Page 20 - World Journal of Laparoscopic Surgery

Mohammed Hamdy Abdelhady, Asaad F Salama
to use a single instrument during the whole surgical pneumoperitoneum was achieved with a closed (Verres
procedure, limiting the number of passages through needle) method, via an infraumbilical transverse inci-
the trocars and consequently, reducing the possibility of sion. The peritoneal cavity was carefully insufflated
causing lesions to the intraabdominal organs. 6 with warmed CO to a pressure of 12 mm Hg. A 30°
2
The aim of this work is to compare clipped vs clip- laparoscope was introduced via the umbilical port and
less cholecystectomy using the ultrasonically activated the peritoneal cavity was inspected. The second 10-mm
(harmonic) scalpel as regards safety and feasibility, with port was inserted under direct vision in the midline in
the aim of developing possible nonsophisticated harmless the epigastrium, passing just to the right of the falciform
technique and has been ethically approved. ligament, toward the gallbladder. Two 5-mm ports were
introduced, one in the right mid-clavicular and one in the
MATERIALS AND METHODS right mid-axillary line, angled toward the gallbladder.
Patient was placed in a steep reverse Trendelenburg posi-
In this 2 years duration of prospective randomized
study, 60 patients with gallbladder stones planned to do tion with a left down tilt. Any adhesions between the
LC were randomly assigned using the sealed-envelope gallbladder and omentum or duodenum were divided,
technique to either group I, including 30 patients who and the gallbladder fundus grasped and retracted toward
will be subjected to traditional LC using clip applier, or the patient’s right shoulder. A 5-mm grasper was then
be compared with group II, including 30 planned clipless placed on Hartmann’s pouch and, was retracted to the
cholecystectomy using harmonic (Ethicon Endosurgery patient’s right, opening up the porta hepatis. The anterior
Ultracision Harmonic Scalpel, Generator 300). and posterior peritoneum over the neck of the gallblad-
Patients with symptomatic gallstones disease proved der was then divided with a diathermy hook, and Calot’s
by ultrasound (U/S) were the only selection criterion. triangle was carefully dissected. Once the cystic duct and
Exclusion criteria include contraindication of LC, abnor- cystic artery are clearly identified, the cystic artery was
mal laboratory investigations, and unfavorable anatomy clipped and divided. The cystic duct was then clipped
intraoperatively. proximally and distally and then divided. The gallblad-
der was carefully dissected off the gallbladder bed. Prior
to the final disconnection, and using the gallbladder as a
Study Pathway
retractor, hemostasis of the gallbladder bed was secured
and the positions of the clips placed on the cystic duct
and the cystic artery were checked. The dissection was
then completed and the gallbladder was retrieved via
the epigastric port. In case of gallbladder perforation, it
was retrieved in a bag, with every effort made to aspirate
the bile and recover any spilt stones. The pneumoperi-
toneum was then released and the ports were removed.
The wounds were infiltrated with local anesthetic and
closed with skin clips.
Group II performed LC using harmonic ACE shears
as single working instrument till skeletonization of both
cystic duct and artery (Figs 1 and 2), for closure and divi-
sion of both the cystic duct and artery, harmonic was set
at the power level “2,” which is translated into less cutting
and more coagulation. First, it was ascertained that there
Preoperative assessment consisted of history taking, were no microcalculi in the lumen of the cystic duct by
general and local examination. Preoperative investi- moving the jaws of the harmonic ACE shears up and
gations include a complete blood count, international down. Second, the cystic duct was inserted between the
normalized ratio, assessment of liver and renal func- jaws at a safe distance from common bile duct to avoid
tion (ALT, total bilirubin, direct bilirubin, albumin, damage to this structure; then the jaws were closed until
alkaline phosphatase, serum creatinine), and pelvi- a click was heard. Third, the harmonic was activated at
abdominal U/S.
the power level “2,” and during this phase, great care
was taken to avoid stretching or rotating cystic duct but
Operative Technique
rather to keep it still until the gallbladder was detached
Group I performed traditional LC. The anesthetized from the cystic duct (Figs 3 and 4). Fourth, the cutting
patient was placed supine on the operating table. The points of the cystic duct were checked for any bile leakage.
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