A prospective, randomized study of comparison of clipless cholecystectomy with conventional laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy has become a gold standard in the treatment of symptomatic gallstone disease. Amalgamation with upcoming technology makes the present-day procedure faster and safer. Ultrasonic shears, which perform dissection and ligation by cavitation and coaptation of vessels, are the latest addition to the armamentarium of laparoscopic surgeons. Acceptance of its safety and efficacy awaits its use as the sole instrument in the widely accepted procedure. METHODS: A prospective, randomized control trial was conducted in 200 patients with symptomatic gallstone disease, who were randomly divided into two comparable groups, one undergoing cholecystectomy using ultrasonically activated shears and the other using conventional clip and electrocautery. Various parameters such as duration of surgery, removal of gallbladder, blood loss, postoperative pain scores, analgesic requirement, duration of stay, and complications were compared between the two groups. RESULTS: Patients who underwent laparoscopic cholecystectomy using ultrasonic shears had a faster surgery (64.7 versus 50 minutes; P < .002) and removal of gallbladder from gallbladder bed (3.94 versus 7.46 minutes; P < .001) with less blood loss and pain scores (1.86 versus 3.01; P < .002). They had a shorter duration of hospital stay (1.89 versus 2.52 days; P < .001) and decreased risk of gallbladder perforation (9 versus 18; P < .005). The analgesic requirement was also less on the first postoperative day. There was no incidence of any major complication or bile leak during a 6-month follow-up period in either of the groups. CONCLUSION: Ultrasonically activated scalpel can be used safely in laparoscopic cholecystectomy without risk of major injuries or leaks. It fairs better than electrocautery in terms of faster and safer surgery with decreased associated morbidity, less pain, and early return back home.

Pleurobiliary fistula secondary to choledocholithiasis --- a rare entity.

Pleurobiliary fistula secondary to common bile duct obstruction due to stone is a very rare clinical entity. A 55-year-old female patient presented in the emergency department with features of septicaemia with left pleural effusion. Intercostal tube drainage drained 5 L of bile on the first day and around 500-600 mL of bile each day subsequently. Magnetic resonance cholangiopancreaticography showed choledocholithiasis with pleurobiliary fistula. The patient underwent bilioenteric bypass and ligation of the fistulous tract with complete cure.