“Clipless” Cholecystectomy: Evolution Marches On, Even for Lap Chole (2011)

It is nearly a quarter century since laparoscopic cholecys-tectomy was introduced to surgeons and forever changedhow we think about surgery. Laparoscopy changed not onlyhow we accessed the gallbladder but almost every singleelement of how the surgery had been done for over100 years, i.e., how the gallbladder was exposed andretracted, how Calot’s triangle was visualized, performingretrograde dissection versus antegrade, and the need for andfrequency of cholangiography. One thing that did notchange, however, was the method of ligating the cystic ductandartery.Atleastinthedevelopedworld,bythemid-1980stitanium clips had largely replaced suture ligation, whichmore often than not was performed only to demonstrate toresidentsandmedicalstudentshowthingswereoncedoneortotesttheirknot-tyingabilities[1].Infact,itwasexclusivelythe development of the laparoscopic clip applier that madepossiblethewidespreadandrapidadoptionoftheprocedure,as the ability to intracorporeally ligate the duct and arterywas unthinkable to all but a handful of the most accom-plished masters of laparoscopy of that time.The article by Kavlakoglu et al. [2] which contributesanother study to the growing body of literature regardingthe safety and efﬁcacy of tissue welding to close the cysticduct during cholecystectomy, hints at the ﬁnal change inthe old paradigm of cholecystectomy. While 25 years intoit may imply that a change is unneeded, the current ‘‘old’’method of clipping the duct and artery is not a perfectsolution. Titanium clips have been known to migrate intoadjacent structures, cause strictures due to a foreign bodyresponse, serve as a nidus for stone formation, and occa-sionally fall off and result in substantial morbidity [3].There is also the element of cost: while reusable clip ap-pliers are available, by far the majority of clips are appliedwith fairly expensive disposable devices. And there is theadded cost of lost efﬁciency caused by yet another instru-ment change. Thus, one might propose that a more perfectcholecystectomy would be where the assistant retracts andexposes the gallbladder and the surgeon inserts twoinstruments, a grasper in one hand and an (relativelyinexpensive) energy source in the other; dissects, divides,and resects the gallbladder without an instrument change;and then at the end withdraws the gallbladder and theinstruments, leaving behind a dry and secure ﬁeld with noforeign bodies.Obviously, the most critical issue at hand is the securityof the duct closure. In the mid-1990s, when new laparo-scopic energy sources (ultrasonic and bipolar) were beingrapidly adopted and widely deployed, a seminal report byMathews et al. [4] reported high leak rates for both ultra-sonic and bipolar devices in an animal model. This prettymuch erased interest in using these devices for a ‘‘cliplesscholecystectomy’’ until recently, when a large number ofreports of clinical and experimental cystic duct sealinghave been reported. Unlike the earlier report, the majorityof recent studies, including that by Kavlakoglu et al. [2],indicate that it is indeed possible to safely use bipolar orultrasonic energy to seal the duct/artery [5–9]. The reasonfor this change in recommendation from the Matthewset al. article is not totally clear; perhaps the pig is a poormodel or maybe the technology has improved over the lastdecade.It is important that the energy source be usable for therest of the gallbladder dissection because there is littleadvantage in simply replacing an expensive clip applier