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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 54-61

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


1 Department of General Surgery, Faculty of Medicine, Menoufia University Hospital, Menoufia, Egypt
2 Department of General Surgery, Shibin Elkoom Teaching Hospital, Egypt

Date of Submission07-Apr-2014
Date of Acceptance24-Jun-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Reda Mohamed Eltiras
Zorkan, Tala, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155942

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  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.

Keywords: Gall stones, harmonic scalpel, laparoscopic cholecystectomy


How to cite this article:
El Mallah SI, Soltan H, Zaid NA, Elsamie MA, Eltiras RM. Comparative study between the conventional laparoscopic cholecystectomy and clipless cholecystectomy using a harmonic scalpel. Menoufia Med J 2015;28:54-61

How to cite this URL:
El Mallah SI, Soltan H, Zaid NA, Elsamie MA, Eltiras RM. Comparative study between the conventional laparoscopic cholecystectomy and clipless cholecystectomy using a harmonic scalpel. Menoufia Med J [serial online] 2015 [cited 2019 Sep 21];28:54-61. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/54/155942


  Introduction Top


Gall bladder disease continues to be one of the most common digestive disorders encountered by physicians [1].

Complete removal of the gall bladder remains the most effective therapy and, until recently, could only be performed by an open laparotomy; the first cholecystectomy was performed by Langenbuch in 1882 [2].

Laparoscopic cholecystectomy was introduced, and it enables the surgeon to remove the gall bladder completely, with a reduced hospital stay, decreased recovery interval, and reduced postoperative discomfort. The first laparoscopic cholecystectomy was performed by Erich Muhe in Germany in 1985 [3].

A modern laparoscopic design and modern instrument, together with the new technology of television cameras, screens, and instruments, have made laparoscopic cholecystectomy a safe procedure for the treatment of gall stone disease [4].

Usually, the procedure involves electrocautery and sealing of the gall bladder duct and artery with titanium clips. The technique of laparoscopic cholecystectomy still required refinement in terms of certain factors, including the potential complication of dislodging of clips. The use of an ultrasonically activated scalpel for tissue cutting and coagulation could be a potential replacement for electrocautery, which can lead to different complications. The harmonic scalpel has been used previously for division of the cystic duct and artery and liver bed dissection. Recent advancements in the harmonic scalpel technology now provide safe division and closure of a cystic duct up to 6 mm in diameter; if the cystic duct has a larger diameter, an alternative ligature or clip technique should be used [5].

Laparoscopic cholecystectomy using a harmonic scalpel was introduced because it provides safe division and closure of both the cystic artery and duct, lower intraoperative blood loss, shorter duration of operation, less postoperative drainage, less postoperative pain, and shorter hospital stay [5].

Laparoscopic cholecystectomy was considered technically difficult for acute calcular cholecystitis. With increasing experience in laparoscopic surgery, a number of centers have reported on the use of laparoscopic cholecystectomy for acute cholecystitis, especially with a harmonic scalpel, which is technically feasible [6].

In cirrhotic patients, a laparoscopic cholecystectomy is still more complicated and difficult than for patients without cirrhosis. The harmonic scalpel provides complete hemobiliary stasis and is a safe alternative to the standard clipping of the cystic duct and artery for cirrhotic patients [7].

This study aimed to compare the conventional laparoscopic cholecystectomy with clipless cholecystectomy using a harmonic scalpel.


  Patients and methods Top


The present study was carried out on 80 patients who presented to Menoufia University during the period from January 2011 to November 2013. All patients had calcular cholecystitis as evaluated from history, clinical examinations, and investigations. Patients were divided randomly into two groups: group A, which included 40 patients with calcular cholecystitis, was subjected to conventional laparoscopic cholecystectomy using electrocautery and titanium clips, and group B, which included 40 patients with calcular cholecystitis, was subjected to laparoscopic cholecystectomy using a harmonic scalpel.

The exclusion criteria included patients older than 80 years of age, patients with a history of upper laparotomy, patients with common bile duct stones, pregnant women, and patients with acute cholecystitis with a history of jaundice.

History and clinical examination and investigations

All patients were subjected to a thorough assessment of history and clinical examination focused on manifestation of gall stone disease and chronic liver disease. The following investigations were performed (whole blood picture, liver function tests, HCV and HBV markers, and abdominal ultrasound) to determine the state of the liver, portal vein, gall bladder, and CBD.

Informed consent was obtained from all patients for inclusion in the study, after the nature of the disease and operative steps and possible complications were explained to them. This study was approved by the local ethics committee.

