Staplers vs. loop-ligature: a cost analysis from the hospital payer perspective

  • Richard HilsdenEmail author
  • Nadia Khan
  • Kelly Vogt
  • Christopher M. Schlachta



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 systematic bias arising from one technique being preferentially employed with more complex presentations, patients were divided into study groups based on the technique routinely employed by their surgeon, loop ligature (LLA) versus stapler (LSA). Pediatric patients and open appendectomies were excluded. Costs were determined using a previously published model derived from publicly 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. In comparing surgeons who routinely employed LLA to LSA, there was a significant decrease in total mean hospital cost with LLA ($1988 ± $143 vs. $2253 ± $99, p = 0.002). In addition, mean disposable cost was reduced for surgeons using LLA ($310 ± $27 vs. $668 ± $26, p < 0.001). This reduction in cost was not associated with a difference in length of stay (1.5 vs. 1.4 days, p = 0.28) or complication rates (8% vs. 10%, p = 0.43).


These findings suggest that surgeons who routinely use loop ligature to secure the appendiceal base during emergency laparoscopic appendectomy offer more cost-effective care compared to stapler users, saving their institution more than $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.


Appendicitis Laparoscopic appendectomy Cost-analysis Endoscopic stapler Loop ligature 


Compliance with ethical standards


Dr. Richard Hilsden, Dr. Nadia Khan, Dr. Kelly Vogt, or Dr. Christopher M Schlachta have no conflicts of interest or financial ties to disclose.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Richard Hilsden
    • 1
    • 4
    Email author
  • Nadia Khan
    • 2
  • Kelly Vogt
    • 1
    • 3
  • Christopher M. Schlachta
    • 1
  1. 1.Department of Surgery, Schulich School of Medicine & DentistryWestern UniversityLondonCanada
  2. 2.Department of Surgery, Faculty of MedicineUniversity of OttawaOttawaCanada
  3. 3.Department of Epidemiology and Biostatistics, Schulich School of Medicine & DentistryWestern UniversityLondonCanada
  4. 4.Department of Surgery, London Health Sciences CentreUniversity of Western Ontario, University HospitalLondonCanada

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