Clipless Versus Clip-Based Cystic Duct Closure in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis

Secure control of the cystic duct and artery is a critical step in laparoscopic cholecystectomy. Although metallic clips remain the standard method, concerns regarding clip migration, bile leak, and long-term safety have led to the use of alternative techniques such as polymer locking clips, endoloops, absorbable clips, sutures, and energy-based devices, including the ultrasonic scalpel and advanced bipolar energy devices. This systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A comprehensive search of PubMed, Embase, Scopus, Web of Science, and the Cochrane Library was performed, with the final search completed in May 2024. Studies comparing at least two cystic duct closure methods and reporting outcomes such as bile leak, bleeding, operative duration, conversion to open surgery, hospital stay, or device-related complications were included. Risk of bias was evaluated using AMSTAR (A Measurement Tool to Assess systematic Reviews) for randomized trials and ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) for observational studies. Random-effects models were used to pool relative risks (RRs) and mean differences (MDs). A total of 14 comparative studies (with supportive case reports) met the inclusion criteria. Polymer locking clips demonstrated 0% bile leak and provided secure closure even in wide cystic ducts. Ultrasonic scalpel and advanced bipolar energy devices were associated with significantly shorter operative times compared with metallic clips. Conversion rates remained low across all techniques, with a nonsignificant trend favoring energy-based devices. Device-specific complications included metallic clip migration and occasional knot loosening with suture ligation. Overall, polymer clips and energy-based devices appear to be safe and effective alternatives to metallic clips, offering comparable safety profiles, reduced operative time, and avoidance of long-term clip-related complications. Larger multicenter randomized controlled trials are needed to validate long-term outcomes and cost-effectiveness.