| Abstract|| |
Background: Financial constraints and pressing priorities are major problems that delay implementation of laparoscopic cholecystectomy (LC) in some countries. This raised the need for improvisation and innovation , . Endoclips are not available in some local markets. They cost $50 for a single set of six clips to import, in contrast to 2/0 polyglacin (Vicryl-Ethicon), which is available at a rate of $1.5 for one thread. Objective of the study: To compare the safety and cost between vicryl ligature and endoclips. Patients and Method: To secure the cystic duct, intracorporeal vicryl ligature (IVL) was applied in 64 LCs. These were divided into 32 patients presented with cystic duct, which was too wide to controlled with endoclips (group A) and 32 patients with normal diameter of cystic duct as controls (group B). Also we describe the test we used to prove the safety of IVL in the two groups. This ligature was tested with high pressure introduced and measured into the gallbladder by sphygmomanometer. Results: The gallbladder can withstand a mean (+ SD) pressure of 197 (+20.94)mmHg and 191.67 (+10.2) in group A and B respectively without statistically significant difference (P 0.1305). Total cost of vicryl was $128 compared to $3200 if endoclips were used. No complication was noted related to these ligatures in a period of two year-follow up. Conclusion: This method is easy, cost effective and suitable in some countries.
Keywords: Laparoscopy, laparoscopic suture, intra-corporeal knots, preformed loops
|How to cite this article:|
Ibn Ouf AM, Al Arabi Y. Intracorporeal vicryl ligatures reduces cost in some countries. Saudi J Gastroenterol 2002;8:14-6
| Introduction|| |
Endoclips do not always substitute traditional sutures of ligatures. In laparoscopic cholecystectomy this true, particularly when the cystic duct is too wide to be safely controlled by endoclips. Moreover, preformed endoclips that require knot pusher and linear cutter are of high cost and may not be available in some countries. For these reasons we believe that surgeons involved in laparoscopic surgery should master the technique of intracorporeal ligature and suturing using ordinary threads.
| Patients and Methods|| |
From June 1995 through Nov 2000, we performed 502 laparoscopic cholecystectomies with conversion rate of 4.6%. Of all these patients there were 32 patients who had widely dilated cystic ducts (group A), nine of them had acute cholecysitis and three had type l Mirizzi's syndrome. In these cases the diameter of the cystic duct was too wide to be safely controlled by the metalic endoclips available to us. We use a simple technique of intracorporeal 2/0 polyglactin (vicryl-Ethicon) ligatures to secure the cystic duct. We tested the safety and tightness of these ligatures. We applied the same method in the other 32 patients with normal diameter of cystic duct as controls (group B). Surgical technique: After dissection of cystic duct and cystic artery, a 10cm long piece of vicryl 2/0 was held at the tip of a Maryland dissector. This thread was passed underneath the cystic duct. While the fundus of the gallbladder was pushed upwards, the grasper holding the Hartman's pouch was released to grasp the protruding vicryl thread behind the cystic duct. The thread was then loosely wrapped twice around the tip of the Maryland forceps, which was moved to grasp the other end of the thread in front of the cystic duct and pulled it through. This made a double squared surgical knot around the cystic duct [Figure - 1]. The knot was then adjusted in the proper place and firmly tightened by the same instruments. When the thread was tightened, instruments were kept in the visual field of the laparoscope to avoid visceral damage. A third single squared surgical knot was applied in a similar way on the top of the first knot. The excess thread held by the grasper was then excised and removed. Anther ligature was made in a similar way on the cystic duct near neck of the gallbadder. The cystic duct was transected in between these ligatures. The margin of transection was at least 4mm from the ligature to prevent slipping of the knot. The time of ligation was recorded in each case. Test of Safety: In 24 patients, after removal of the gallbladder, the ligature near its neck was tested in vitro for tightness and safety. A canula was inserted through the fundus and tightly fixed with a seromuscular stitch to prevent any leak. The canula was connected to a sphygmomanometer and pressure was applied till the gallbladder was distended. The maximum pressure the gallbladder withstood was recorded. Quality Control: Video films were produced and the patients were followed for evidence of bile leak, intra-abdominal collection or sepsis based on clinical grounds and/or ultrasound scanning. Statistical analysis: Data were fed in statistical scientific package (SSPS). Wilcoxon Matched Pairs Signed-Ranks test was used for analysis.
| Results|| |
Intracorporeal vicryl ligature was applied in 64 patients. Thirty two patients of them had wide diameter of cystic duct (group A) and the other 32, with normal calibre of cystic duct, as case control (group B). The tested gallbladder in group A and B withstood a mean (+SD) pressure of 197(+10.94)mmHg and 191.67 (+10.2) respectively without evidence of leak at the ligature site. kilcoxon Matched Pairs Signed-Ranks) Z= -1.512 and P 0.1305). The mean (+ SD) time of the ligature in group A and B was 6.9 (+0.93) and 5.39 (+0.72) min respectively. Wilcoxon test Z = 4113 and p 0.0000). None of the patients developed intraperitoneal collection, evidence of intraabdominal sepsis or common bile duct stricture. The follow-up period was two years. The total cost of vicryl used for securing 64 cystic ducts was $128. If endoclips were applied the total cost would have raised to $3200.
| Discussion|| |
Studies of cost effectiveness, utility, and benefit assume an increasing importance as developments impose extra burdens on limited resources  . Although intracorporeal suturing and knot-tying in laparoscopic surgery reproduces the phases of the same technique known to the traditional surgeon, it requires great manual dexterity. The knots performed laparoscopically must be safe, easy, tight and reproducible. Safety of sutures depends also on the type of material of the thread. Therefore, chronic catgut, dacron, polyglactin have been safe while polydiaxanone and polyamide have been less reliable. The ideal length of suture for IVL is 10cm  . The incidence of bile leak from the cystic duct stump was reported to be 0.3-1%  . This is often due to badly fitting clips on a wide cystic duct, particularly in acute cholecystitis  . None of our patients developed this complication. The time taken to apply IVL when the cystic duct is too wide to be safely controlled by the endoclips was more than the time spent when the cystic duct is of normal calibre.
This could be explained by the carefulness to prevent postoperative leak or loosing of the ligatures, particularly in the three patients of type1 Mirizz's syndrome. The time of laparoscopic cholecystectomy varies from patient to another according to the difficulty of the dissection. Only reusable endolip applier was available in our hospital set-up. Reusable endoclip applier takes relatively longer time than the disposable ones to apply the clips. For these reasons, we considered the time consumed during IVL, which was definitely longer than that of endoclips was not of a great significance. This was particularly true when. bad fitting of endoclips was anticipated and linear cutter was not available. Vicryl being an absorbable suture leaves no radio-opaque shadow to be seen if ultrasonic scan, CT scan or other radiological studies are taken for any reason in the future.
| Conclusion|| |
Intracorporeal vicryl ligaure is feasible, safe and cost effective. It is very useful when the diameter of the cystic duct is more than what can be secured by the endoclips. It is of particular value in some countries, where the meagre resources and pressing priorities reduce the chances of importing endoclips and other sophisticated materials.
| References|| |
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|3.||Croce E, Olmi S. Intracorporeal Knot-tying and Suturing Techniques in Laparoscopic Surgery: Technical Details. JSLS 2000; 4:17-22 [PUBMED] [FULLTEXT]|
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Ahmed Mohammed Ibn Ouf
Consultant Gastrointestinal Surgeon, P. O. Box 15126, Code 12217, Ibn Sina Hospital, Khartoum
Source of Support: None, Conflict of Interest: None
[Figure - 1]