The Safety and Efficacy of Clipless versus Conventional Laparoscopic Cholecystectomy – our Experience in an Indian Rural Center

Abstract

Background: Laparoscopic cholecystectomy is one of the most common surgeries performed nowadays. There are lot of advances in closure of cystic duct and artery (clip ligation, suture ligation), but it remains an enigma regarding efficacy, safety and postoperative complications for using non-absorbable suture material or Liga clip for the operating surgeon in laparoscopic cholecystectomy. Objectives: Our study aimed to evaluate the efficacy, safety and complications of non-absorbable sutures ligation versus clips application in laparoscopic cholecystectomy, and to compare the operative time and cost effectiveness of the two surgical approaches in laparoscopic cholecystectomy. Methods: This prospective study was performed between August 2014 and February 2015 in M. M. Institute of Medical Science and Research, in a rural center, Mullana, India. The study included 160 patients who were diagnosed with chronic cholecystitis in a single unit. Subjects were divided into two groups and all cases were operated by a single surgeon. The cystic pedicle was tied with non-absorbable material (silk 2-0) in group A and with Titanium clips using a clip applicator in group B. Results: The application of silk and clips for cystic duct and artery ligation in laparoscopic cholecystectomy can be safely used. The mean time for ligation of cystic duct was 2.50 (SD ±0.25) in group A and 1.50 min (SD ±1.85) in group B, with P<0.001, which was significant. Similarly, the mean time for ligation of cystic artery was 1.50 min (SD±0.20) in group A and 1.36 min (SD ±0.11) in group B, with P>0.001. There were no postoperative complications, such as wound infection or bile leakage, in any of the two methods. The cost of material for silk suture (40-60 Rupees or 0.62-0.92 $) is definitely much lower than that for Liga clips (790-1000 Rupees or 12.28-15.55 $). For the use of clips, a clip applicator is required, but in case of silk ligation no special instrument is required and silk is also easily available. Conclusion: In laparoscopic cholecystectomy, ligation of cystic duct and cystic artery with clips takes less time than by silk suture. We conclude that both ligation techniques can be safely and effectively used. Training for junior surgeons is necessary to avoid potential complications.

Systematic review of cystic duct closure techniques in relation to prevention of bile duct leakage after laparoscopic cholecystectomy

“…Locking clips failed in 52 patients from a total of 1853 (2.8%) during surgery, reported in 4 studies[ 20 , 24 , 25 , 39 ]. In 1270 patients 18 ligatures failed (1.4%), which was reported in three studies[ 19 , 37 , 50 ]. Failure of closure technique usually meant the need to switch to a different closure technique.…”

“…Of the 38 included studies, 14 were used in the comparative analysis and 24 in the non-comparative analysis. Of the comparative studies, 4 were randomized controlled trials[ 13 - 16 ], 3 were prospective[ 17 - 19 ] and 7 had a retrospective design[ 20 - 27 ] (Tables 1 and 2 ). Six studies compared the harmonic energy with metal clips[ 13 - 15 , 22 , 23 , 26 ], locking vs non-locking clips were the subject of four studies[ 20 , 21 , 24 , 25 ] and the other three covered either ligatures[ 16 , 19 ] or a vessel sealing device[ 17 , 18 ].…”

“…The use of locking clips vs non-locking clips was compared in three studies (Figure 4 ); the pooled Peto odds ratio was 0.17 (95%CI: 0.03-0.93)[ 20 , 24 , 25 ]. Figure 5 depicts the CDL rate for closure of the cystic duct by metal (non-locking) clips in 20 studies (also including the relevant single group from the comparative studies) including 38573 patients; the overall pooled event rate is 0.01% (95%CI: 0-0.01)[ 13 - 17 , 19 , 21 - 26 , 30 , 31 , 33 , 35 , 40 - 43 ]. Harmonic energy was used to close the cystic duct in 14 non-comparative analysis including 1692 patients (Figure 6 ); the pooled event rate for CDL was 0.01% (95%CI: 0.01-0.02)[ 13 - 15 , 18 , 22 , 26 - 29 , 44 - 47 ].…”

Concomitant Laparoscopic Hiatal Hernia Repair with Cholecystectomy: A Multicentric Study

“…Common bile duct injuries are the Achilles heel in laparoscopic surgery versus open surgery with reported rates being higher in the laparoscopic group. [14][15][16][17][18][19][20] Although laparoscopic cholecystectomy is a relatively common and simple procedure, the surgeon is performing it after a hiatal hernia repair, which can lead to fatigue. The surgeon should be in a familiar position for cholecystectomy, with good operative view, good ergonomy and should bear in mind the risk of this injury especially if fatigued.…”

Clip Occlusion Versus Extracorporeal Suture Ligation (Roeder Knot) of the Cystic Duct in Laparoscopic Cholecystectomy – A Comparative Study

“…There was no significant (p>0.05) difference in presenting symptoms between the groups. Singal et al (2018) 11 conducted a similar study comprising of 160 patients, all of them (100%) having abdominal pain as the chief complaint prior to admission. Vomiting (35%) was the second most common complaint.…”