Extra corporeal knotting vs harmonic scalpel for appendicular stump ligation in laparoscopic appendectomy

Background: Acute appendicitis is one of the most common cause of surgical abdomen requiring emergency surgery, with a life time incidence of about 6% to 8%. One of the most important steps in appendectomy procedure is closure of appendix stump. In laparoscopic appendectomy extra corporeal or intra corporeal knotting are used for stump ligation. Harmonic scalpel is an energy device that can be used to deal with appendicular stump. Materials and Methods: This prospective randomized comparative study was conducted in Post Graduate Department of Surgery, Government Medical College Jammu. All patients with clinical evidence of acute appendicitis, recurrent appendicitis and patients dated for interval appendectomy were included in this study and laparoscopic appendectomy was performed in all. Patients with clinically apparent perforation, appendicular lump and co morbid condition contraindicating surgery under general anaesthesia were excluded from this study group. 84 patients were taken up for the study but data of four patients were excluded from study as they needed conversion to open surgery. Rest of the 80 patients were randomly divided into two groups. Group A included 40 patients in whom appendicular stump was dealt with extracorporeal knotting and group B included 40 patients in whom appendicular stump was dealt with harmonic scalpel. Results: Mean age of patients in extracorporeal knotting group was 27.6 years (7-62 years) and in harmonic scalpel group it was 26.9 years (8-64 years) with M:F ratio in extracorporeal knotting group (Group A) being 1.5:1 and in Group B (Harmonic scalpel) it was 1.7:1. Mean Operative time in Group B was 35.44 minutes and it was 50.8 minutes in Group A. The difference in operating time was statistically significant (p < 0.00001).Mean appendicular stump closure time in harmonic scalpel group was 44.6 seconds and in extracorporeal knotting group was 295.6 seconds and difference was statistically significant (p<0.0001). Post operative ileus was present in 5% (n=2) patients in knotting group and in harmonic group it was present in 7.5% (n=3) patient. Statistically difference in two groups was not significant (p=1.000). Mean pain score as observed was 4.12 in Group A and 3.8 in Group B. In majority of the patients in both groups; only 02 doses of analgesics were required. Port site infection was observed in 2.5% (n=1) patient in harmonic group and 7.5% (n=3) in knotting group (P=0.609). The mean duration of post operative hospital stay was 3.12 days (2-5 days) in knotting group and 2.76 days (2-4 days) in harmonic group. The mean interval to return to daily routine was 7.4 days in knotting group and 7.64 days in harmonic group. There is no statistically significant difference between two groups (p=0.513). Conclusion: The technique of laparoscopic appendectomy by harmonic scalpel is very simple and safe that is changing surgeons’ performances to refined, quicker and efficient procedures. In view of the results available from the present study it is concluded that harmonic scalpel appendicular stump closure is safe, time saving, easily accessible and simple when compared with extracorporeal knotting closure of appendicular stump. In situations where facilities of harmonic scalpel are available patients of appendicitis must be extended the benefit of ligating appendicular stump with harmonic scalpel.