Total Intracorporeal Ligation of the Cystic Duct and Artery in Laparoscopic Cholecystectomy

Vishwanath Golash and Shakilur Rahman

Clips are known to slip, dislodge, ulcerate, migrate, internalise and give rise to necrosis of the cystic duct with the risk of bile leakage and other complications. Ligation of the cystic duct has been practised since 1991 and several modifications of both intracorporeal and extracorporeal techniques have been described. The C technique has an advantage in assessing tension on the suture without minimising the risk of cutting through the tissue. The technique below has been used in 120 cases. Standard ports are placed in the epigastrium, mid clavicular line and anterior axillary line below the costal margin. A 75 cm length of 3/0 Vicryl is cut into 4 equal portions.

	The suture is fed through the mid clavicular port on a needle holder and retrieved by a dissector through the epigastric port under the cystic duct as shown. The C loop is created.
	The needle holder is placed over the loop from the left. The dissector in the right hand is used to create two "overwrap" loops on the needle holder using the "two-hand technique". Grasp the "short free suture" end with the needle holder and pull the instruments in opposite directions.
	Re-position the instruments bringing them closer to the knot whilst pulling in opposite directions with equal force. This results in a flat surgical knot. Tighten it near the junction of the cystic duct with Hartmann's pouch.
	A reversed C loop is now created and the right instrument is placed on this loop. The the left instrument is used to overwrap the suture.
	The short end is grasped by the right hand. The position of the graspers is again placed closer to the knot and they are pulled apart with equal strength to tie the flat surgical knot. In our experience two knots only are required.

In 120 cases there has been no bile leak. We are confident that we would be able to do this ligation using 2-3 mm ports in the majority of our patients using only one 10 mm port at the umbilicus for the laparoscope and gall bladder extraction.

In 140 previous cases where clips were used, we had two bile leaks. In one case laparotomy revealed 2500 mls of free bile in the peritoneal cavity and slipped clips from the cystic duct. The patient made an uneventful recovery. The second case presented with bile leakage through a drain on the second post-operative day. MRCP revealed leakage from the cystic duct stump and this was managed by CT guided drainage ERCP and stenting.

Intracorporeal tying is cost effective, particularly when compared with disposable clip devices. Once learned, the time taken for ligation is only a few minutes more than clipping.