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Ultrasonic Dissection vs Conventional Method
patients are operated annually by the conventional laparoscopic was then closed till the click sound was heard. The instrument was
(CL) method. Through this study, we wanted to see how effective then activated with the minimum power set at 2, with care not to
and safe harmonic shear is in dividing the cystic duct in LC, to move stretch or rotate the cystic duct, and it was kept activated till the GB
forward with time, and to find if it actually confers benefit in relation was detached from the cystic duct. And finally the cut end of the
to operative time, bleeding, reduced postoperative morbidity; cystic duct was checked for any possible bile leak. In the CL group,
and we also planned to embrace a new technology for the better dissection of the Calot’s triangle was performed with Maryland’s
outcome and patient’s satisfaction. dissector. Closure of the cystic duct and artery was achieved by
applying titanium clips and dividing in-between with scissor.

MAterIAls And Methods Mobilization of the GB from the liver bed was started posteriorly
It was a single institutional randomized controlled trial done at BP at the Calot’s triangle with anterolateral traction and was preceded
anteriorly. In the CLC group, dissection of the GB from the liver bed
Koirala Institute of Health Sciences, Dharan, Nepal, for a period of was performed by using the harmonic scalpel. In the CL group, the
1 year (2015–2016). All the patients with symptomatic gallstone dissection of the GB from the liver bed was performed by using the
disease and between 18 years and 70 years of age were included monopolar cautery (hook or spatula). Finally, the GB was removed
in the study. Those patients with cholangitis, wide cystic duct >5 through the subxiphoid port, and a subhepatic tube drain was
mm, CBD stones or dilated CBD, history of jaundice, impaired liver inserted through the most lateral port whenever indicated (bleed/
function test, pregnant patients, and suspicion of GB malignancy ooze and/or bile spillage).
were excluded from the study. Ethical clearance was taken from the The operative time, intraoperative difficulties, postoperative
Institutional Review Committee before starting the study. pain scores using the VAS, and analgesic requirement at 6 hours
All the patients presenting to the surgical outpatient and days 1 and 2 were all noted by an observer who was unaware
department with symptomatic gallstone disease were assessed of the procedure being performed. Postoperative hematocrit and
thoroughly by clinical examination and investigations. History hemoglobin level (postoperative day 1), duration of placement of
was taken about the duration of the pain and the last episode of drain (days), and postoperative complications, if any, were recorded.
pain. Physical examination was done and all patients underwent Gallbladder perforation and the need for placement of drain and
transabdominal ultrasonography and the details were noted. Liver its removal were noted. Once discharged, patients were reviewed
function test and hemoglobin level were done in all the patients. at the end of the first postoperative week for any evidence of
Other investigations including computed tomography of the biliary leak (clinical examination and abdominal ultrasound when
abdomen and endoscopic retrograde cholangiopancreatography indicated). Patients were asked to follow-up with histopathological
were done if required. examination report at the end of first month. At the end of the
The procedure was explained in the native language to the first and sixth postoperative months, the clinical examination was
patients and informed written consent was obtained in all cases done and abdominal ultrasonography when indicated. In addition,
for randomization to clipless laparoscopic cholecystectomy (CLC) blood was sampled for bilirubin, amino alanine transferase, alkaline
or CL. Randomization was done by the person not otherwise phosphatase, and gamma-glutamic transferase levels accordingly.
involved in the clinical setting. Randomization was undertaken by All the data were entered in computer and descriptive analysis
consecutively numbered opaque sealed envelopes containing the was done manually, using SPSS software. For descriptive statistic
treatment options, which were assigned with computer-generated percentage, mean, standard deviation, median, and interquartile
random numbers. range (IQR) were calculated along with graphical and tabular
Each surgeon who was participating in the study had an presentation. Inference statistics, Chi-square and independent t
experience of performing at least 100 successful laparoscopic test, was applied to find the significant difference between the
cholecystectomies. General anesthesia was administered during the groups at 95% confidential index, where p = 0.05. For multivariate
procedure. The standard supine position was used for all patient, analysis p valued <0.20, and in bivariate analysis those variables
i.e., reverse Trendelenburg position with right up. Laparoscopic were considered for multivariate logistic regressions to find the
cholecystectomy was performed with uniform technique, including combined risk factor for the CLC group.
the standard four-trocar ports, a pneumoperitoneum by open
method with a maximum pressure of 15 mm Hg, and a 30° optic
scope. Dissection of the GB was initiated at the posterior peritoneal results
fold and the dissection proceeded forward anteriorly to skeletonize Over the period of 1 year, a total of 215 patients underwent LC.
the cystic artery and duct in the Calot’s triangle. Forty-nine patients denied consent for randomization and 51
In the CLC group, the ultracision harmonic scalpel, Ethicon patients were excluded for the following reasons: 12 patients did not
Endo-Surgery, was used for dissecting the triangle of Calot (power meet age criteria (7 patients were <18 years and 5 patients were >70
level set at 5). For the closure and division of both the cystic duct years), 28 had dilated common duct/cystic duct or stones, 4 each
and artery, the instrument was set at power level 2. Before ligation had a recent history of jaundice and impaired liver enzymes, and
of cystic duct with ultrasonic shears, the size of the cystic duct and 3 patients had cholangitis. A total of 115 patients met the criteria
CBD were noted with the help of the jaws of the harmonic shears. and underwent randomization into either CL group or CLC group.
After confirming the appropriate size of the cystic duct and artery, Three patients required conversion and were not included in the
they were subsequently closed using the instrument. While closing analysis. We studied a total of 112 patients: 53 in the CLC group and
the duct, it was made sure that the cystic duct was free of calculi 59 in CL group formed the study subjects.
by moving the jaws of harmonic scalpel proximally and distally The mean age of the patients in our study was 45.64 ± 14.84
with an intent to swipe any possible stone in cystic duct toward years, ranging from 20 years to 70 years with a female to male ratio
the GB. Then the cystic duct was placed between the jaws of the of 5:1. Majority [92 (82.14%)] of the patients had multiple GB calculi.
harmonic scalpel with the care to avoid injury to the CBD. The jaw A total of 10 (8.92%) patients were operated for acute calculus

World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019) 121