Single or double endoloop ligation in laparoscopic appendicectomy: a mixed-methods study of clinical outcomes and surgeon perspectives.

BACKGROUND

Securing the appendiceal stump is a critical step in laparoscopic appendicectomy, the gold-standard treatment for managing acute appendicitis. Endoloops are widely used in appendiceal stump ligation owing to their simplicity and cost-effectiveness, but practice varies between surgeons in the use of one or two loops. This study aimed to compare outcomes between single and double endoloop closure and to explore surgeon perspectives.

METHODS

A mixed methods approach was used to compare the use of one or two endoloops. A retrospective cohort analysis included patients undergoing laparoscopic appendicectomy in a UK district general hospital between August 2023 and January 2025, comparing post-operative complications and operating time between single and double endoloop ligation. Overall complications were defined as any complications within the 30-day post-operative period while clinically relevant complications referred to intra-abdominal abscess, stump leak, or stump appendicitis. A focus group of operating surgeons was analysed thematically to explore decision-making factors.

RESULTS

Among 191 patients included, 50 (26%) received a single endoloop and 141 (74%) received two. No statistically significant difference in clinically relevant 30-day complications was observed (12% vs. 9.9%; p = 0.07) with overlapping confidence intervals for all complication outcomes. Operative time was shorter in the single-endoloop group (84 ± 41.5 vs. 108.5 ± 31.9 min; p = 0.004). Thematic analysis identified three key influences on endoloop choice: perceived security through tradition, assessment of appendiceal base integrity, and training considerations.

CONCLUSION

No statistically significant difference in clinically relevant post-operative complications was observed between single and double endoloop closure, although the study may be underpowered to detect rare events. Single endoloop closure was associated with a shorter operative time, which may be partly confounded by disease severity. Surgical decision-making remains influenced by training culture and tradition rather than evidence-based practice, and full standardisation is challenging given variability in case complexity and surgeon expertise.