Surgical techniques

Under general anesthesia and the same antibiotics (third-generation cephalosporin), surgery was performed using a conventional four-port umbilical port, a port below xiphoid, and two ports below the right costal margin. Pneumoperitoneum at a pressure of 12 mmHg was used.

In group A, laparoscopic cholecystectomy was performed using the traditional method by dissection of Calot's triangle and clipping of both the cystic duct and artery by metal clips. Then, dissection of the gall bladder was performed from its bed by a hook using the electrocautery technique. Finally, we inserted an abdominal drain into the Morrison pouch.

In group B, laparoscopic cholecystectomy was performed using a harmonic scalpel by dissection of Calot's and then occlusion of both the cystic duct and artery using a harmonic shear. For closure and division of the cystic pedicle, we set the instrument at power 2, that is, more coagulation was performed; this was done at two levels, with separation of the duct at the proximal level toward the gall bladder. When dissecting the gall bladder from its bed, we set it to level 5, that is, greater cutting power, and control of any bleeding from the bed using the active blade of the harmonic shear. Finally, we inserted an abdominal drain into the Morrison pouch.

Note that insertion of an abdominal drain in both groups was performed routinely to enable a comparison of the amount of postoperative drainage.

The statistical analysis of the data in this study was carried out using the SPSS (version 10; SPSS Inc., Chicago, Illinois, USA). Analysis of data was based on an intention-to-treat principle. For continuous variables, descriptive statistics were calculated and reported as mean ± SD. Categorical variables were described using frequency distributions. Student's t-test for paired samples was used to detect differences in the means of continuous variables and the c2 -test was used in cases with low expected frequencies (P < 0.05 was considered to be significant).

Postoperative care and assessment

The patients were started on oral fluid 8 h postoperatively and then a soft diet. The duration of operations was recorded. Postoperative pain was evaluated at 12, 24, and 48 h and 1 week after the operation using a visual analogue scale (VAS); postoperative analgesia in the form of a NSAID was administered intramuscularly when required. If the patients still complained of pain, a strong analgesic (1 mg/kg pethidine intramuscularly) was administered and the total doses of this medication were recorded.

Cirrhotic patients were only administered paracetamol intravenously for postoperative pain.

The frequency of nausea, vomiting, and postoperative complications were recorded. The amount of postoperative drainage and hospital stay were recorded. Patients were usually discharged after the removal of the drain when the patient is surgically free.

Regular follow-up was performed for all patients at the outpatient clinic every week up to 1 month to ensure that there were no postoperative complications.


  Results Top


In this study, we found that the following.

Demography of patients

In terms of age, there was no significant difference between group A (40.12 ± 7.84 years) and group B (41.80 ± 7.20 years) [Table 1]. Similarly, BMI showed no statistically significant difference between both groups (29.12 ± 4.90 and 30.17 ± 5.48 kg/m 2 , respectively) [Table 2]. This study included 80 patients; there were more women [27 (37.5%)] in group A compared with men [13 (32.5%)], whereas there were 18 men (45%) and 22 women (55%) in group B. All data for age groups are shown in [Table 2].
Table 1: Demographic data of the patients

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Table 2: Intraoperative and postoperative parameters

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As for associated comorbid conditions (diabetes mellitus, hypertension, liver cirrhosis, or smoking); all were not significantly correlated in both groups with the technique.

Intraoperative and postoperative parameters

There was a statistically significant difference between the two groups in the incidence of blood loss and drain amount; however, there was no statistical significance for the comparable incidence of intraoperative gall bladder perforation (17.5 vs. 7.5% for group A and group B, respectively) [Table 2]. Fortunately, no conversion to open cholecystectomy was required in group B versus only two patients in group A. The duration of surgery was statistically significantly shorter in group B compared with group A as shown in [Table 2].

Postoperative pain

Postoperative pain was significantly more in group A at 12 and 24 h and consequently higher doses of analgesic were needed than in group B [Table 3]. VAS in group B was lower than that in group A at 12 and 24 h, and the difference was statistically significant as shown in [Table 3].
Table 3: Postoperative pain

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Postoperative oral analgesia was prescribed for patients in both groups routinely and was monitored in the outpatient clinic during the follow-up.

Note that the VAS is a subjective measure of pain. It consists of a 10 cm line with two end-points representing 'no pain' and 'worst pain imaginable'. Patients are asked to rate their pain by placing a mark on the line corresponding to their current level of pain. The distance along the line from the 'no pain' marker is then measured with a ruler, yielding a pain score out of 10.

