Page 34 - World Journal of Laparoscopic Surgery

RESEARCH ARTICLE
Clipless Laparoscopic Cholecystectomy: Ultrasonic Dissection

vs Conventional Method

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Laligen Awale , Narendra Pandit , Shailesh Adhikary 3
AbstrAct
Introduction: Laparoscopic cholecystectomy (LC) is now the gold standard treatment of gallstone disease, but with advancement in technology,
there is always a scope for improvement. Ultrasonic shears has been shown to seal the duct and small-size vessel adequately but the fear
of complication and sleepless nights has always hindered its use as the sole instrument for LC. Proper use of ultrasonic shears can provide
improvement or refinement in LC.
Materials and methods: It is a randomized controlled trial conducted at BP Koirala Institute of Health Sciences, Dharan, Nepal, from 2015 to
2016 (1 year). All the patients with symptomatic gallstone disease were assessed thoroughly and randomized into the harmonic scalpel [clipless
laparoscopic cholecystectomy (CLC)] or conventional laparoscopic group (CL).
Results: Over a period of 1 year, 112 patients were enrolled into CLC (53) and CL (59) groups. The demography of the patients in both the
groups including age, sex, history of previous surgery, comorbid conditions, and history of acute cholecystitis was comparable. The mean
operative time in our study was 38.65 ± 13.28 minutes. The operative time in the CLC group (35.91 ± 11.66 minutes vs 41.12 ± 14.23 minutes)
was less though it was not statistically significant (p 0.054). However, when the “gallbladder (GB) was not perforated,” the operative time was
significantly less in the CLC group (34.30 ± 9.30 minutes vs 38.70 ± 10.76 minutes, p 0.03). In our study, three (2.6%) patients required conversion
to open cholecystectomy. One (1.85%) in CLC and 2 (3.2%) in the CL group (p 0.63). The visual analog score (VAS) for pain in the first 12 hours
and median fall in hemoglobin was significantly less in the CLC group. In our study group, a total of seven (6.25%) patients had morbidity and
there was no mortality.
Conclusion: With the development of ultrasonic energy source and its ability to seal the vessel and cystic duct safely, it can be utilized during
LC without the need of clips.
Keywords: Harmonic scapel, Laparoscopic cholecystectomy, Symptomatic cholelithiasis.
World Journal of Laparoscopic Surgery (2020): 10.5005/jp-journals-10033-1384

IntroductIon 1–3 Department of Surgery, Division of Gastrointestinal Surgery, BP

Laparoscopic cholecystectomy (LC) is now the gold standard Koirala Institute of Health Sciences, Sunsari, Nepal
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treatment of gallstone disease; and no doubt, presently it is Corresponding Author: Laligen Awale, Department of Surgery,
one of the most commonly performed laparoscopic procedures Division of Gastrointestinal Surgery, BP Koirala Institute of Health
worldwide. The advantages of this minimal invasive approach Sciences, Sunsari, Nepal, Phone: +977 9841227258, e-mail: lalijan@
have been widely reported, showing the positive impact on the hotmail.com
short- and long-term outcomes. With the rapid advancement in How to cite this article: Awale L, Pandit N, Adhikary S. Clipless
the technology, there is always new scope for improvement in the Laparoscopic Cholecystectomy: Ultrasonic Dissection vs Conventional
procedure. Method. World J Lap Surg 2019;12(3):120–125.

Laparoscopic cholecystectomy is an arguably safe procedure, Source of support: Nil
but there are few issues with the current technology and Conflict of interest: None
technique, which have been seen to increase the risk of injuries and
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postoperative complications. Standard LC is usually performed Ultrasonic shears adequately seal the vessel and duct, so avoid the
by instruments such as Maryland dissector, scissors, hook, and/ need of metallic clips. Minimum bleeding while dissection with this
or spatula. Cystic artery and duct is most frequently occluded by technique keeps the surgical field clear, avoiding misidentification
simple metallic clips. Common problems include common bile duct of the structures. Substantial number of studies reports the positive
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(CBD) stone formation due to the migration of suture materials, bile or favorable outcome in closure of cystic artery and duct using
4,5
leak due to the inappropriate clip placement or slippage of clips, the ultrasonically activated shears, 2,9–12 with acceptable rate of
lateral injury to bile duct and/or vessels from heat of monopolar complications. In these studies, cases of bile leak associated with this
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cautery, and possibility of visceral organ injury due to the need for technique were reported but comparable (2–4%) to the standard
frequent instrumental exchange. 6–8 technique.
Ultrasound shear is the vessel and duct sealing device which Ultrasound shear has been shown to have added benefit over
6,9
tackles the issue related to clips, suture, and lateral thermal injury. the conventional technique but the fear and hesitancy still exist
It can also be used as dissector, hence decreases not only the regarding its widespread acceptance as a sole instrument for LC.
frequency of instrumental exchange and associated possibility Hesitancy and fear of using it as a sole instrument for “cystic duct
of visceral injury but also the operative time loss during the closure” seem to be the core issue, in spite of the adequate evidence
process. It provides the surgeon with newer armamentarium in LC. to suggest its effective closure. In our institute, approximately 500

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