JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 19, Number 3, 2009

© Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2008.0368

Comparison of the Electrothermal Vessel-Sealing System

Versus Endoclip in Laparoscopic Appendectomy

Fatih Aydogan, MD,1 Kaya Saribeyoglu, MD,1 Osman Simsek, MD,1 Ziya Salihoglu, MD,2
Sinan Carkman, MD,1 Tamer Salihoglu, MD,2 Adem Karatas, MD,1 Bilgi Baca, MD,1
Ozan Kucuk, MD,1 Nihat Yavuz, MD,1 and Salih Pekmezci, MD1

Abstract

Background: Various techniques have been used for the division of mesoappendix, such as endoloops, endo-
scopic linear cutting staplers, an electrothermal vessel-sealing system (LigaSure), the Harmonic Scalpel, clips,
and bipolar coagulation. In the present study, LigaSure and an endoclip were compared in laparoscopic ap-
pendectomy (LA).
Materials and Methods: This study included patients who underwent LA for acute appendicitis at Istanbul
University, Cerrahpasa Medical Faculty, Emergency Unit (Istanbul, Turkey) between May 2003 and April 2007.
The patients were assigned to two groups according to the mesoappendix dissection device: LigaSure and en-
doclip groups. The main outcome measures (e.g., operating time, conversion rate, hospital stay, postoperative
complications, etc.) were then compared.
Results: LA was performed in 280 patients with acute appendicitis. LigaSure and endoclips were used in 127
and 153 patients, respectively. The mean operative times were 41 and 54 minutes in the LigaSure and endoclip
groups, respectively. Conversions to open rates were found to be 9.4% (12 patients) in the LigaSure and 11.1%
(17 patients) in endoclip groups. No statistically significant differences regarding hospital stay or complications
were found, whereas significant differences were observed in surgical time and conversion rate.
Conclusion: The use of LigaSure facilitates the dissection of mesoappendix and shortens the operation time in
LA. We believe that LigaSure is a safe, useful tool for mesoappendix dissection.

Introduction elastin within the vessel wall and surrounding connective

tissue. The LigaSure vessel-sealing system allows laparo-

S INCE ITS INITIAL DESCRIPTION by Semm in 1983, the laparo-

scopic appendectomy (LA) has been increasingly used
over the last decade for the management of acute appen-
dicitis.1 Meta-analyses of randomized, controlled trials sug-
gest that the LA offers several distinct advantages over the
open technique, including decreased postoperative pain,
shorter hospital stay, faster recovery, fewer wound infec-
tions, and improved cosmesis.2,3 The underlined disadvan-
tages of the laparoscopic approach are longer operative times
and increased operative costs.4,5 The LigaSure™ (Valleylab,
Boulder, CO) is an electrothermal vessel-sealing system, de-
signed as an alternative to suture, staplers, hemoclips, and
ultrasonic coagulators for ligating vessels and tissue bundles.
LigaSure uses bipolar electrocoagulation and seals blood
vessels up to 7 mm in diameter by denaturing collagen and
scopic dissection and vascular control to be done in a quicker,
safer, and easier manner.6–8 In the present study, LigaSure
and endoclips were compared in their use in LA.
Materials and Methods
The patients who underwent LA for acute appendicitis, at
Istanbul University, Cerrahpasa Medical Faculty, Emergency
Unit (Istanbul, Turkey) between May 2003 and April 2007
were included into the study. Those who underwent an ap-
pendectomy without a histopathologic proof of acute ap-
pendicitis were excluded from the study. The patients were
assigned into two groups regarding the devices that had
been used for mesoappendix dissection: LigaSure and en-
doclip groups. Patients’ records were retrospectively evalu-

Departments of 1General Surgery and 2Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul,
Turkey.

375
376 AYDOGAN ET AL.

