A Review article submitted towards completion of D.MAS course World Laparoscopy Hospital, Gurugram, NCR Delhi, India-110018
Abstract
Background:
Many study published in different literature clearly demonstrates that the Harmonic scalpel provides complete and reliable hemobiliary stasis in most patients undergoing laparoscopic cholecystectomies. We have done similar study at World Laparoscopy Hospital and In all patients who underwent division of the cystic duct and artery during securing the cystic pedicle by Harmonic scalpel alone, there were no clinically apparent immediate or even remote postoperative cholecystectomy bile leaks or postoperative hemorrhages.
Methods:
Patients undergoing routine laparoscopic cholecystectomy at the World Laparoscopy Hospital were prospectively enrolled in the study. They were sorted into 2 groups (1) those undergoing cholecystectomy consisting primarily by clip or suture fixation and (2) those undergoing laparoscopic cholecystectomy consisting primarily of sealing the cystic duct and artery by ultrasonic dissector using Harmonic Scalpel. The patients were not randomized. The technique of surgical repair was based on surgeon preference. A telephone survey was used to follow-up at 1 week, 1 month, and 2 months postoperatively.
Results:
From 2004 through 2005, 50 patients were enrolled in the study. Thirty five patient had laparoscopic cholecystectomy primarily using sutures by extra corporeal Mishra's Knot or Titanium Clip, and 20 had primarily with harmonic scalpel. Both groups had similar average age, BMI, and free from any complication. None of them had more than 6 mm dilated wall of the Gallbladder. 5 patients were suffering from acute cholecystitis in knotting group and none were having acute cholecystitis in Harmonic scalpel group, operative time, and postoperative length of stay. Pain scores at 1 week, 1 month, and 2 months were similar. There was no conversions required to open cholecystectomy in both the group one patient had slightly dilated cystic duct and in that Mishra's Knot was applied. there was no intra operative or immediate postoperative complications. The operative times varied depending on the degree of pericholecystic and cholecystic and there was no any associated intra peritoneal adhesions with an average operative tome was 38 minutes. Both groups also had similar times to return to work and need for narcotic pain medication. The use of Harmonic scalpel in laparoscopic cholecystectomy is a safe, efficient, and practical instrument to use during sealing cystic duct and cystic artery, and its role as a primary dissector can be expanded to include complete hemobiliary stasis.
Keywords:
Clipless Cholecystectomy, Role of Harmonic Scalpel in Laparoscopic Cholecystectomy
The patients were not randomized. The technique of surgical repair was based on surgeon preference. A telephone survey was used to follow-up at 1 week, 1 month, and 2 months postoperatively. RESULTS: From 2004 through 2005, 50 patients were enrolled in the study. Thirty had clip or Mishra's extra corporeal knot for cystic duct and cystic artery applied and 20 had laparoscopic cholecystectomy surgery primarily with harmonic scalpel by clip less cholecystectomy. Both groups had similar average age, BMI, hernia defect size, operative time, and postoperative length of stay. Pain scores at 1 week, 1 month, and 2 months were similar. Both groups also had similar times to return to work and need for narcotic pain medication. At World Laparoscopy Hospital during clipless cholecystectomy of this study no intra operative cholangiograms were performed. Any patients presenting with clinical evidence of choledocholithiasis. Any patient has no complication of biliary pancreatitis underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) evaluation and treatment.
Conclusion:
For Laparoscopic Cholecystectomy Harmonic scalpel provides reliable complete hemobiliary stasis for most patients in non complicated gallstone and is a safe alternative to standard titanium clip or extra corporeal knot closure of the cystic duct. Furthermore, there may be a cost concern inherent in a procedure utilizing a single use disposable harmonic scalpel instrument. If the cost is not an important factor than it can be used in un complicated laparoscopic cholecystectomy
