Is Monopolar Electrocautery Safe and Effective for Control of the Cystic Artery During Laparoscopic Cholecystectomy?

Introduction

Laparoscopic cholecystectomy is one of the most common surgical procedures. Classically, the cystic artery is controlled during the procedure using simple metal clips. Recently, ultrasonic devices have been used successfully to achieve closure and division of the cystic duct and artery,^1–3 but their cost remains a concern. Although many feel that electrocautery is an unsafe method of controlling the cystic artery because of concerns over both adequacy of hemostasis and collateral tissue damage, we noted an increasing trend among surgeons to use monopolar electrocautery for control of the cystic artery during laparoscopic cholecystectomy. Here we report our experience with the use of monopolar electrocautery to control the cystic artery during laparoscopic cholecystectomy.

Subjects and Methods

This study was conducted in the Department of Surgery of Alexandria Main University Hospital (Alexandria, Egypt) during the period from January through July 2010. The study was approved by the Ethics Committee of the Faculty of Medicine of the University of Alexandria. An informed consent was obtained from all patients included in the study. All patients with symptomatic gallstone disease scheduled for laparoscopic cholecystectomy were eligible for the study. No intraoperative cholangiograms were performed. Patients presenting with abnormal serum bilirubin, alkaline phosphatase, and gamma-glutamyltransferase levels and/or abnormal ultrasonographic findings (e.g., dilated biliary tree) underwent a preoperative endoscopic retrograde cholangiopancreatography for diagnosis and treatment. The following preoperative data were collected: age, sex, and associated co-morbidities. Each surgeon participating in the present study had performed at least 200 successful laparoscopic cholecystectomies.

Operative procedures were performed with the patient under general anesthesia and placed in the standard supine, crucifix, reverse Trendelenburg position with the right shoulder up. A uniform technique of the laparoscopic cholecystectomy was applied, including the use of four trocar ports. Dissection of the gallbladder was initiated at the triangle of Calot with the identification and skeletonization of both the cystic duct and artery. No structure was divided before demonstrating the space between the gallbladder and the liver clear of any structure other than the cystic artery (critical view of safety). Closure of the cystic artery was achieved by either applying simple titanium clips or using monopolar electrocautery, whereas the division was achieved by scissors in the first case and cautery in the second. When cautery was used to control the artery, this was done very close to the gallbladder wall, using short bursts with the power level set at 4–5. The choice of the method of control of the cystic artery was left to the discretion of the operating surgeon. The cystic duct was then closed by applying simple titanium clips and divided by scissors. Mobilization of the gallbladder from the liver bed started posteriorly at the triangle of Calot and proceeded anteriorly using the electrosurgical hook or spatula. Finally, the gallbladder was subsequently removed through the subxiphoid port. A subhepatic tube drain, inserted through the most lateral port, was not routinely used but was whenever it was seen as needed by the surgeon.

The surgeon was asked to complete a separate sheet immediately after surgery commenting on details of the cystic artery control. The details included number, site, size, method of control of the cystic artery, and position of its division relative to the cystic lymph node. The operative time, intraoperative difficulties, and postoperative complications were also recorded.

Patients were discharged on the morning of postoperative Day 1 after the removal of the drain (when used). At the end of the first postoperative week, patients were seen in the outpatient clinic and underwent a clinical examination. This was repeated after 3 months. At the end of the sixth postoperative month, clinical examination and abdominal ultrasonography were done. In addition, blood was sampled for bilirubin, aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase levels.

Data were prospectively collected. All data analyses were performed with Statistical Package for the Social Sciences version 15 software (SPSS, Inc., Chicago, IL). Student's t test was used for continuous variables. The chi-squared and Fisher's exact tests were used for categorical variables. All P values were two sided. A value of P≤.05 was considered statistically significant.

Results

The present study included 158 patients with symptomatic gallstone disease. There were 130 females (82.3%) and 28 males (17.7%). Their ages ranged from 17 to 64 years, with a mean of 41.5±11.4 years. Twenty-one patients (13.3%) were operated on for acute cholecystitis. Cholecystectomy was completed laproscopically in all patients. During surgery, the cystic artery was identified in 147 patients (93%). Two arteries were controlled in 25 patients (15.8%) and one artery in 122 patients (77.2%), while the artery was not identified in 11 patients (7%). Excluding the patients with unidentified cystic artery, the details of control of the cystic artery in 147 patients are shown in Table 1. The cystic artery was located inside Calot's triangle in 142 patients and outside it in 5 patients. When two arteries were controlled, only data of the larger one were included. The artery was graded as small in 43 patients (29%), medium in 72 patients (49%), and large in 32 patients (22%). The artery was controlled using monopolar electrocautery in 114 patients (77.5%) and by metal clips in 33 patients (22.5%). There was a statistically significant relation between the size of artery and the method of its control: the smaller the artery, the more frequently the cautery was used. The cystic artery was controlled lateral to the cystic lymph node in 100 patients (68%) and medial to it in 26 patients (18%), while the relation was not identified in 21 patients (14%). Although the electrocautery control was more frequently lateral to the lymph node compared with clipping (70.2% versus 60.4%, respectively), there was no statistically significant association between the method of control and its site in relation to the lymph node. Similarly, no association was found between the method of control and the number of vessels controlled or the use of a drain. The mean operative time for laparoscopic cholecystectomy was 49.4±21.1 minutes (range, 19–150 minutes). There was no statistically significant difference related to the method of control of the cystic artery.

