Clipless Versus Conventional Laparoscopic Cholecystectomy

Abstract

Laparoscopic cholecystectomy has been the gold standard technique for cholecystectomy and has proven more effective than the conventional open technique. The laparoscopic technique utilizes surgical clips for cystic duct occlusion, which come with their own set of complications. With the advent of new vessel and duct sealing technology, alternative energy instruments have been explored for the occlusion of the cystic duct without the use of clips. The Harmonic(®) scalpel (Ethicon Endo-Surgery, Cincinnati, OH) has become one of the more widely used instruments. In this retrospective study, 208 patients received surgical clip placement or the Harmonic scalpel was used for cystic duct occlusion. The postoperative complications were documented, and rates were calculated for outpatient follow-up, for re-admission, and specifically for the complications of a bile leak. When adjusted for the cause of bile leak (cystic duct versus common bile duct versus accessory duct), the use of the Harmonic scalpel versus clip placement had comparable rates of bile leak at 1.75% and 0.66%, respectively. The use of the Harmonic scalpel is deemed safe and comparable to clip placement at the discretion of the surgeon for cystic duct ligation. Further research with larger homogeneous studies and assessments of cost-effectiveness would further enhance the increasing use of the Harmonic scalpel in laparoscopic cholecystectomy.

Total clipless cholecystectomy by means of harmonic sealing

“…Several worldwide studies reported the clipless cholecystectomy by using the ultrasonically activated shears as the sole instrument to achieve complete hemo-biliary stasis (cystic duct and artery), most of them with case-series 13 , 8 , 28 , 27 , 3 , 31 , 7 , 24 , 6 , 17 , 14 , 30 . In these 1221 cases there was no hemorrhage reported and the overall incidence of postoperative bile leakage was in agreement with the literature showing that this technique seems to be as safe as the surgical clip.…”

The Better Surgical Option for Chronic Cholecystitits; Harmonic Scalpel or Conventional Laproscopic Cholecystectomy?

“…Willis et al reported the use of the Harmonic scalpel as safe and comparable to clip placement especially for the bile leakage. 3 Similarly, another study reported HS as a better procedure with a shorter operative duration, less incidence of gallbladder perforation, postoperative pain, and rate of conversion to open cholecystectomy as compared to the conventional laproscopic cholecystectom. 7 However, one major limitation of these studies as compared to the current study is a smaller sample size of patients included in them.…”

“…1,2 Laparoscopic technique is based upon use of surgical clips, electric scalpel and cautery for dissection and coagulation resulting in much lesser complications and short in-hospital stay as compared to open cholecystectomy. 3 However, recently harmonic scalpel (HS) has been introduced as an alternative for conventional laproscopic technique in which ultrasonically activated gadgets are utilized to perform dissection and coagulation without using electrocoagulation and minimum tissue injury and wandering currents. 4 This results in a clean and clear field of operation making it a more attractive option over electrocautery but it comes with a DOI: 10 5 Literature has shown that the selection of either of the two methodologies as a superior dissection, in terms of post-operative complications, is contradictory.…”

“…In a retrospective study, rates of bile leak in Harmonic scalpel versus clip placement were 5.26% and 0.66%, (p value= .0322) and readmission rates were 10.53% and 0.66% (p value=0.005) respectively. 3 While in a local study HS was labeled equivalent in terms of post-operative complications (leakage and perforation). 6 Kandil et al reported that no postoperative bile leak was encountered in HS but it occurred in 2.9% of patients along with a significantly less incidence of gallbladder perforation (7.1% vs. 18.6%, p = 0.04) in conventional method.…”

Cholangitis caused by surgical clip migration into the common bile duct: a rare complication of a daily practice

“…However, since the rarity of surgical clip migration, there is not enough data to compare between the clip type techniques. Clipless cholecystectomy using a harmonic scalpel may also be a safe solution in order to prevent such a complication 14–16…”