الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Cholecystectomy for gall stones 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 gall stones disease. 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. 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. 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 the scalpel or shears. The basic mechanism of coagulating blood vessels by high energy ultrasound is similar to that of diathermy and laser. Vessels are sealed by pressure and coaptation with denaturated protein coagulum. As the thermal energy generated by this system remains under 80 ºC, necrosis and charring are minimal. Summary & Conclusion 99 Harmonic scalpel can be effectively used for dissection of calot’s triangle, sealing of cystic duct if less than 6 mm and artery, and removal of the gall bladder from the 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. 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 harmonic scalpel in laparoscopic cholecystectomy has been for division of the cystic artery and liver bed dissection. So total harmonic scalpel dissection in the performance of 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 more traditional electrocautry. In addition ,the elimination of inadvertent, sometimes unrecognized, electrical arcing injuries with their potentially hazardous sequlae 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. This study has shown that laparoscopic cholecystectomy using the harmonic scalpel provide shorter operative duration, less incidence of gall bladder perforation, less postoperative pain, less biliary leak, it proved the efficacy of the harmonic scalpel in dissection of gall bladder from the liver bed and sealing of cystic duct if the duct less than 6 mm and artery, in patients with acute calcular cholecystitis and also the harmonic scalpel Summary & Conclusion 100 provides complete hemobiliary stasis and a safe alternative to the standard clipping of cystic duct and artery for 6 cirrhotic patients in our study. The disadvantages of harmonic scalpel in laparoscopic cholecystectomy is that it is used only for ducts less than 6 mm, it takes more time to coagulate and cut the tissue and it is very costly. To conclude: The harmonic scalpel can be used safely for sealing of cystic artery and cystic duct less than 6 mm in diameter in laparoscopic cholecystectomy without risk of major injuries or leak, if the diameter more than 6 mm clips technique should be used. It is better than electrocautry in terms of not just a faster and safer surgery, but also a surgery with less intraoperative blood loss, less postoperative drainage, with decreased associated morbidity and pain but it is very costly.