Clipless laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is the gold standard treatment of gallstones. The ultrasonically activated scalpel (Harmonic Scalpel - Ethicon) may be used as sole instrument for both gallbladder dissection and section of cystic artery and duct with no need of further ligatures.
Methods: In a series of 40 consecutive patients, laparoscopic cholecystectomy was performed with Harmonic. In 8 patients an additional cystic duct ligature with clips was performed because of the large size of the duct (5 cases of associated common bile duct stones, 1 case of acute cholecystitis and 2 of gallbladder empyema). There were 31 females and 9 males. Indications were: 27 simple gallstones, associated in 5 cases to common bile duct stones, 12 acute cholecystitis and 2 gallbladder empyema. In 11 cases associated procedures were performed.
Results: The mean operative time was of 62 minutes, intraoperative cholangiography was performed in 5 cases and common bile duct exploration in 3. A drainage was left in 17 patients. There were no conversions. No patients developed postoperative complications and the mean postoperative hospital stay was of 2,1 days.
Conclusions: Laparoscopic cholecystectomy performed with ultrasonically activated scalpel is feasible and effective. The advantages are represented by using a unique instrument both for dissection of the gallbladder and division of artery and duct. Furthermore, because of the minimal thermal dispersion, the use of Harmonic reduces the risk of injuries. The main limit of the procedure is represented by the cystic duct size: if more than 5 mm in diameter an additional ligature is necessary.