This review concluded that endo-loop to secure the appendicular stump during laparoscopic appendicectomy took longer than endo-GIA but had equal length of hospital stay, perioperative complications and intra-abdominal abscess. The small number of studies, high level of heterogeneity and method of meta-analysis mean these conclusions should be treated with caution.

To compare laparoscopic appendicectomy using endo-loop with endo-GIA (a linear stapling device).

MEDLINE via PUBMED, EMBASE, CINAHL and The Cochrane Library were searched between January 1992 and December 2006. Search terms were reported and reference lists were screened. There were no language restrictions.

Parallel group randomised controlled trials (RCTs) of any size that compared endo-loop with endo-GIA used for a laparoscopic appendicectomy procedure in patients of any age or gender and that reported at least two standardised outcome measures (from operative time, hospital stay, intra-abdominal access and perioperative complications) were eligible for inclusion.

Complications were defined as a condition that resulted from surgery that required reoperation, further treatment or prolonged hospital stay and included wound or other infections and abscesses. The included trials were published between 1993 and 2001.

The authors did not report how many reviewers performed the study selection.

Trial validity was assessed using the following criteria: reporting of inclusion and exclusion criteria; baseline comparability of groups; blinding; cross-over; randomisation method; allocation concealment; and intention-to-treat analysis.

The authors did not report how many reviewers performed the validity assessment.

The mean and standard deviation (SD) or range for operative time (minutes) and hospital stay (days) and numbers of patients who experiencied intraoperative abscesses and complications were extracted by two reviewers independently. The extracted details were used to calculate the standardised mean difference (SMD using Hedge's g statistic) for each trial.

The studies were pooled in meta-analyses using fixed-effect (Mantel-Haenszel with inverse variance weighting) and random-effects (DerSimonian and Laird) models. Heterogeneity was assessed using the X² test.

Five RCTs (n=622, 263 endo-GIA and 359 endo-loop patients) were included. All five were considered to be of inadequate quality, with allocation concealment and blinding poorly reported.

As all outcomes showed statistically significant heterogeneity (p<0.001), only results from the random effects models are reported here.

Total operative time was longer for the endo-loop group than endo-GIA group (SMD 3.14, 95% CI 0.85 to 5.43; four studies). There was no evidence of any difference between the groups for the length of hospital stay (three studies), perioperative complications (four studies) or intra-abdominal abscess ( four studies).

Use of endo-loop to secure the appendicular stump during laparoscopic surgery took longer than endo-GIA, but resulted in equal length of hospital stay, perioperative complication rates and incidence of intra-abdominal abscess.

This review had a clearly stated question and specified inclusion criteria regarding study design, interventions, patients and outcomes. The search covered a number of relevant sources and included studies of any language, which reduced risk of language bias. The authors stated that they did not assess publication bias due to the small number of studies. Data were extracted by two reviewers, which reduced risk of error; it was not reported whether study selection and validity assessment were performed the same way. No information about the studies (such as the participants or length of follow-up) were reported. It was unclear why dichotomous outcomes were converted to standardised mean differences for the analysis and given the high between-study heterogeneity for all outcomes, the validity of the pooled results, even those from the random-effects models, is in doubt. The findings of this review suggested that the two procedures were similar, but the small number of studies, high level of heterogeneity and method of meta-analysis used for binary outcomes mean the conclusions should be treated with caution.

Practice: The authors stated that endo-loop could be used as an alternative to other stump securing techniques.

Research: The authors stated that a multicentre RCT was needed to provide reliable and high-quality evidence on the use of endo-loop.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.