Clipless laparoscopic cholecystectomy is a better technique in reducing intraoperative bleeding

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients undergoing cholecystectomy is the clipless laparoscopic cholecystectomy associated with lower rates of intraoperative bleeding compared to conventional cholecystectomy? The search has been devised and 5 studies were deemed to be suitable to answer the question. The outcome assessed was the rate intraoperative blood loss in clipless cholecystectomy compared to conventional laparoscopic cholecystectomy. Authors recommend adopting clipless laparoscopic cholecystectomy especially in patients with high risk of intraoperative bleeding.


Introduction
This BET was constructed using a framework outlined by the International Journal of Surgery [1]. A BET provides evidence-based answers to common clinical questions, using a systematic approach of reviewing the literature.

Clinical scenario
You are going to perform a laparoscopic cholecystectomy in a patient with anticipated high tendency of intraoperative bleeding especially during the dissection of the gallbladder liver bed. You are thinking about the best technique to decrease this risk. Therefore, you decide to conduct a systematic review to look for a based evidence answer to this question.  (please refer to the table) Table 1 7

. Discussion
In 2009, Kandil et al. [2] devised a randomized controlled trial. The study included 140 patients who were randomized into two groups. Group A included 70 patients in whom laparoscopic cholecystectomy was conducted using the traditional method by clipping both cystic duct and artery and dissection of gallbladder from liver bed by diathermy. Group B included 70 patients where laparoscopic cholecystectomy was conducted using harmonic scalpel. Closure and division of both cystic duct and artery and dissection of gallbladder from liver bed by harmonic scalpel. They have found that Intraoperative blood loss was significantly more in the traditional group than in the Harmonic scalpel group (83.31 + 46.23 vs. 43.28 + 31.27; p = 0.0001). The authors concluded that Harmonic scalpel provides a complete haemostasis and is a safe alternative to stander clip of cystic duct and artery.
In 2010, Nakeeb et al. [3] conducted a similar study which included 120 cirrhotic patients where the risk of bleeding is higher than fit and well patients. They found that intraoperative blood loss was significantly greater in the traditional group than in the HS group (133 ± 131.13 vs. 70.13 ± 80.79 ml; p = 0.002). The authors concluded that the Harmonic scalpel provides complete haemostasis and is a safe alternative to the standard cholecystectomy.
Jain et al. [4] in 2011 conducted another randomized controlled trial which included 200 patients and there was a greater fall in haemoglobin (0.53 versus 1.33 g%; P value of 0.001) and haematocrit (1.59 versus 2.60; P value of 0.001) when electrocautery was used compared to Harmonic scalpel.
In 2017, Sanawan et al. [5] conducted a randomized controlled trial which included 150 patients who were randomized into two groups. Half of them underwent clipless cholecystectomy and the other half underwent conventional cholecystectomy. The authors found that Intraoperative blood loss in clipless laparoscopic cholecystectomy was significantly lower than in conventional cholecystectomy group (p = 0.001).
In a recent randomized controlled trial, which was conducted by Awale et al. [6] in 2019. The study included 112 patients who were randomized into two groups comparing clipless laparoscopic cholecystectomy and conventional cholecystectomy. They found that the amount of blood loss as demonstrated by the median fall in haemoglobin level was significantly (p 0.001) less in the clipless laparoscopic cholecystectomy group.
The observed limitation to the studies: 1 Risk of bias.
2 Most of the studies excluded particular groups of patients (e.g., >70year-old and pregnant patients) which might decrease its external validity.

Clinical bottom line
Five randomized controlled trials proved that intraoperative blood loss is significantly reduced using clipless laparoscopic cholecystectomy. Authors recommend adopting clipless laparoscopic cholecystectomy especially in patients with high risk of intraoperative bleeding.

Ethical approval
Not Applicable.

Sources of funding
None.

Author contribution
SA: devised the idea of the study, conducted literature search and wrote the paper. TA: assisted in literature search and collecting the data. SAA: assisted in literature search and writing the paper. RI: assisted in literature search editing and writing the paper.