TABLE 1. PATIENT DEMOGRAPHICS AND PATHOLOGIC FINDINGS

Ligasure group Endoclip group

Demographics (n  127) (n  153) P-value

Age 31.49  13.99 30.92  14.1 0.215

Sex ratio (MF) 71/56 83/70 0.780
Pathologic findings
Phlegmonous 97/127 (76.4%) 115/153 (75.2%) 0.810
Gangrenous 22/127 (17.3%) 28/153 (18.3%) 0.830
Perforated 8/127 (6.3%) 10/153 (6.5%)0 0.940

ated and analyzed, regarding demographics, pathologic
findings, operative time, conversion rate, hospital stay, and
postoperative complications.
Technique
LA was performed via three ports. An infraumbilical 10-
mm port was inserted by blind (Veress needle) or open (Has-
son) technique, and a 30-degree laparoscope was inserted to
explore the abdomen. An additional second port of 10 mm
was inserted under direct vision from the left iliac fossa; the
third port of 5 mm was placed either from the right iliac fossa
or above the pubis. The appendix was identified and freed
from inflammatory adhesions. The mesoappendix was di-
vided by using LigaSure (LigaSure™ Atlas, Vessel Sealing
System; Valleylab) or endoclip (Ligaclip; Ethicon Endo-Sur-
gery, Cincinnati, OH). The appendix was ligated and divided
with an endoloop at its base. The appendix was then re-
moved from the abdomen in an endobag or surgical glove
via the 10-mm left iliac fossa trocar. The entire abdomen was
inspected for any intra-abdominal fluid and irrigated vigor-
ously. All patients received a single dose of broad-spectrum
intravenous antibiotic at the induction of anesthesia. Post-
operative antibiotic prescription was dependent on opera-
tive findings and postoperative complications.
Statistical analysis
For the statistical analysis of the collected data, unpaired
student’s t-test and chi-square test were used. A value of P 
0.05 was considered significant. Results were given as the
mean  standard deviation.
Results
A total of 280 patients underwent surgery for acute ap-
pendicitis. The postoperative histopathologic examination
confirmed the diagnosis of acute appendicitis in all patients.
LigaSure and endoclips were used for mesoappendix dis-
section in 127 and 153 patients, respectively. The LigaSure
group included 71 men and 56 women, for a male-to-female
ratio of 1.2:1; the mean age was 31 years (range, 16–75). The
endoclip group included 83 men and 70 women, with a
male-to-female ratio of 1.1:1; the mean age was 30 years
(range, 14–87). Patient demographics and pathologic find-
ings of the LigaSure and endoclip groups are summarized
in Table 1. The mean operative time was 41 and 54 minutes
in the LigaSure and endoclip groups, respectively (P 
0.05). Conversion rates were found to be 9.4% (12 patients)
in the LigaSure and 11.1% (17 patients) in the endoclip
groups, and the difference was statistically significant (P 
0.05). In the LigaSure group, conversion to laparotomy was
due to perforated appendicitis and inadequate surgical ex-
posure in 6 patients each. Then again, in the endoclip group,
the conversion was related to perforated appendicitis and
inadequate surgical exposure in 7 patients each, bleeding in
2 patients (laparoscopy was converted to an open procedure
in 2 patients, due to uncontrollable mesoappendix bleeding,
which was associated with endoclip application), and an in-
appropriate endoloop closure in 1 patient. As for the bleed-
ing-related conversion rates, there was no statistically sig-
nificant difference between the LigaSure and endoclip
groups. There was no significant difference in terms of the
hospital stay in both groups. Postoperative complications
occurred in 3 patients in the LigaSure (2.3%) and 4 patients
in the endoclip groups (2.6%), with no statistically signifi-
cant difference (Table 2).
Discussion
In our study, the LigaSure and endoclip were compared
regarding their use in LA. There was no significant differ-
ence in hospital stay and complication rates, whereas a sig-
nificant difference was found in surgical time and the con-
version to open rate.

