laparoscopic appendectomy with Hem-o-lok clips is technically feasible and clinically effective. The predominance of younger patients is in line with the established epidemiology of appendicitis where lymphoid hyperplasia is more common in younger age groups [13].
The female predominance in this study might also be explained by increased healthcare utilization by female patients presenting with recurrent abdominal pain requiring diagnostic laparoscopy. The commonest presentation was recurrent appendicitis. This supports the concept that recurrent appendiceal inflammation is a significant clinical entity.
Mean operative time of 53.5 minutes compares well with the published literature. Hem-o-lok clips facilitated appendiceal stump closure, making it less technically demanding and allowing the operation to be completed quickly. The locking mechanism provided a sense of security that the stump was safe.
There were no major post-operative complications like stump leak, intra-abdominal abscess, fecal fistula or mortality. These findings strongly support the reliability of polymeric clips for appendiceal stump closure.
The lack of serious complications may be related to proper selection of patients, exclusion of perforated appendicitis, good visualization and safe application of clips. Hem-o-lok clips effectively sealed the appendiceal base with minimal tissue trauma.
DISCUSSION
The improvement in postoperative results, early mobilization and better cosmetic outcome have led to laparoscopic appendectomy being the surgical treatment of choice for appendicitis. However, the best appendiceal stump closure is still an important determinant of post-operative morbidity. The objective of the present study was to evaluate the efficacy and safety of Hem-o-lok clips for appendiceal stump closure during laparoscopic appendectomy.
The mean age in the current study was 30.14 ± 13.47 years, which is comparable to the studies of Lucchi et al. and Kennedy et al., where most of the patients were young adults [14,15]. Appendicitis is common in the second and third decades because of increased activity of lymphoid tissue.
The female predominance observed in the present study contrasts with the classical epidemiological trends where males slightly predominate. Reinle et al. [16] reported similar female predominance. This disparity could be explained by referral patterns, health-seeking behavior or increased diagnostic workup in women presenting with right iliac fossa pain.
The most common clinical presentation was recurrent appendicitis. This finding highlights the growing recognition of recurrent appendiceal inflammation as an important surgical entity. Chronic low-grade inflammation can result in recurrent abdominal symptoms and ultimately in appendectomy.
The mean operative time in the present study was 53.5 minutes which is comparable to the results reported by Oz et al., Wilson et al., and Srikantegowda et al. [17–19]. The Hem-o-lok clips facilitate stump closure by obviating the need for intracorporeal knotting or repeated manipulation of loops. The lock provides security of application and reduces clip slip.
Several comparative studies have shown shorter operative duration with hemolock clips as compared to endoloops. Poon et al. (systematic review and meta-analysis) demonstrated a significant reduction in operative time with the use of polymeric clips [20]. This is supported by the findings of this study.
One of the great concern regarding appendiceal stump closure techniques is the development of postoperative complications such as stump leak, intra abdominal abscess and wound infection. There were no major complications in the current series. Hue et al., Parlakgumus et al., and Christopher Soll et al. [21–23] reported similar results.
In this study, there was no stump leakage, which proves the reliability of the Hem-o-lok clips in securing the appendiceal stump. The integrated locking teeth prevent the clip from being displaced and provide enough compression at the base of the appendix. Also, there are polymeric, nonconductive and inert clips that reduce tissue reactivity.
Another important factor is cost effectiveness. Endoscopic staplers are reliable but increase the cost of the procedures significantly. Hem-o-lok clips are relatively cheap and easy to use. Significant cost reduction has been demonstrated using polymeric clips by authors such as Reinle et al. and Al-Temimi et al. [16,24].
The present study also demonstrated good post-operative recovery with less hospital stay and no mortality. Less tissue manipulation, smaller incisions and secure stump closure all contribute to quicker recovery after laparoscopic appendectomy.
The study has several strengths. The prospective design, the standardized surgical technique, and the systematic follow-up after surgery reinforced the study. But there are some limitations. Sample size was relatively small and there was no comparison group with other stump closure techniques (endoloop or stapler). Long term follow-up was not available beyond 30 days.
Despite these limitations, the results strongly support the use of Hem-o-lok clips as a safe and feasible method for appendiceal stump closure in laparoscopic appendectomy. Further validation of these results is recommended by larger randomized controlled trials comparing different closure techniques.
CONCLUSION
The Hem-o-lok clip is a safe, effective and technically simple technique of appendiceal stump closure in laparoscopic appendectomy. They are accustomed to:
The study recommends the use of Hem-o-lok clips in laparoscopic appendectomy for wider use especially in resource-constrained settings where cost containment is of importance without compromising surgical safety.
REFERENCES
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