Page 18 - World Journal of Laparoscopic Surgery

Extracorporeal Knotting vs Clips for Ligating Cystic Duct
Follow-up cholecystectomy in 60 patients reported that most common age-
All patients were followed up for a period of 1 month, and no group of presentation was between 30 and 50 years. 1
significant complication was noted. In this study, the male-to-female ratio is almost 1:1; a study done
by Nidoni et al. on predicting difficult laparoscopic cholecystectomy
based on clinicoradiological assessment in 180 patients reported
dIscussIon that male-to-female ratio was 1:1.76. 10
The mankind was affected with gall stones from centuries, Another study done by Kuldip Singh et al. on extracorporeal
and the best treatment for the symptomatic gall stone disease knotting with silk vs liga clips for ligating cystic duct in laparoscopic
is cholecystectomy. In elective cholecystectomy, laparoscopic cholecystectomy in 60 patients reported that there was a female
cholecystectomy is considered best and feasible. Laparoscopic predominance, i.e., 90%. 1
cholecystectomy yields good results and better prognosis In the present study, the mean operating time for group in
when compared to the open cholecystectomy in terms of early which extracorporeal knotting done was 67.37 minutes when
postoperative recovery, pain, shorter hospital stays, and early compared to control group using clips was 61.83 minutes. However,
getting back to routine life style. statistical analysis showed that the difference between the two
In laparoscopic cholecystectomy, preferably titanium clips groups was not significant. Using clips reduce the intraoperative
are used to clip the cystic duct. In recent times, different ways time which has advantage over the extracorporeal knotting,
of suturing and knotting are used by either intracorporeal or whereas clips have the drawback of slippage resulting in leakage or
extracorporeal technique. However, there are only few case series hemorrhage and there are situations such as wide cystic duct where
analyzes that compare the cystic duct occlusion with knotting and clipping is difficult, in such cases using the extracorporeal knotting
using titanium clips in laparoscopic cholecystectomy. for occluding the cystic duct is best alternative. Extracorporeal
In the present study, for extracorporeal knotting, Vicryl No knotting with absorbable suture material is feasible, practical,
1 was used for ligating the cystic duct and knots are pushed economic, and safe as well.
using a knot pusher. The duct was ligated in two places, once However, the difference in the operating time between the
near to the common bile duct and another one distally near the two groups was mainly because surgeons do not commonly use
gallbladder (Fig. 1). Cystic duct is cut in between the two knots, the extracorporeal knotting when compared to the frequently
and gallbladder is dissected from the liver bed. In 90% of the used clips during laparoscopic cholecystectomy and also there
patients, gallbladder was extracted by using sterile glove and, in was technical skill associated with extracorporeal knotting. As
few affordable patients, sterile bags were used. skill increase with extracorporeal knotting, we have observed that
In Obstructive jaundice due to accidental ligation of common operating time decreased.
bile duct was seen with clip ligation as compared to with suture Intracorporeal knotting is another method of knotting the
ligation. This result is further supported by a study by Bali and Singal cystic duct. There is a need to learn the skill, and it is little difficult
who concluded that silk suture can be tied near the common bile while knotting as compared to extracorporeal technique of
duct, as risk of involving the common bile duct wall is very little as knotting (Fig. 1).
compared to clips. 9 In the present study, cost of the suture (Vicryl No 1 Round
In the present study, the maximum percentage of patients who Body) used was 302 rupees when compared to titanium clips that
underwent laparoscopic cholecystectomy were under the age- cost 500 rupees.
group of 30–49 years of age, i.e., 77%; another study done by Nidoni A study done by Kuldip Singh et al. on extracorporeal knotting
et al. on predicting difficult laparoscopic cholecystectomy based with silk vs liga clips for ligating cystic duct in laparoscopic
on clinicoradiological assessment in 180 patients also reported cholecystectomy in 60 patients concluded that though it takes
that 30–50 years was the most common age-group to undergo more time for extracorporeal knotting of cystic duct when
laparoscopic cholecystectomy. 10 compared to liga clips, it makes a significant difference with respect
Another study done by Kuldip Singh et al. on extracorporeal to cost without affecting the safety and efficacy in laparoscopic
knotting with silk vs liga clips for ligating cystic duct in laparoscopic cholecystectomy. 1

Figs 1A and B: Extracorporeal knotting of cystic duct

16 World Journal of Laparoscopic Surgery, Volume 15 Issue 1 (January–April 2022)