Ligation of the structures of the cystic pedicle during laparoscopic cholecystectomy

Advances in optics, endotelevision monitoring, and instrumentation have led to the development of laparoscopic cholecystectomy. As in the open, standard operation, the crucial step is the dissection of the cystic pedicle containing the respective duct, artery, and lymph node. All the groups involved in laparoscopic cholecystectomy have to date opted for the use of applicators to clip the cystic duct and artery. As there are intrinsic disadvantages to the use of clips, we report an alternative method which involves ligation of these structures using the Roeder slip knot with dry chromic catgut. The safety margin of this knot was initially tested in vitro using a Instrom tensiometer. Under these experimental conditions, the Roeder slip knot tied with #0 dry chromic catgut ligature started to yield at 225 g. As the estimated tension on the cystic duct (1.1 g) and a 4-mm artery (6.0 g) in vivo is well below this figure, the safety of this knot with dry catgut in clinical practice is beyond question. The technique of Roeder slip-loop knotting was used to ligate the cystic artery and duct in a consecutive series of 80 patients undergoing laparoscopic cholecystectomy. This clinical experience has confirmed its safety and ease of execution. The particular advantages of Roeder loop ligation include execution through a 5.5-mm cannula and accurate placement of the knot. In addition, the technique requires less length of mobilized duct and artery, which is an important practical consideration in patients with a fibrosed gallbladder and shortened cystic pedicle.