SINGLE WORKING INSTRUMENT, DOUBLE TROCARS, CLIPLESS CHOLECYSTECTOMY USING HARMONIC SCALPEL. A FEASIBLE, SAFE, AND LESS INVASIVE TECHNIQUE

Aim: To evaluate safety and efficacy of harmonic scalpel in closure/division of the cystic duct and artery, 
and bladder dissection in laparoscopic cholecystectomy as a single working instrument, with the use of two 
working trocars technique, compared with clip/cautery, three trocars technique.
Method: A prospective study included 160 patients with symptomatic gall stone disease were randomly 
assigned for laparoscopic cholecystectomy by either harmonic shear, with two trocars (Group I = 80 
patients), or Group II (clip/cautery, 3 trocars) including 80 patients.
Results: No significant complications were encountered in either group; however 1 case of Group II suffered
mild leakage treated conservatively. Intra-operative bile spillage was insignificantly lower in Group I (10% 
vs. 13%; P=0.46). The median operative time was significantly shorter in Group I (20 vs. 45 minutes; 
P=0.0001). Also hospital stay was significantly shorter in Group I (1 vs. 1.5 days; P=0.001), but no significant 
difference found in the incidence of post-operative complications. The overall cosmetic results and patient 
satisfaction was better in Group I.
Conclusion: Harmonic shear is as safe and effective as clip/cautery technique in achieving hemo-biliary 
stasis; with shorter operative time, especially if used solely as a working instrument. Two trocars technique 
is safe, feasible, and provides better cosmetic results and patient satisfaction.