There was no statistically significant relation between the age, sex, or associated co-morbidities and the method of control of the cystic artery in the present study (Table 2).

There was neither operative nor postoperative bleeding. Similarly, no bile duct injuries were encountered in the present study.

Discussion

Currently, laparoscopic cholecystectomy is widely accepted as the gold standard in the treatment of cholelithiasis.^4,5 This technique was initially associated with a significant increase in morbidity and, in particular, in iatrogenic biliary injury and arterial hemorrhage,^6–8 perhaps because of a lack of knowledge of the laparoscopic anatomy of the gallbladder pedicle.

Anatomic variations in and around Calot's triangle are frequent (biliary tree, cystic artery). ⁹ Among the variations in the biliary tree are cystic artery variations, based on its origin, position, and number; these variations are quite common, being found in 25%–50% of cases.^10–12 Therefore, accurate identification of the anatomy of the cystic artery is important. In the present study, the cystic artery was identified in 147 patients (93%). In 11 patients, the artery was not identified during the course of surgery. The lack of artery identification may be explained by a small artery that was cut, being unrecognized, by electrocautry during dissection of Calot's triangle. Another possibility is an unrecognized variant of the cystic artery. For example, a cystic artery running along the cystic duct could have been clipped and divided together with the duct. Suzuki et al. ¹³ reported a single cystic artery running posterior or anterior to the cystic duct in 0.8% and 0.4% of their cases, respectively. A cystic artery originating from the bed is another variant reported by Ding et al. ¹⁴ in 2.5% of laparoscopic cholecystectomy cases and may not be observed until bleeding is caused by dissection of the gallbladder. The 11 patients with unidentified cystic artery were excluded from our data analysis. The artery was identified inside Calot's triangle in 96.6% of patients. A cystic artery passing through the hepatobiliary triangle, crossing the biliary ducts from the ventral or dorsal side, found within the two peritoneal folds, and on laparoscopic visualization found within the hepatobiliary triangle is the most common pattern of the cystic artery approaching the gallbladder and is found in 80%–96% of cases.^10–17 A single artery was identified in 122 patients, while in 25 patients, two arteries had to be controlled. This could be either a double cystic artery or the usual anterior and posterior branches of the cystic artery controlled separately. The origin of the artery was not clear in our study. The cystic artery usually gives off a superficial or anterior branch and a deep or posterior branch. This branching usually takes place near the gallbladder. One may have to separately control the two branches when the dissection is very close to the gallbladder. When the two branches, anterior and posterior, of the cystic artery are separated at their origin, Michels ¹⁸ called them double cystic arteries. A double artery is found in 11%–25% of patients operated on.^{12–14,17,19}

Control of the cystic artery is an important step to avoid complications during laparoscopic cholecystectomy. Classically, the artery is controlled by metal clips. Recently, the Harmonic^® scalpel (Ethicon Endosurgery) has been used safely to control the cystic duct and artery.^1–3 Harmonic technology is, however, considered expensive and not used widely during laparoscopic cholecystectomy. Although the safety of using electrocautery alone to divide the cystic artery has been questioned for fear that it may not be adequate to seal the artery or may cause collateral tissue injury, this has not been our experience. We used monopolar electrocautery safely and efficiently to control the cystic artery in 77.5% of our patients. There were neither operative nor postoperative bleeding complications and no bile duct injury as well. We believe good visualization of the cystic artery and careful use of cautery are essential to achieve these results. Misuse of cautery in dissecting Calot's triangle has been recognized as a possible cause of serious bile duct injury. ⁷ Injury due to electrocautery can be avoided by taking simple precautions like avoiding diathermy near the metal clips on the cystic duct and staying close to the gallbladder wall during dissection and control of the cystic artery, preferably lateral to the cystic lymph node. It is pertinent that always short bursts of a minimal amount of energy required to secure homeostasis should be applied. ⁷ Ponsky and Rothenberg ²⁰ found electrocautery safe and effective in the division of the mesoappendix during laparoscopic appendectomy in children. This is, to our knowledge, the first report on the use of electrocautery to control the cystic artery during laparoscopic cholecystectomy. The size of the artery was the only factor identified in this study to affect the decision to choose between cautery and clipping for its control. However, electrocautery was used safely and efficiently to control small and medium as well as the large cystic arteries. When the artery was graded as large (≥3 mm), electrocautery was used to control it in 15 out of 32 laparoscopic cholecystectomies.

In conclusion, electrocautery is safe and effective for control of the cystic artery during laparoscopic cholecystectomy. Neither bleeding nor bile duct injury was encountered throughout the study period. Cautery should be applied very close to the gallbladder, preferably lateral to the cystic lymph node. A future randomized study is needed to confirm the findings of the present study.