Laparoscopic cholecystectomy using harmonic: not only clipless

Background: Laparoscopic cholecystectomy is the gold
standard treatment of gallstones. The ultrasonically acti-
vated scalpel (Harmonic scalpel, Ethicon) may be used as
the sole instrument for both gallbladder dissection and
section of the cystic artery and duct with no need of further
ligatures.
Methods: In a series of 40 consecutive patients, laparo-
scopic cholecystectomy was performed with the Harmonic
scalpel. 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 of
acute cholecystitis, and 2 of gallbladder empyema). There
were 31 females and 9 males. Indications were 27 sim-
ple gallstones, associated in 5 cases with common bile
duct stones; 12 acute cases of cholecystitis; and 2 cases
of gallbladder empyema. Associated procedures were
performed in 11 cases.
Results: The mean operative time was 62 minutes. Intraop-
erative cholangiography was performed in 5 cases and
common bile duct exploration in 3. A drain was left in 17
patients. No conversions were necessary. No patients
developed postoperative complications, and the mean
postoperative hospital stay was 2.1 days.
Conclusions: Laparoscopic cholecystectomy performed
with an 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 the artery and duct. Furthermore, because
of the minimal thermal dispersion, the use of the Harmonic
scalpel reduces the risk of injuries. The main limit of the
procedure is represented by the cystic duct size: if more
than 5mm in diameter an additional ligature is necessary.