Can Clipless Division of Cystic Duct be Performed Safely Using Harmonic Scalpel?

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Introduction: The increasing frequency of cholecystectomy implies that there is a potential for increasing incidence of rare complications like migration of clips applied for occlusion of cystic duct into the common bile duct and causing biliary obstruction, many times several years after the initial surgery. Though use of Harmonic Scalpel (HS) alone for occlusion and division has been described, most surgeons are reluctant to use it. Aim: To assess the feasibility of cystic duct closure by using HS in laparoscopic cholecystectomy, done by comparing the burst pressures of excised gallbladders where cystic duct was closed using either conventional clip method or by HS. Materials and Methods: One hundred intact excised gallbladders from patients undergoing elective laparoscopic cholecystectomy for uncomplicated gall-stone disease were used for this study. Ex-vivo the cystic ducts of these gallbladders were randomly occluded by clip or HS (50 in each group). Then the gallbladder was immersed in isothermic saline and connected to a pressure transducer using 20-gauge cannula inserted through the body of the gallbladder. The gallbladder was slowly instilled with normal saline (1 mL/sec) until the gallbladder burst, while pressure recordings were continuously made. The burst pressure and site of burst was noted. The data on burst-pressure was subjected to Student’s t-test. Results: The overall mean burst pressure of extracted gallbladders was 164.12 mmHg, being 162.26±19.25 mmHg and 165.98±21.34 mmHg in the clip and HS group respectively (p-value=0.362). Analysis of subgroups based on sex, age, BMI, gallbladder wall thickness, cystic duct diameter, site of burst or eventual histopathological report also showed no significant difference between the burst pressures in the two groups. The minimum pressure at which burst occurred was 102 mmHg. Conclusion: HS provides equivalent safety (on comparison of burst pressure) for occlusion of cystic duct compared to metallic clip. Thus, HS alone can be used for cystic duct occlusion safely without any clip application.

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