Clipless lap chole (our experience).
Laparoscopic cholecystectomy has now become the gold standard for the treatment of symptomatic gallstones disease. Most of the surgeons use simple metal clips to close the cystic duct and artery.  However, the use of clips in laparoscopic cholecystectomy is associated with some problems. Small clips that are put on the blood vessels or bile tubes are left in the body can come off. This can cause an internal bile leak in 1-2% of people. [4,5] In addition, clips that are moved to the duodenum or the hepatic duct causing duct obstruction. Application of clips can cause bile duct necrosis resulting in post-operative cystic duct leak.
Alternate techniques have included the use of locking absorbable clips and the Harmonic scalpel. But these are more expensive, not readily available and used infrequently. [6,7] Thus, we describe a novel technique for dealing with cystic duct and artery during laparoscopic cholecystectomy.
MATERIAL AND METHODS
This randomised controlled trial was conducted on 62 patients admitted to the Department of Surgery, Rama Medical College, Mandhana, Kanpur; and Aastha Health Centre, Singhpur Kanpur, from April 2015 to March 2016. All subjects provided written informed consent to be included in the study. Patients were selected for laparoscopic cholecystectomy based on clinical and radiographic evaluation showing cholelithiasis.
Ultrasound was the diagnostic procedure of choice in virtually all patients. Operations were all conducted using general anaesthesia. In all those patients, the cystic artery was divided by bipolar cautery and the cystic duct was ligated intracorporeally using non-absorbable suture.
Four Ports are used. Positions of Ports are:
A. Umbilicus camera port 10 mm.
B. Epigastric working port 10 mm.
C. Right subcostal port at midclavicular line 5 mm.
D. Right lateral port at anterior axillary line 5 mm.
Place the patient in reverse Trendelenburg position approximately 20-30 degrees and turn the operating to the left.
Exposure of Hilum
Cranial traction of fundus of gall bladder shifts right lobe of liver in cephalad manner and there is exposure of calot's triangle and hilum of liver.
Adhesions to the underside of the liver and gall bladder are carefully taken down beginning near the fundus and proceeding down towards the neck. Adhesions may contain omentum, colon, stomach, duodenum and hence must be dissected with care. It is prudent to use cautery as little as possible to avoid transmission of thermal energy to the attached structures.
If the gall bladder is acutely inflamed and tense, decompress it under visual control.
Calot's Triangle Dissection
Calot's triangle is exposed and the peritoneal covering overlying the triangle of calot's is gently dissected by elevation of this thin tissue. Once the peritoneal covering is dissected off the cystic triangle, the cystic duct and artery are identified and dissected individually using blunt dissection. The cystic artery is dealt with before cystic duct to avoid avulsion injury of the artery. An Endo-Dissector is applied to the dissected cystic artery on the wall of gall bladder and the cystic artery is cauterized at two levels using bipolar diathermy at low power settings. After this the cystic artery is carefully divided with the help of Endo-Scissor.
After this, a 15 cm long thread of 2/0 silk suture is introduced into the abdomen by using a needle holder through the 10 mm epigastric port. In a surgeon's knot, configuration, the cystic duct is ligated intracorporeally as described by Nathanson and Colleagues.  The cystic duct is cut between the two ligatures with the help of Endo scissors as well as the thread ends are also cut by Endo scissors. The second tie near the gall bladder plays two important roles.
a. Prevent spillage of gall bladder contents.
b. Facilitates dissection of gall bladder from liver bed by freeing the left hand instrument.
After this the cholecystectomy is completed in the usual manner. The board of our hospital approved the performance of the study and an informed consent was obtained from all included patients.
Since April 2015, 62 cases of laparoscopic cholecystectomy have been included in this study. These patients were operated in Department of Surgery, Rama Medical College, Mandhana, Kanpur; and Aastha Health Centre, Singhpur, Kanpur. No postoperative bleeding was reported. There were no bile duct injuries either. There was no intraoperative bleeding was reported from cauterized cystic artery.
Nowadays, most surgeons use simple metal clips to close the cystic duct, since Muhe reported the first successful laparoscopic cholecystectomy in 1985.  However, the use of simple metal clips has many disadvantages, which are as follows:
1. In laparoscopic cholecystectomy, there is evidence of cystic duct leakage reported in up to 2% of cases.
2. Postoperative cystic duct leakage, which can further lead to serious complications like biloma formation or biliary peritonitis.
3. There is a significant inflammatory reaction to metallic clips. 
4. Clip migration from their initial site to common bile duct serves as a potential nidus for gallstone formation.
5. Computed tomography or magnetic resonance imaging scans show subsequent artifacts. [11,12]
Recently locking absorbable clips were used instead of simple clips to close the cystic duct, but these clips are expensive.  Harmonic scalpel, an alternative technique for cystic duct closure is also very expensive and not readily available and therefore used infrequently. 
However, there are Many Advantages of Simple Ligation of the Cystic Duct
* It is feasible.
* More practical.
* Easily available.
* Very economical.
* Simple manoeuvre that could be easily learnt.
* Only required skill is to make intracorporeal knotting.
Additionally, this technique avoids the intrinsic disadvantages of the use of clips. Moreover, we believe in advanced and complex laparoscopic procedures, intracorporeal knotting plays an important role. In order to obtain the best results by using this technique, some prerequisites should be fulfilled.
1. Cystic artery should be controlled prior to cystic duct ligation, so that the cystic artery may not get torned during manoeuvres needed for duct ligation.
2. Dissection of the cystic artery should be up to the gall bladder wall, so that the diathermy current may not pass to the hilar structures.
3. In order to avoid infective complication due to spillage of gall bladder contents, the distal end of cystic duct should be ligated. This can also allow the use of the left hand instrument for dissection of gallbladder from liver.
We can conclude after our study that the new proposed modification of clipless laparoscopic cholecystectomy is feasible, practical, safe as well as economic. It is also associated with reduced risk of post-operative complications.
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Shailesh Kumar Katiyar (1), Pankaj Kapoor (2), Ashish Kumar Katiyar (3)
(1) Professor, Department of General Surgery, Rama Medical College, Kanpur.
(2) Assistant Professor, Department of General Surgery, Rama Medical College, Kanpur.
(3) Registrar, Department of General Surgery, Aastha Health Centre, Singhpur, Kanpur.
Financial or Other, Competing Interest: None.
Submission 28-06-2016, Peer Review 30-07-2016, Acceptance 06-08-2016, Published 13-08-2016.
Dr. Shailesh Kumar Katiyar, Aastha Health Centre, Singhpur, Kanpur.
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|Title Annotation:||Original Research Article; laparoscopic cholecystectomy|
|Author:||Katiyar, Shailesh Kumar; Kapoor, Pankaj; Katiyar, Ashish Kumar|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Aug 15, 2016|
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