Clipless Laparoscopic Cholecystectomy with Knot Pusher: Experience from More Than 500 Cases

Phichai Phongmanjit

doi:10.64387/tjs.2025.271871

Authors

Phichai Phongmanjit Department of Surgery, School of Medicine, Mae Fah Luang University

DOI:

https://doi.org/10.64387/tjs.2025.271871

Keywords:

Laparoscopic cholecystectomy, Extracorporeal knotting, Sliding knot, Knot pusher

Abstract

Objective: This study aims to demonstrate that laparoscopic cholecystectomy utilizing the extracorporeal sliding knot technique with a knot pusher can achieve satisfactory outcomes, such as no dislodgement of the tied cystic duct and minimal complications. The technique was efficient, secure, and cost-effective, with no instances of accidental knot failure observed, and requiring only a single nylon suture for knot tying.

Materials and Methods: A retrospective study was conducted on the elective symptomatic gallstone disease treatment outcomes via LC utilizing the extracorporeal sliding knot technique with a knot pusher. The diagnosis was confirmed in all cases using ultrasound, and no instances of acute cholecystitis were included in this study. This study was carried out at the General Surgery Department of Chiangrai Prachanukroh Hospital between September 2008 and August 2019.

Results: The results of this study indicated favorable outcomes for LC performed using this method. A total of 512 patients were included, comprising 94 males and 418 females. The mean age of the participants was 49.1 years, with an age range of 21 to 91 years. The average duration of surgery was 35 minutes, ranging from 16 to 72 minutes. Blood loss during surgery averaged 15 ml, ranging from 2 to 120 ml. The average hospital stay was 2.5 days, ranging from 1 to 5 days. No serious complications related to cystic duct ligation were observed using the extracorporeal sliding knot technique. The average time required to tie all knots in each case was 4 minutes, ranging from 2 to 7 minutes.

Conclusion: Laparoscopic cholecystectomy using the extracorporeal sliding knot technique with a knot pusher enhances cystic duct closure efficiency by simplifying surgery, lowering complications, and reducing costs. It ensures secure closure, is easy to learn, and adds minimal time to the procedure compared to clipping, making it an effective alternative technique.

References

Keus F, Broeders IA, van Laarhoven CJ. Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis. Best Pract Res Clin Gastroenterol. 2006;20(6):1031-51. doi: 10.1016/j.bpg.2006.05.008.

Mufti TS, Ahmad S, Naveed D, et al. Laparoscopic cholecystectomy: an early experience at Ayub Teaching Hospital Abbottabad. J Ayub Med Coll Abbottabad. 2007;19(4):42-4.

Kapoor T, Wrenn SM, Callas PW, et al. Cost analysis and supply utilization of laparoscopic cholecystectomy. Minim Invasive Surg. 2018;2018:7838103. doi: 10.1155/2018/7838103.

Kane RL, Lurie N, Borbas C, et al. The outcomes of elective laparoscopic and open cholecystectomies. J Am Coll Surg. 1995;180(2):136-45.

Soper NJ, Stockmann PT, Dunnegan DL, et al. Laparoscopic cholecystectomy. The new 'gold standard'? Arch Surg. 1992;127(8):917-21; discussion 921-3. doi: 10.1001/archsurg.1992.01420080051008.

Massoumi H, Kiyici N, Hertan H. Bile leak after laparoscopic cholecystectomy. J Clin Gastroenterol. 2007;41(3):301-5. doi: 10.1097/MCG.0b013e31802c29f2.

Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180(1):101-25.

Seenu V, Shridhar D, Bal C, et al. Laparoscopic cholecystectomy: cystic duct occlusion with titanium clips or ligature? A prospective randomized study. Trop Gastroenterol. 2004;25(4):180-3.

Suo G, Xu A. Clipless minilaparoscopic cholecystectomy: a study of 1,096 cases. J Laparoendosc Adv Surg Tech A. 2013;23(10):849-54. doi: 10.1089/lap.2012.0561.

Golash V. An experience with 1000 consecutive cystic duct ligation in laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2008;18(2):155-6. doi: 10.1097/SLE.0b013e3181685834.

Shah JN, Maharjan SB. Clipless laparoscopic cholecystectomy--a prospective observational study. Nepal Med Coll J. 2010;12(2):69-71.

Carvalho GL, Silva FW, Silva JS, et al. Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: the first 1000 cases. Surg Laparosc Endosc Percutan Tech. 2009;19(5):368-72. doi: 10.1097/SLE.0b013e3181b7d3c7.

Nowzaradan Y, Meador J, Westmoreland J. Laparoscopic management of enlarged cystic duct. Surg Laparosc Endosc. 1992;2(4):323-6.

Akoh JA, Watson WA, Bourne TP. Day case laparoscopic cholecystectomy: reducing the admission rate. Int J Surg. 2011;9(1):63-7. doi: 10.1016/j.ijsu.2010.09.002.

Victorzon M, Tolonen P, Vuorialho T. Day-case laparoscopic cholecystectomy: treatment of choice for selected patients? Surg Endosc. 2007;21(1):70-3. doi: 10.1007/s00464-005-0787-0.

Ji W, Ding K, Li LT, et al. Outpatient versus inpatient laparoscopic cholecystectomy: a single center clinical analysis. Hepatobiliary Pancreat Dis Int. 2010;9(1):60-4.

Berrevoet E, Biglari M, Sinove Y, et al. Outpatient laparoscopic cholecystectomy in Belgium: what are we waiting for? Acta Chir Belg. 2006;106(5):537-40. doi: 10.1080/00015458.2006.11679947.

Kasem A, Paix A, Grandy-Smith S, et al. Is laparoscopic cholecystectomy safe and acceptable as a day case procedure? J Laparoendosc Adv Surg Tech A. 2006;16(4):365-8. doi: 10.1089/lap.2006.16.365.

Teja HV, Chavan DR, Kullolli G. A Comparative Study of Extracorporeal Knotting vs Clips for Ligating Cystic Duct in Laparoscopic Cholecystectomy. World J Lap Surg 2022;15(1):14–17. doi: 10.5005/jp-journals-10033-1494.

Madany MEM, Kabbash MM, Mostafa HA, et al. Safety and feasibility of cystic duct control with suture ligation during laparoscopic cholecystectomy. Egypt J Surg. 2024;43(2):579-87. doi: 10.4103/ejs.ejs_2_24.

van Dijk AH, van Roessel S, de Reuver PR, et al. Systematic review of cystic duct closure techniques in relation to prevention of bile duct leakage after laparoscopic cholecystectomy. World J Gastrointest Surg. 2018;10(6):57-69. doi: 10.4240/wjgs.v10.i6.57.

Singal R, Sharma A, Zaman M. The safety and efficacy of clipless versus conventional laparoscopic cholecystectomy - our experience in an Indian rural center. Maedica (Bucur). 2018;13(1):44-50. doi: 10.26574/maedica.2018.13.1.44.

Hage JJ. On the origin and evolution of the Roeder knot and loop--a geometrical review. Surg Laparosc Endosc Percutan Tech. 2008;18(1):1-7. doi: 10.1097/SLE.0b013e3181572b00.

Ishii Y, Tahara S, Oyama K, et al. Easy slip-knot: a new simple tying technique for deep sutures. Acta Neurochir (Wien). 2011;153(7):1543-5. doi: 10.1007/s00701-011-0988-3.