Page 38 - World Journal of Laparoscopic Surgery

Ultrasonic Dissection vs Conventional Method
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Jain et al. in his prospective randomized control study reported The postoperative fall in hemoglobin was significantly less in
significantly less time to remove GB from its bed using ultrasonic the CLC group (0.40 g/dL vs 0.70 g/dL; p 0.001), though there was no
shears (nearly 4 minutes vs 7.36 minutes with electrocautery, p incidence of clinically significant (severe) bleeding in either group
0.001). We had similar experience, though it was not statistically requiring blood transfusion, the sole reason for conversion. The
significant in our study. The difference is because ultrasonic shear conversion requirement was more because of the difficult anatomy,
is all in one tool for the procedure (dissection, ligation of the duct not solely because of bleeding. This significant difference may be
and artery, and removal of GB from the liver bed). Besides, ultrasonic because of minor to moderate bleeding in the CL group. On the
device has been said to produce small vacuoles or cavitation which contrary, ultrasonic shear is known for hemostasis. It coagulates
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enlarge and separate the tissue, making it easy to separate the before separating the tissue and stays between the planes, so there
GB from the GB bed. Even in the case of inflammation where the is decreased bleeding and oozing from the surfaces.
tissue is tougher, vascular, and more fibrous, the ultrasonic energy No surgery is without complication. Laparoscopic
and its hemostatic ability keep the operative field clear, decreasing cholecystectomy is the most common elective surgery being
the operative time and avoiding inadvertent injuries. performed worldwide, and research has proved its perfection
The CLC group demonstrated less need for drainage. The to avoid associated complications. Clipless laparoscopic
decreased drain placement led to reduced pain scores, early cholecystectomy is one of the techniques that needs to be
discharge, and decreased morbidity. The drain was placed addressed. As with any new procedure, fear and hesitancy to
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according to the operative surgeon’s preference. It was kept for adopt this noble technique can be observed. Hüscher et al.
those who had bleeding/oozing, bile stain, or in difficult dissections. has histologically confirmed the effective sealing of the cystic
In our study, the drain was removed mostly within 48 hours (median duct stump by the harmonic shears. Post LC bile leak can give
2 days) though few of our patients required a prolonged drainage. the surgeon sleepless nights. This can be the main reason why
Less need for abdominal drain in the CLC group is also one of the most of the surgeons hesitate to perform CLC. This myth has been
contributing factors for less operative time and morbidity. challenged in the recent days, providing better outcome and sound
The reported conversion to open cholecystectomy rate in sleep for surgeons. By using ultrasonic shear closure, division of
the literature is 1.2–8.2%. 13,22–24 We had three (2.6%) conversions, vessels up to 5 mm can be done safely. 2,14,29–37 We had a total of
one (1.85%) in the CLC group and two (3.2%) in the CL group. 6.25% morbidity following the surgery; however, no mortality
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Conversion rate in the prospective study by Hüscher et al. was even was reported in either group. Two (3.77%) patients had morbidity
lower (0.87%) than that in the literature and showed theoretical in the CLC group and five (8.47%) in the CL group (p 0.44). Three
benefits of ultrasonic dissection. The reasons for conversion in (2.67%) patients in our study had bilious drainage, one (1.88%) in
different studies 2,22,25,26 varied between the two subgroups, i.e., the CLC group and two (3.38%) in the CL group. All were managed
surgeon in training and expert. But, in general, conversion was with drains and none required further interventions. In the present
due to the dense adhesion/frozen Calot’s triangle, intraoperative study, one case in the CLC group (1.88%) had port site infection
complications, difficult anatomy, or inability to identify the and two cases (3.38%) in the CL group had port site infection and
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structures. Difficult anatomy of the Calot’s triangle was the only a single case (1.69) had chest infection. Bessa et al.’s finding also
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reason for 4% conversion rate in the study by Jain et al., and did not report any bile leak in either group, demonstrating the
it was equal in both the groups. Our reason for conversion in effectiveness of harmonic shears in closing the duct as safely as with
the CL group was obscured anatomy and bleeding, and another the application of metallic clips. This capability, safety, and efficacy
case had dilated CBD with multiple calculi requiring an open of harmonic shears in sealing and dividing the cystic duct without
choledochoduodenostomy. increasing the complication rate also have been demonstrated in
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Alexander has extensively described the causes of pain other studies. 2,10,20 In the present study, as well as in the Westervelt
after laparoscopy. The major cause of post laparoscopic pain was and Bessa et al. 10,20 studies, the harmonic shears were applied to
attributed to the sudden distension/stretching of the peritoneum, only one side of the cystic duct where sealing and division were
leading to the traumatic traction of the nerves, vessel injury, and achieved, with no bile leaks from the cystic duct stump encountered
release of the inflammatory mediators. In addition, phrenic nerve in any of the two studies. So the double application of the harmonic
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irritation due to gas used for the pneumoperitoneum was pointed shears to the cystic duct as explain by Hüscher et al. may be
out to be responsible for the prolonged persistence of shoulder unnecessary and an unsafe practice. 2,10,20 Lateral energy spread is
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tip pain. The use of ultrasonic shear led to (a) minimal lateral the other mechanism for bile duct injury. Unlike the CL group which
thermal injury, minimal damage to the surrounding nerves, and witnessed high chances of lateral thermal injury to the bile duct,
minimal tissue charring, and, therefore, minimal inflammation and ultrasonic instruments cause negligible lateral damage. 36,37 In the
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less release of inflammatory mediators; (b) decreased operative present study, the low incidence of the bile duct leak or injury in
time contributing to less pneumoperitoneum-related peritoneal the CLC group (1.88%) is not only comparable to the CL group but
distension. This may have accounted for low pain score in the also within the acceptable range of bile duct injury following LC.
CLC group. The significant difference in pain scores was obtained Also, the leak that we had in the CLC group was a minor duct injury,
between the two groups in the first 12 hours and it was more with which was managed successfully with pigtail catheter.
the CL group (p < 0.01). No significant differences were obtained Most of the patients in our study were discharged on the
in the pain scores in the first week after surgery. The postoperative first postoperative day following surgery and was not significant
analgesic requirement was less in the ultrasonic shear group between the groups (p 0.23), though there was significantly less
compared with the electrocautery group (1.89 vs 2.66; p 0.001) in hospital stay in the ultrasonic group in other studies. 2,12 Shorter
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the study by Jain et al., but in our study analgesic requirement in duration has been attributable to the less number of patients
both the groups was similar, which may be because patients were requiring drainage and less incidence of GB perforation, leading
given analgesia even when they had low pain score on their demand. to localized peritonitis and less pain.

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