New Technique of Clipless Laparoscopic Cholecystectomy

Ahmed A. ElGeidie

Faculty of Medicine, Mansoura University, Dakahlia, Egypt.

DOI: 10.4236/ss.2012.36061                

Abstract

Background: In laparoscopic cholecystectomy (LC), application of clips is the standard method for controlling the cystic duct and artery. However, this is not without problems. We propose a modified technique for management of cystic duct and artery in LC. Methods: Since 2007, 328 patients presented with symptomatic gallstones were included. In those patients, the cystic artery was divided by monopolar cautery and the cystic duct was ligated intracorporeally using nonabsorbable suture. Results: Three patients (0.9%) have bleeding from cauterized cystic artery; bleeding was controlled by diathermy in two of them and application of metal clip was necessary in the remaining patient. Cystic duct leak was detected in only one patient (0.3%), and it was managed by percutaneous drainage. At follow up we did not encounter abnormalities suggestive of bile duct stricture. Conclusion: The proposed modification of LC is feasible, practical, safe and economic as well. It is associated with reduced risk of postoperative morbidity.

Keywords

Laparoscopic Cholecystectomy; Clipping; Ligation; Cystic Artery; Cystic Duct; Monopolar Diathermy

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	E. C. Ellison and L. C. Carey, “Cholecystectomy, Cholecystostomy, and Intraoperative Evaluation of the Biliary Tree,” In: J. R. Baker and J. E. Fishcer, Eds., Mastery of Surgery, 4th Edition, Lippincott Williams & Wilkins, Philadelphia, 2001.
[2]	J. S. Barkun, A. N. Barkun, J. S. Sampalis, et al., “Randomised Controlled Trial of Laparoscopic versus Mini Cholecystectomy. The McGill Gallstone Treatment Group,” Lancet, Vol. 340, No. 8828, 1992, pp. 1116-1119. doi:10.1016/0140-6736(92)93148-G
[3]	S. Adamsen, O. H. Hansen, P. F. Jensen, et al., “Bile Duct Injury during Laparoscopic Cholecystectomy: A Prospective Nationwide Series,” Journal of the American College of Surgeons, Vol. 184, 1997, pp. 571-578.
[4]	X. Huang, Y. Feng and Z. Huang, “Complications of Laparoscopic Cholecystectomy in China: An Analysis of 39,238 Cases,” Chinese Medical Journal, Vol. 110, 1997, pp. 704-706.
[5]	K. L. Leung, K. H. Kwong, W. Y. Lau, et al., “Absorbable Clips for Cystic Duct Ligation in Laparoscopic Cholecystectomy,” Surgical Endoscopy, Vol. 10, 1996, pp. 49-51. doi:10.1007/s004649910012
[6]	A. J. McMahon, G. Fullarton, J. N. Baxter and P. J. O_Dwyer, “Bile Duct Injury and Bile Leakage in Laparoscopic Cholecystectomy,” British Journal of Surgery, Vol. 82, No. 3, 1995, pp. 307-313. doi:10.1002/bjs.1800820308
[7]	M. Miroshnik, A. Saafan, S. Koh, et al., “Biliary Tract Injury in Laparoscopic Cholecystectomy: Results of a Single Unit,” ANZ Journal of Surgery, Vol. 72, No. 12, 2002, pp. 867-870. doi:10.1046/j.1445-2197.2002.02587.x
[8]	E. Muhe, “Die erste Cholecystektomie durch das Laparoskop: English Summary,” Langenbecks Archiv fur Klinische Chirurgie, Vol. 369, 1986, pp. 804.
[9]	L. K. Nathanson, D. W. Easter and A. Cuschieri, “Ligation of the Structures of the Cystic Pedicle during Laparoscopic Cholecystectomy,” American Journal of Surgery, Vol. 161, No. 3, 1991, pp. 350-354. doi:10.1016/0002-9610(91)90596-6
[10]	W. Reynolds Jr., “The First Laparoscopic Cholecystectomy,” Journal of the Society of Laparoendoscopic Surgeons, Vol. 5, No. 4, 2001, pp. 89-94.