TABLE 2. PERIOPERATIVE OUTCOMES

Ligasure group Endoclip group

Outcomes (n  127) P-value (n  153)

Average operative time, minutes (range) 41  21 (23–105) 0.05 54  26 (20–130)

Average hospital stay, days (range) 1.5 (1–8) NS 1.5 (1–10)
Conversion rate 12/127 (9.4%) 0.05 17/153 (11.1%)
Postoperative complications 3 (2.3%) NS 4 (2.6%)
Wound infections 2 3
Intra-abdominal collections 1 1
COMPARISON OF LIGASURE AND ENDOCLIP
Shorter mean operative time in the LigaSure group can be
attributed to several factors. In the case of a bulky or ex-
tremely inflamed mesoappendix, dissection with electro-
cautery and endoclips can be difficult and requires a longer
time. The LigaSure is a multifunctional instrument and re-
places four instruments routinely used in LA: the dissector,
endoclip, scissor, and electrosurgical hook. Its use, therefore,
prevents the frequent blind extraction and reinsertion of
these different instruments with the subsequent prevention
of time loss. On the other hand, the use of the electrosurgi-
cal hook for appendicular mesentery dissection might cause
smoke to get into the abdominal cavity and impede vision.
If so, the smoke must be evacuated by opening the valves of
the trocars, which is associated with repeated loss of the
pneumoperitoneum and a subsequent loss of time.9
In this study, 2 of 17 conversions (11.7 %) were due to un-
controllable bleeding in the endoclip group. Even though
there was no statistically significant difference between the
two groups, there was no bleeding incident associated with
LigaSure use. Bleeding from the appendiceal vessels during
the dissection of the mesoappendix is not uncommon and
has been reported to be the main reason for conversion to
open surgery in several studies.10,11 Various techniques have
been used for the division of the mesoappendix, such as en-
doloops, endoscopic linear cutting staplers (endo-GIA), the
Harmonic Scalpel, polymeric clips, and bipolar coagula-
tion.12–17 Clips, although easily placed, may slip or become
detached and necessitate retained nonabsorbable foreign ma-
terial into the abdominal cavity. Suturing or surgical knots
can be tedious options that are time-consuming in laparo-
scopic surgery and leave foreign materials.8 The use of an
endostapler requires a 12-mm port and can result in the
spillage of fired staples beyond the tissue margins, which
may give rise to significant morbidity.18,19 The efficacy of the
endostapler was reported by Olguner et al.20 as well, who
also suggested the usage of a single stapling device for the
simultaneous division of both the mesoappendix and the
base of the appendix. Although the mesoappendix and ap-
pendix can be transected by using one staple load in chil-
dren, this is likely not the case in adult appendectomies. Cur-
rently, laparoscopic stapler devices are not commonly used
in LAs.
The use of the LigaSure in laparoscopic surgery seems to
be more expensive than the conventional technique. This is
probably the major disadvantage of this device. However,
the potential added cost to the procedure by using the Liga-
Sure ($600 for the LigaSure Atlas and $400 for the endoclip)
should be compared with substantial benefits in surgical
time saving. In general, the use of the LigaSure is associated
with a significant decrease in thermal injury to the adjacent
tissues, compared with monopolar electrocoagulation. Dia-
mantis et al.21 compared the safety and efficacy of monopo-
lar electrocoagulation, bipolar coagulation, the Harmonic
Scalpel and the LigaSure experimentally. They reported that
the LigaSure and Harmonic Scalpel caused more minimal
thermal injury of the surrounding tissue than other tech-
niques. The results show the clear superiority of the Liga-
Sure and Harmonic Scalpel systems over the mono- and
bipolar coagulation techniques. In the current study, there
was not any complication related to the use of the LigaSure
or the endoclip.
377
Conclusion
In this study, the comparison of two groups revealed that
the use of the LigaSure was associated with a shorter oper-
ating time and less conversion rate than endoclip applica-
tion in LA. The LigaSure seems to be a safe, useful tool for
mesoappendix dissection. Further studies are required for
elucidating the definite role of the LigaSure in LA.
Disclosure Statement
No competing financial interests exist.
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