Page 9 - WALS Journal

Harmonic Scalpel and Clipless Cholecystectomy
Methods This can happen with steering of the blade extender during
laparoscopic surgery and may increase the exposure risk of
Patients undergoing elective laparoscopic cholecystectomy adjacent tissues to injury.
were randomized to electrocautery or ultrasonic dissection of
the gallbladder. The main outcome measures were gallbladder Results
perforation, operating time and the number of times the lens
was cleaned. Univariate and multivariate analyses were There was no conversion to open cholecystectomy and no
performed. intraoperative or immediate postoperative complications. The
operative times varied depending on the degree of
Conclusion pericholecystic and cholecystic and/or associated
intraperitoneal adhesions with an average incision to closure
The use of ultrasonic dissection in laparoscopic cholecystectomy
reduces the incidence of gallbladder perforation and helps the time of 42 minutes. Division of the cystic duct by the harmonic
operation to progress. Less experienced surgeons benefit most scalpel required approximately 2 to 3 minutes, depending on
from ultrasonic dissection, particularly in complicated the ductal thickness and associated inflammation. In general,
intraoperative circumstances. the cavitational effect on the surrounding pericholecystic
tissues, especially in the region of the liver bed, allowed for
Advantages and Limits easier mobilization of the gallbladder, thus avoiding inadvertent
compromise of the gallbladder wall and bile spillage. No Liver
The disadvantage of monopolar coagulation, the limits of the bed charring or bilious seepage from any ducts of Luschka was
bipolar coagulation and the frequent changes of instruments observed. Length of procedure, hospital stay, and return to full
during laparoscopic procedures, are three elements that make functional status did not vary significantly from patients
the harmonic dissectors very useful in laparoscopic surgery.
observed previously (personal experience) who underwent clip
and cautery procedures.All patients evaluated in the office
Results and Conclusions
postoperatively demonstrated no evidence of bile leakage or
After our short experience with HS and in concordance with atypical complaints.
literature, we consider that: The advantages are: the features to
coagulate nearest delicate anatomic structures (biliary tree, large DISCUSSION
bowel, blood vessels) the absence of the smog and the slag; This study clearly demonstrates that the Harmonic scalpel
the scissors is a versatile device which allows the dissection provides complete and reliable hemobiliary stasis in most
and the coagulation without changes the instruments. The limits patients undergoing laparoscopic cholecystectomies. In all
are: hemorrhages after insufficient coagulation or prehension, patients who underwent division of the cystic duct and artery
the necessity of the learning curve, high costs of the disposable by harmonic scalpel alone, there were no clinically apparent
materials. The HS device represents a real progress, especially immediate or remote postoperative bile leaks or hemorrhages.
for that laparoscopic surgery which requires the coagulation of In the 2 patients with larger diameter cystic ducts (greater than
blood vessels placed in thick and fat structures.
5 mm) identified intraoperatively, closure was accomplished
with application of a chromic Endoloop. Harmonic scalpel
COMPLICATION OF HARMONIC SCALPEL
division alone was not attempted due to the inherent limitations
Background of the instrument. Except for the 2 to 3 minute interval required
for cystic duct division, use of the harmonic scalpel did not
The harmonic scalpel is an ultrasonically activated surgical adversely affect the length of procedures. In fact, properties
instrument for tissue dissection. Despite its expanding surgical intrinsic to the harmonic scalpel (cavitation and smokeless
applications, there are no reports about associated complications. coagulation) seem to provide an advantage over electrocautery
CASE: A 35-year-old woman sustained injury to the sigmoid in the dissection of the gallbladder and may enhance surgeon
colon from the use of the harmonic scalpel during laparoscopic performance. Certainly, harmonic scalpel division of the cystic
lysis of pelvic adhesions. The injury was identified and repaired duct could be utilized independently of the direction of
laparoscopically in a primary fashion with no subsequent gallbladder dissection. One additional benefit of harmonic
sequelae.
scalpel dissection of the liver bed is the more effective closure
of the ducts of Luschka. While rarely of clinical significance,
Conclusion
bile leakage from the liver bed may contribute to postoperative
Acoustic energy coupling and overheating of the laparosonic pain, small bilomas, and the occasional return to the operative
blade extender sheath occur with bending of the instrument. room. Objective data documenting length of hospitalization and

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