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

## TL;DR

This study compared single and double endoloop ligation in laparoscopic appendicectomy and found no significant difference in complications, but shorter surgery time with single loops.

## Contribution

The study provides mixed-methods evidence on clinical outcomes and surgeon decision-making for endoloop use in appendicectomy.

## Key findings

- No significant difference in clinically relevant 30-day complications between single and double endoloop groups.
- Single endoloop closure was associated with shorter operative time.
- Surgeon decision-making was influenced by tradition, appendiceal base integrity, and training.

## Abstract

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.

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.

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.

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.

The online version contains supplementary material available at 10.1186/s12893-026-03544-5.