الفهرس 
Anatomy of The Gall bladder and Biliary SystemOnly 14 pages are availabe for public view
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Abstract
Cholecystectomy for gallstone disease presently accounts for a large share of laparoscopic procedures being done worldwide. Laparoscopic technique for performing cholecystectomy is now the gold standard treatment for gallstone disease. Being a commonly performed surgery, laparoscopic cholecystectomy is undergoing a thorough makeover with the incorporation of newer technologies (Minutolo et al., 2008).
But, still the problem of cystic duct leak leading to biloma, an infrequent but one of the most dreaded complications mandates the need to review the efficacy of the use of Clips comparing with the Harmonic Scalpel in sealing of Cystic Duct and artery (Rohatgi and Widdison, 2006).
The risk of slippage is high if the clip is selected too small for the vessel, does not project beyond the whole width of the vessel, is not applied at right angles to the vessel, is subjected to traction and includes fat or adventitial tissue around the vessel. The correctly applied clips generally offer a pressure between 450 and 700 mbar. Clips with pressure less than 100 mbar are never tight and inadvertently fall off. Most of the surgeons have been using simple clips to close the cystic duct since Professor Muhe reported the first successful laparoscopic cholecystectomy in 1985 (Miroshnik et al., 2002).
The Harmonic Scalpel is a new ultrasonic coagulating and cutting system has been developed for use in laparoscopic surgery. It consists of a generator and a hand piece which houses the ultrasonic transducer. Its ultrasonic energy is delivered as 55,000 Hz vibrations with a maximum longitudinal displacement of 80 um by either a hook-blade (scalpel) or a shears (grasper). The basic mechanism for coagulating blood vessels by high energy ultrasound is similar to that of diathermy and laser. Vessels are sealed by pressure and coaption with a denatured protein coagulum. As the thermal energy generated by this system remains under 80C, necrosis and charring are minimal (Najmaldin and Guillou, 2007).
Harmonic Scalpel can be effectively used for dissection of Calot’s triangle, ligation of cystic duct and artery, and removal of the gallbladder from liver bed, making it an all in one tool for the procedure. This minimizes not only the operating time but also inadvertent injury to the viscera occurring during instrument change (Bessa et al., 2008).
The ultrasonically activated (Harmonic) scalpel has proven to be an effective, efficient, and safe instrument for dissection and hemostasis. It works on the tissue’s cutting and coagulating very effectively with the replacement of high frequency current, which can be connected with diverse complications. The primary use of the Harmonic scalpel in laparoscopic cholecystectomy has been for the division and sealing of the cystic duct during successful clipless cholecystectomy. So total Harmonic scalpel dissection in the performance of a laparoscopic cholecystectomy was described. The resulting decrease in temperature, smoke, and lateral tissue damage placed the Harmonic scalpel in contrast to the effects seen with the more traditional electrocautery. In addition, the elimination of inadvertent, sometimes unrecognized, electrical arcing injuries with their potentially hazardous sequelae supported the role of the Harmonic scalpel as a potentially safer instrument for tissue dissection. It tackles the concerns regarding smoke production, and inadvertent injuries to the abdominal organs and structures. Moreover, it shortens the operative time and decreases the rate of accidental bile spillage (Foschi et al., 2009).
The disadvantages of Harmonic Scalpel in laparoscopic cholecystectomy is that it is used only for ducts less than 6mm, it takes more time to coagulate and cut tissue, division of the cystic duct by the Harmonic Scalpel required approximately 2 to 3 minutes depending on the ductal thickness and associated inflammation and it is very costly (Bessa et al., 2008).
It is concluded that the Harmonic Scalpel can be used safely in laparoscopic cholecystectomy without risk of major injuries or leaks. It is better than electrocautery in terms of not just a faster and safer surgery but also a surgery with decreased associated morbidity and pain and early return back home.