Postoperative complications

There were two cases of postoperative pulmonary complications in group A versus only one case in group B with the use of the harmonic scalpel (diagnosed in both as bronchitis) [Table 4].
Table 4: Postoperative complications

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The reported cases of postoperative infection were related to the port sites.

The patients in whom postoperative biliary leakage occurred were diagnosed by re-laparoscopy as having a leaking accessory cystic duct and were managed by clipping of the duct.

There was no statistically significant difference between both groups for any of the reported complications as shown in [Table 4].

Hospital stay

The hospital stay was statistically significantly shorter in group B than group A as shown in [Table 5].
Table 5: Hospital stay

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Note that patients in whom biliary leakage occurred were readmitted to the operating room after only a few hours and were included in the hospital stay statistics [Figure 1],[Figure 2],[Figure 3],[Figure 4] and [Figure 5].
Figure 1: Division of the cystic artery.

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Figure 2: Clipping of th e cystic duct.

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Figure 3: Division of the cystic duct by a h armonic shear.

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Figure 4: Division of the cystic artery by a h armonic shear.

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Figure 5: Dissection of the gall bladder out of the gall bladder fossa by a harmonic shear.

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  Discussion Top


The traditional laparoscopic cholecystectomy is commonly performed using a dissector, an electrosurgical hook spatula, and or scissors; metal clips are frequently used to perform cystic duct and artery closure. Various energy sources are routinely used as cutting and coagulating aids in laparoscopic surgery; monopolar electrosurgery is the method preferred by more than 85% of surgeons [8].

Bipolar electrosurgery has not been used widely in laparoscopic cholecystectomy [9].

Several studies have described the use of ultrasonic dissection technology in laparoscopic cholecystectomy, and ultrasonic dissection is considered safe and easy to use [10].

The primary use of a harmonic scalpel in laparoscopic cholecystectomy has been for division of the cystic artery and liver bed dissection; advancements in ultrasonic dissection technology now provide for the reliable ultrasonic division and closure of the cystic duct [11].

In our study, we observed a difference between the duration of operation in group A and group B. The mean operative time was significantly shorter in group B than in group A (34.21 ± 9.62 vs. 41.7 ± 13.79, respectively, P = 0.006). This was supported by the study carried out by Bessa et al. [12], who reported a significant difference in the duration of surgery in favor of laparoscopic cholecystectomy using a harmonic scalpel, which may be attributed to fewer number of insertions and extractions of the instrument; in addition, an ultrasonic-activated harmonic scalpel produces no smoke. Thus, the viability of the operative field is preserved during the entire procedure, and there is no need to remove the smoke and to recreate the pneumoperitoneum or to repeatedly clean the lens.

In terms of the conversion rate to open cholecystectomy, in our study two patients with acute calcular cholecystitis were converted to open cholecystectomy because of extensive adhesion, bleeding, and unclear anatomy in group A (5%), whereas the conversion rate in group B was zero. This is in agreement with the result of a study carried out by Minutolo et al. [13], who reported that in patients with acute calcular cholecystitis, the efficacy of the harmonic scalpel in the dissection of the gall bladder from the liver bed has been proven, with a low perforation rate compared with the electrocautery. It enables complete and safe closure of the cystic duct and artery without injury to the common bile duct.

In our study, intraoperative blood loss was significantly more in group A than group B (96.62 ± 53.33 vs. 64.20 ± 44.01, respectively, P = 0.004). (Blood loss was measured by calculating the amount of fluid in the suction jar.) This is in agreement with the study carried out by Perissat [14], who reported that in a single randomized clinical trial that included 200 patients undergoing a laparoscopic cholecystectomy procedure, a small but statistically significant difference in blood loss was detected in favor of cholecystectomy using a harmonic scalpel. This is in agreement with the result of a study carried out by Huscher et al. [15], who reported that the harmonic scalpel has been proven to be an effective and safe instrument for dissection and hemostasis. This is in agreement with the result of a study carried out by Bessa et al. [12], who reported that the decrease in hemoglobin and hematocrit levels was statistically much lower in the ultrasonic shear group in comparison with the electrocautery group. Decreased reduction in hemoglobin and hematocrit levels indicates less blood loss. The reduced blood loss in the ultrasonic group can be explained by the fact that the harmonic scalpel can differentiate between natural tissue planes and inflammatory planes.

