Comparative study between the conventional laparoscopic cholecystectomy and clipless cholecystectomy using a harmonic scalpel

Abstract

Objective This was a comparative study between laparoscopic conventional cholecystectomy and clipless cholecystectomy using a harmonic scalpel. Background This study aimed to compare the laparoscopic conventional cholecystectomy and clipless cholecystectomy using a harmonic scalpel in terms of the duration of the operation, intraoperative blood loss, postoperative complications, postoperative pain, and hospital stay. Patients and methods This study included 80 patients who were classified into two groups: group A (40 patients) was subjected to laparoscopic cholecystectomy by clipping of the cystic duct and cystic artery and dissection of the gall bladder from the gall bladder fossa by electrocautery and group B (40 patients) was subjected to laparoscopic cholecystectomy by a harmonic scalpel, closure and division of both the cystic duct and artery and dissection of the gall bladder from the liver bed by a harmonic scalpel. The intraoperative and postoperative parameters were determined including duration of operation, intraoperative blood loss, postoperative drainage, postoperative pain, complications, and hospital stay. Results The harmonic scalpel provided a shorter operative duration than the conventional method (34.21 ± 9.6 vs. 41.7 ± 13.79, respectively, P = 0.006), and the difference was statistically significant. A statistically significantly lower volume of intraoperative blood loss was observed in group B than group A (64.20 ± 44.01 vs. 96.62 ± 53.33, respectively, P = 0.004) and fewer incidences of gall bladder perforation in group B (7.5 vs. 17%, respectively, P = 0.176), but this was not statistically insignificance, and a lower rate of conversion to open cholecystectomy in group B than group A (0 vs. 5%, respectively, P = 0.246), but this was not statistically significant. The amount of postoperative drainage was significantly less in group B than group A (60.30 ± 11.48 vs. 79.0 ± 36.95, respectively, P = 0.004). Three patients in group B with dilated cystic duct discovered intraoperative and clip technique used for closure; otherwise, no postoperative bile leak was encountered in group B, but it occurred in 5% of patients in group A as a minor biliary leak. In terms of postoperative pain, it was less in group B than group A at 12 and 24 h (45 vs. 70%, P = 0.024, and 37.5 vs. 60%, P = 0.044, respectively), which was statistically significant and insignificant at 48 h and 1 week. Visual analogue scale in group B was lower than that in group A at 12 and 24 h (3.12 ± 0.33 vs. 3.49 ± 0.49, P = 0.01, and 2.5 ± 0.34 vs. 3.34 ± 0.47, P = 0.01, respectively) and statistically significant and insignificant at 48 h and 1 week; the hospital stay was shorter in group B than in group A (20.15 ± 5.65 vs. 24.65 ± 6.22, P = 0.006) and the difference was statistically significant. Conclusion The harmonic scalpel can be used safely for sealing of the cystic artery and cystic duct less than 6 mm in size in laparoscopic cholecystectomy without a risk of major injuries or leak; if the diameter is more than 6 mm, the clips technique should be used. It is better than electrocautery in terms of not just a faster and safer surgery, but also less intraoperative blood loss and less postoperative drainage, with decreased associated morbidity and pain and early return home; however, it is very costly.