Comparative effectiveness of stump closure methods during laparoscopic appendectomy: a systematic review and network meta-analysis of randomized controlled trials with CINeMA assessment

Laparoscopic appendectomy is one of the most performed emergency surgical procedures worldwide, and secure appendiceal stump closure remains a key step for ensuring favorable postoperative outcomes. Multiple closure techniques are currently available; however, comparative evidence remains inconsistent and is largely limited to pairwise comparisons. Therefore, we conducted a network meta-analysis to compare techniques in patients undergoing laparoscopic appendectomy. A systematic search of PubMed, Scopus, Web of Science, Cochrane Library, and EMBASE was conducted through April 2026 following PRISMA guidelines and PROSPERO registration (CRD420261392158). Randomized controlled trials comparing appendiceal stump closure techniques were included. A network meta-analysis was performed, heterogeneity was assessed using I² statistics, and interventions were ranked according to SUCRA values. Confidence in the evidence was evaluated using the CINeMA framework. We included fourteen articles with 2,507 participants. The network included up to eight closure techniques: endoloop, Hem-o-lok, endostapler, extracorporeal ligature, intracorporeal ligature, lapro-clip, metallic/titanium clip, and unspecified clips. For operative time, Hem-o-lok was the only technique that showed statistical significance compared to endoloop (MD = -5.33, 95% CI: -8.72 to -1.93; p < 0.01; I² = 82%), ranking highest by SUCRA (0.73). Compared to endoloop, no closure method showed a statistically significant reduction in hospital stay, with Hem-o-lok having the highest SUCRA ranking (0.73). The rates of complications showed no significant differences among the techniques, with metallic/titanium clips achieving the highest SUCRA ranking (0.81). Cost analysis included three studies and found no statistically significant differences, with extreme heterogeneity (I² = 99.8%). CINeMA assessment rated confidence in the evidence as very low for most comparisons across outcomes. In conclusion, predominantly very low-certainty evidence suggests that Hem-o-lok clips may reduce operative time compared with Endoloop ligation. However, the available evidence is insufficient to establish the superiority of any single stump closure technique regarding postoperative complications, hospital stay, or cost. Substantial heterogeneity, imprecision, and inconsistency in some analyses limit the reliability of the estimates and preclude definitive clinical recommendations.