Page 37 - World Journal of Laparoscopic Surgery

Ultrasonic Dissection vs Conventional Method
Table 4: Postoperative parameters in the clipless laparoscopic Cholelithiasis is most reported among the middle-aged fertile
cholecystectomy and conventional laparoscopic groups female. 2,13,14 According to our study, the mean age-group was 45.64
Variables CLC group (53) CL group (59) p value ± 14.84 years and 83.9% was female, with a female to male ratio of
Analgesic requirement 5:1. Adhesion following previous surgery is a known hurdle during
12 hours 53 (100%) 59 (100%) – LC, which not only increases the risks of injury but also prolongs
operative time by additional need for dissection and bleeding,
24 hours 51 (96.22%) 58 (98.3%) 0.49 finally influencing the outcome. In our study, 16 (14.28%) patients
VAS (mean) had a previous history of surgery, i.e., 6 (11.32%) in CLC and 10
12
12 hours 3.91 ± 0.94 5.31 ± 1.65 <0.001 (16.94%) in CL group, which was similar to the study by Jain et al.
24 hours 2.5 ± 0.80 2.97 ± 0.87 0.50 where harmonic scalpel to CL ratio for “history of previous surgery”
1 week 1.17 ± 0.47 1.10 ± 0.30 0.055 was 8:9. In our study, 10 (8.92%) patents underwent emergency
Hemoglobin (g/dL) surgery for acute cholecystitis, 4 (7.54%) in the CLC group and 6
Preoperative (mean) 12.50 ± 1.44 12.02 ± 1.42 0.85 (10.16%) in the CL group. The low incidence in our study is because
Postoperative (mean) 12.12 ± 1.44 11.23 ± 1.34 0.60 we avoided early surgery, though several meta-analysis showed
that early LC not only decreases the length of hospital stay but also
Fall in Hb (median) 0.40 (0.20–0.50) 0.70 (0.30–1.20) 0.001 prevents disease relapse without any increase in the complication
Drain removal (median) 2 (2–3.75) 2 (2–4.5) 0.52 rate. 13–17 Several retrospective series, in fact, demonstrated the
days advantages of the use of harmonic scalpel in acute cases, because
Hospital stay (median) 1 (1–1) 1 (1–2) 0.23 of its ability to maintain hemostasis and effectiveness in closure of
days the duct. 2,17–19 Few (8.92%) of our patients underwent emergency
Morbidity 2 (3.77%) 5 (8.47%) 0.44 surgery and hence were not included in the study.
Bilious drain 1 (1.88%) 2 (3.38%) 0.62 The mean operative time in our study was 38.65 ± 13.28
Port-site infection 1 (1.88%) 2 (3.38%) 0.62 minutes, ranging from 20 minutes to 85 minutes. The operative
Chest infection 0 (0%) 1 (1.69%) 0.34 time in the CLC group (35.91 ± 11.66 minutes) was less than that in
the CL group (41.12 ± 14.23 minutes), though it was not statistically
significant (p 0.054). It was slightly longer, according to Bessa
wound gap was closed subsequently in the presence of healthy et al. [Harmonic Scalpel (HS) 18–75 mean 32 vs conventional
20
granulation tissues. laparoscopic cholecystectomy (CC) 21–85 mean 40 and p < 0.001],
Three (2.67%) patients in our study had bilious drainage, but our time was similar to that of Kandil et al. (33.21 + 9.6 vs. 51.7
21
consisting of one in the CLC group and two in the CL group. + 13.79, HS and CL, respectively, p 0.001). This shorter operative time
The one in the CLC group developed abdomen pain, distension, in the CLC group is because of the added benefit of the harmonic
multiple episodes of vomiting along with tachycardia on the first ACE: (a) it is the multifunctional device (dissection and closure of
postoperative day. On ultrasound imaging, she had collection artery and duct) and hence minimizes the need for instrumental
in the subhepatic space, and diagnostic aspiration revealed exchange, thereby minimizing the time loss during the process
bile and was managed with pigtail catheter and drainage. Her and the loss of pneumoperitoneum, (b) smokelessness allows to
drain was removed on the sixth day and discharged on the work in clear operative field and also avoids the need for smoke
seventh postoperative day. The other two patients in the CL evacuation and loss of pneumoperitoneum, and (c) lower incidence
group were found to have bile in the drain postoperatively but of GB perforation in the CLC group (7 vs 12), thereby avoiding the
were managed conservatively as the collection was localized, time loss in retrieving the spilled stone and lavage.
with no evidence of peritonitis or sepsis. In one patient, the The lateral energy spread is less with ultrasonic shears (1.5
drain output turned out to be serous on the third day and it mm vs 0.5 cm in electrocautery); therefore, there is a decreased
2
was removed after ultrasound of no collection. Another patient chance of GB perforation, spillage of gallstone and bile, and biliary
was found to have bilious drain on the second postoperative peritonitis. After spillage, there is obvious increase in the duration
day. She continued to have low output (50–70 mL/day) bilious of surgery due to the time take for suction–irrigation, retrieval of
drainage and did not have sepsis and hence discharged with spilled stones, and poor field and visibility. 12,20 We had slightly
drain on the eighth postoperative day. She was kept on regular higher rate of GB perforation in the CL group, though statistically
follow-up. Her drain was removed on the 14th day when it was not significant; and the mean operative time in patients with GB
dry for 24 hours and also after ultrasound confirmation of no perforation was shorter in the CLC though it was not statistically
intra-abdominal collection. All three patients were doing well (p 0.34) significant. In patients without GB perforation, the
at 1 month follow-up. There was no jaundice or abdominal operative time was significantly less in the CLC group. When the
symptoms. The morbidity was similar in both the groups (p 0.44), GB perforation complicated the procedure, it does significantly
without mortality in either group (Table 4). increases the operative time in both the groups and the time taken
is comparable. 12,20 Different studies have reported the incidence
dIscussIon of GB perforation during the LC ranging from 10% to 50%. 9,20 In
9
Laparoscopic cholecystectomy has now become the gold standard our study, 17% patients had perforated GB. Janssen et al. also
treatment for gallstone disease but is not without flaws. With the had a similar lower incidence of GB perforation with ultracision
development of new vessel sealing devices, research are done removal of GB (16 vs 50%, respectively; p 0.001) and also found
continuously to minimize the shortcomings. In our study, we that the risk of GB perforation with bile (four times higher) and
compared the CL technique with CLC using harmonic scalpel to stone (six times higher) spillage was significantly higher in the
seal both the cystic artery and the cystic duct. electrocautery group.

World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019) 123