Presently, there is equipoise regarding the surgical technique used to manage the appendiceal stump during laparoscopic appendectomy. The purpose of this research was to determine whether the routine use of loop ligature, compared to stapling, is cost effective from a hospital payer perspective.

A retrospective cohort study was conducted amongst patients undergoing emergency laparoscopic surgery for acute appendicitis at two major academic hospitals. In order to eliminate possible systemic bias arising from one technique being preferentially employed with more complex presentations, regardless of how their surgery was conducted, patients were divided into study groups based on the technique routinely employed by their surgeon, loop ligature (LLA) versus stapler (LSA). Pediatric patients and patients having open appendectomy were excluded. Costs were determined using a previously published model derived from publically available data from the Ontario Case Costing Initiative, in conjunction with local cost data for disposable procurement. Secondary outcomes included operating room time, length of stay, and complication rates.

Between Jan 1 2014 and Dec 31 2015, 567 adult patients had an emergency laparoscopic appendectomy for acute appendicitis. Comparing surgeons routinely employing LLA to LSA, there were no significant differences observed in mean operation time (73 +/- 4.4 vs. 68 +/- 2.8 minutes, p=0.080) or mean length of stay (1.5 +/- 0.19 vs. 1.4 +/- 0.11 days, p=0.32). Mean disposable cost was $300 higher for surgeons routinely using LSA ($308+/- 32 vs. $608+/- 26, p<0.001) as was total mean hospital cost ($2002+/- 160 vs. $2202+/- 99, p=0.032).

These findings suggest that surgeons who routinely use loop ligature to secure the appendiceal base during emergency laparoscopic appendectomy offer more cost effective care than stapler users from a hospital payer perspective, saving their institution $200 per case with no clear disadvantages. A shift from routine use of staplers to loop ligature should result in significant overall cost savings to the hospital.

Cost-effectiveness of surgical technique for the management of appendicitis.