In our study, in two patients in group A (5%), a minor biliary leak was detected from the accessory duct and diagnosed postoperatively after a few hours by diagnostic laparoscopy; it was managed by clipping with 5 mm clips. In group B, three patients with a dilated cystic duct were detected intraoperatively (roughly measured) and clips were placed and the duct was divided; otherwise, no biliary leak was detected in group B, indicating that the harmonic shear is as safe and efficient as simple clips in achieving the closure of the cystic duct stump in a laparoscopic cholecystectomy if the duct is less than 6 mm in size. This was in agreement with the result of a study carried out by Westervelt [16], who found no bile leaks from the cystic-duct stump in 100 patients in whom the closure and division of the cystic duct was achieved by harmonic shears. This was in agreement with the result of a study carried out by Samer et al. [17], who reported the absence of either minor or major bile leaks from the cystic-duct stump after closure and division by harmonic shears. This is in agreement with the result of a study carried out by Kandil et al. [18], who reported the main finding of his study as the absence of either minor or major bile leaks from the cystic-duct stump in the harmonic scalpel group, indicating that the harmonic shears are as safe and efficient as simple metal clips in achieving the closure of the cystic-duct stump in a laparoscopic cholecystectomy. However, Fulum et al. [5] reported that harmonic shears can enable safe division and closure of the cystic duct up to 6 mm in diameter; if the size of the cystic duct is larger, then the ligature or clip technique should be used.

In our study, gall bladder perforation was greater in group A than group B (17.5 vs. 7.5%, respectively, P < 0.167), but this was statistically insignificant; the use of a harmonic scalpel in laparoscopic cholecystectomy was associated with a statistically insignificantly lower incidence of gall bladder perforation compared with the use of electrocautery in laparoscopic cholecystectomy.

A study carried out by Jan et al. [19] found that the use of an ultrasonic scalpel for dissection of the gall bladder in laparoscopic cholecystectomy was associated with lower incidence of gall bladder perforation and the operation progressed more smoothly. However, a study carried out by Samer et al. [17] found that the use of the harmonic ACE was associated with a statistically significantly lower incidence of gall bladder perforation compared with electrocautery.

In our study, the incidence of pain was more in group A at 12 and 24 h postoperatively (70 vs. 45%, P = 0.024, and 60 vs. 37.5%, P = 0.0.024, respectively) and VAS in the group B was lower than that in group A; the difference was significant at 12 h postoperatively (3.37 ± 0.49 vs. 3.12 ± 0.33, P = 0.01) and 24 h postoperatively (3.34 ± 1.47+2.30 ± 0.34, P = 0.01) and insignificant at 48 h and 1 week.

This is in agreement with the result of a study carried out by Kandil et al. [18] who reported that the incidence of pain was significantly more in the traditional group at 12 and 24 h postoperatively and VAS in the harmonic group was lower than that in the traditional group; the difference was significant at 12 h postoperatively and 24 h postoperatively. This statistical difference may be attributed to several factors such as shorter duration of operation, so we use less amount of gases and less incidence of perforation of gall bladder perforation in harmonic group so less escape of bile in the peritoneum. This is in agreement with the result of a study carried out by Jan et al. [19], who reported that the use of an ultrasonic scalpel in laparoscopic cholecystectomy was associated with significantly lower incidence of postoperative pain than traditional cholecystectomy, which may be because of less diaphragmatic stretch and a short duration of operation, with the use of lower volumes of gases.

In our study, we observed there was a difference between group A and group B in the incidence of nausea and vomiting postoperatively. In group A, the incidence of nausea was more than that in group B at 24 and 48 h postoperatively (30 vs. 20% and 10 vs. 7.5%, respectively), but statistically insignificant; in group A, the incidence of vomiting was more in group A than group B at 24 h postoperatively (5 vs. 2.5%), but this was statistically insignificant. This is in agreement with the result of a study carried out by Westervelt [16], who reported that the total incidences of nausea and vomiting were higher in the traditional group; the number of patients who had nausea or vomiting did not differ significantly at different time points.

In our study, the mean amount of postoperative drainage was statistically significant greater in group A than group B (79.0 ± 36.95 vs. 60. 30 ± 11.48, P = 0.004). (Drain was inserted routinely in both groups for comparison.) This is in agreement with the result of a study carried out by Kandil et al. [18], who reported that the mean amount of postoperative drainage was significantly more in the traditional cholecystectomy group than in the harmonic scalpel group.

In our study, the hospital stay was shorter in group B than group A (20.15 ± 5.65 vs. 24.65 ± 6.22, P = 0.006). This is in agreement with the result of a study carried out by Huscher et al. [15] who reported that the hospital stay was shorter in the harmonic scalpel group than in the traditional cholecystectomy. This is in agreement with the result of a study carried out by Kandil et al. [18], who reported that the hospital stay was shorter in the harmonic scalpel group.

