Ultrasonic Sealing Versus Titanium Clip Ligation of the Cystic Duct and Cystic Artery Measuring Less Than 5 mm in Laparoscopic Cholecystectomy: A Prospective Randomized Comparative Study

Background: Titanium clips are the standard method for securing the cystic duct and artery in laparoscopic cholecystectomy (LC). The harmonic scalpel can seal and divide them without clips. We compared the two for structures under 5 mm. Material and Methods: In this prospective randomized study at a tertiary hospital in Chandigarh, India, 58 adults with symptomatic cholelithiasis were allocated to titanium clips (n = 29) or harmonic scalpel closure (n = 29). The primary outcome was operative time. Secondary outcomes were conversion, complications, day-1 pain, liver function tests and hospital stay. Results: Groups were similar at baseline. Mean operative time was 52.1 ± 15.0 min with clips and 57.4 ± 12.6 min with the harmonic scalpel, a difference of 5.3 min (95% CI −2.0 to 12.6; p = 0.150). Conversion to open surgery occurred in 3/29 (10.3%) and 2/29 (6.9%) patients (p = 1.000), all for a frozen Calot's triangle. There was no bile leak, duct injury or haemorrhage. Wound infection (6.9% vs 13.8%; p = 0.670), pain (p = 0.366) and hospital stay (3.4 ± 0.7 vs 3.5 ± 0.7 days; p = 0.487) did not differ. The postoperative rise in AST was smaller after harmonic closure (+2.4 vs +7.5 IU/L; p < 0.001). Conclusion: For a cystic duct and artery under 5 mm, harmonic scalpel closure was as safe as clip ligation in the early postoperative period. It did not shorten the operation during the unit's early experience with the device. Larger multicentre trials with longer follow-up are needed.

Keywords: Ultrasonic sealing, Titanium clips, Cystic duct, Cystic artery, Laparoscopic cholecystectomy, Biliary complications, Surgical outcomes, Randomized comparative study.