[11]	J. A. Shea, M. J. Healey, J. A. Berlin, et al., “Mortality and Complications Associated with Laparoscopic Cholecystectomy,” Annals of Surgery, Vol. 224, No. 5, 1996, pp. 609-620. doi:10.1097/00000658-199611000-00005
[12]	U. S. Wise, G. L. Glick and M. Landeros, “Cystic Duct Leak after Laparoscopic Cholecystectomy: A Multiinstitutional Study,” Surgical Endoscopy, Vol. 10, No. 12, 1996, pp. 1189-1193. doi:10.1007/s004649900276
[13]	V. H. Chong, “Iatrogenic Biliary Stone,” Surgical Technology International, Vol. 14, 2005, pp. 147-155.
[14]	L. D. Reis, “Surgical Clips Incorporated into a Duodenal Ulcer: A Rare Complication after Elective Laparoscopic Cholecystectomy,” Endoscopy, Vol. 32, 2000, p. S3.
[15]	C. C. Yao, H. H. Wong, C. C. Chen, et al., “Migration of Endoclip into Duodenum. A Rare Complication after Laparoscopic Cholecystectomy,” Surgical Endoscopy, Vol. 15, 2001, p. 217.
[16]	K. Ammann, J. Kiesenebner, M. Gadenst?tter, et al., “Embolism of a Metallic Clip: An Unusual Complication Following Laparoscopic Cholecystectomy,” Digestive Surgery, Vol. 17, No. 5, 2000, pp. 542-44. doi:10.1159/000051959
[17]	A. L. Rohatgi and A. Widdison, “An Audit of Cystic Duct Closure in Laparoscopic Cholecystectomies,” Surgical Endoscopy, Vol. 20, No. 6, 2006, pp. 875-877. doi:10.1007/s00464-004-2253-9
[18]	H. Yano, K. Okada, M. Kinuta, et al., “Efficacy of Absorbable Clips Compared with Metal Clips for Cystic Duct Ligation in Laparoscopic Cholecystectomy,” Surgery Today, Vol. 33, No. 1, 2003, pp. 18-23. doi:10.1007/s005950300003
[19]	J. Westervalt, “Clipless Cholecystectomy: Broadening the Role of the Harmonicsc Alpel,” Journal of the Society of Laparoendoscopic Surgeons, Vol. 8, No. 3, 2004, pp. 283-285.
[20]	G. D. Tebala, “Three-Port Laparoscopic Cholecystectomy by Harmonic Dissection without Cystic Duct and Artery Clipping,” American Journal of Surgery, Vol. 191, No. 5, 2006, pp. 718-720. doi:10.1016/j.amjsurg.2005.07.029
[21]	D. L. Clarke-Pearson and W. T. Creasman, “A Clinical Evaluation of Absorbable Polydiaxanone Ligating Clips in Abdominal and Pelvic Operations,” Surgery Gynecology & Obstetrics, Vol. 161, 1985, pp. 250-252.
[22]	B. Geissler, F. Lindemann, L. Hausser and J. Witte, “Dislocation of Clips of the Cystic Duct Stump,” Zentralblatt fur Chirurgie, Vol. 123, 1998, pp. 102-105.
[23]	C. J. Schaefer, P. M. Colombani and G. W. Geelhoed, “Absorbable Ligating Clips,” Surgery Gynecology & Obstetrics, Vol. 154, 1982, pp. 513-516.
[24]	F. Michel, Y. Ponsot, J. Roland, et al., “Biological Tolerance to Polydiaxanone Absorbable Clips: A Comparison with Metallic Ligating Clips,” European Surgical Research, Vol. 17, No. 6, 1985, pp. 383-387. doi:10.1159/000128495
[25]	D. Weishaupt, H. H. Quick, D. Nanz, et al., “Ligating Clips for Three-Dimension MR Angiography at 1.5 t in vitro Evaluation,” Radiology, Vol. 214, 2000, pp. 902-907.
[26]	F. Cetta, C. Baldi, F. Lombardo, et al., “Migration of Metallic Clips Used during Laparoscopic Cholecystectomy and Formation of Gallstones around Them: Surgical Implications from a Prospective Study,” Journal of Laparoendoscopic & Advanced Surgical Techniques, Vol. 7, No. 1, 1997, pp. 37-46. doi:10.1089/lap.1997.7.37
[27]	V. H. Chong and C. F. Chong, “Biliary Complications Secondary to Post-Cholecystectomy Clip Migration: A Review of 69 Cases,” Journal of Gastrointestinal Surgery, Vol. 14, No. 4, 2010, pp. 688-696. doi:10.1007/s11605-009-1131-0