In our study, of 10 patients with liver cirrhosis Child's classification A and B, five patients were subjected to conventional laparoscopic cholecystectomy using electrocautery and titanium clips and five patients were subjected to laparoscopic cholecystectomy using a harmonic scalpel. We found that the harmonic scalpel led to complete and safe closure of the cystic duct and artery and the separation of the gall bladder was bloodless. This is in agreement with the result of a study carried out by El Nakeeb et al. [7], who reported that cholecystectomy with the harmonic scalpel may be an acceptable alternative in patients with cirrhosis to ovoid intraoperative bleeding from the liver bed or during dissection of the cholecystohepatic triangle.


  Conclusion Top


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 expensive.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Hermann RE. Manual of surgery of the gall bladder, bile duct and pancreas. New York: Springer-Verlag; 1979.  Back to cited text no. 1
    
2.
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Fullarton GM, Bell G. A prospective audit of the introduction of laparoscopic cholecystectomy in West of Scotland. West of Scotland Laparoscopic Cholecystectomy Audit Group. Gut 1994; 35 :1121-1126.  Back to cited text no. 3
    
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Fulum T, Kim S, Dan P, Turner PL. Laparoscopic dome-down cholecystectomy with the LCS-5 harmonic scalpel, Soc Laparoendosc Surg 2005; 9 :51-57.  Back to cited text no. 5
    
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El Nakeeb A, Askar W, Elithy R, Mohamed A. Laparoscopic cholecystectomy in cirrhotic patients by harmonic scalpel. J Gastrointest Surg 2010; 24 :41.  Back to cited text no. 7
    
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Rohatgi A, Widdison A. An audit of cystic duct closure in laparoscopic cholecystectomies. Surg Endosc 2006; 20 :875-877.  Back to cited text no. 8
    
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Edelman DS, Unger SW. Bipolar versus monopolar cautry scissors for laparoscopic cholecystectomy: a randomized prospective study. Surg Laparosc Endosc 1995; 5 :459-462.  Back to cited text no. 9
    
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Tebala GD. Three-port laparoscopic cholecystectomy by harmonic scalpel dissection without cystic duct and artery clipping. Am J Surg 2006; 9 :718-720.  Back to cited text no. 10
    
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Janssen IMC, Swank DJ, Boonstra O, Knipscheer BC, Klinkenbijil JH, Goor HV. Randomized, clinical trial of ultrasonic versus electrocautry dissection of the gall bladder in laparoscopic cholecystectomy. Br J Surg 2003; 90 :799-803.  Back to cited text no. 11
    
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Bessa SS, Al-Fayoumi TA, Katri KM, Awad AT. Clipless laparoscopic cholecystectomy by ultrasonic dissection. J Laparoendosc Adv Surg Tech A 2008; 18 :593-598.  Back to cited text no. 12
    
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Minutolo V, Gagliano G, Rinzivillo C, Li Destri G, Carnazza M, Minutolo O. Usefulness of ultrasonically activated scalpel in laparoscopic cholecystectomy: our experience and review of literature. G Chir 2008; 29 :242-245.  Back to cited text no. 13
    
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Perissat JIn: Vitale GC, Sanfilippo JS, Perrisat J, editors. Laparoscopic cholecystectomy, the French experience in laparoscopic cholecystectomy. Philadelphia: J. B. Lippincott Company; 1999. 147-163,   Back to cited text no. 14
    
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Huscher CGS, Lirici MM, Di Paola M, Crafa F, Napolitano C, Mereu A, et al. Laparoscopic cholecystectomy by ultrasonic dissection without cystic duct and artery ligature. Surg Endosc 2003; 17 :442-451.  Back to cited text no. 15
    
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Westervelt J. Clipless cholecystectomy - broadening the role of harmonic scalpel, J Soc Laparosc Surg 2004; 8 :283-285.  Back to cited text no. 16
    
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Samer S, Bessa, Alaa H, Abdel-Razag, Mohamed A, Sharaan M, et al. Evaluation of laparoscopic cholecystectomy by harmonic scalpel. J Laparoendosc Adv Surg Tech 2011; 21 :116-119.  Back to cited text no. 17
    
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Kandil T, El Nakeeb AM, El Hefhawy E. Comparative study between laparoscopic conventional cholecystectomy and clipless cholecystectomy using harmonic scalpel. J Gastrointest Surg 2010; 14 :323-328.  Back to cited text no. 18
    
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Jan SK, Tanwar R, Kaza RC, Agarwal PN. Clipless cholecystectomy using harmonic scalpel. J Laparosc Adv Surg Techn 2011; 2:203-208.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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