Harmonic ace

Infraumbilical incision was placed and deepened. A 10-mm camera port was inserted by open technique and pneumoperitoneum was established. Subsequent ports were placed under vision for a standard 'four-port' LC. It included a 10-mm epigastric port, and additional two 5-mm ports were placed in the right midclavicular line and the right anterior axillary line. Adhesiolysis was performed [Figure 1a] when required. Energy devices were used liberally. Calot's triangle was carefully dissected to avoid bleeding [Figure 1b]. This was aided by ultrasonic shears (Harmonic Ace™, Ethicon Endo-Surgery, USA), sealer/divider (LigaSure™, Medtronic, Dublin, Ireland) and a 5-mm bipolar diathermy.
Dominant collateral veins were preferentially divided between two clips or Hem-o-lok (Hem-o-lok clip, Weck Closure Systems, Research Triangle Park, NC) [Figure 1c]. The cystic artery was divided between 5 mm Hem-o-lok clips [Figure 1d]. The cystic duct along with the collaterals was divided between two 5/10 mm Hem-o-lok clips [Figure 1e]. Endostapler was used for wide cystic ducts. The GB is gently retracted to avoid bleeding from the collateral veins in the GB fossa [Figure 1f]. Dominant veins were again clipped and divided while dissecting the GB of the liver bed. GB was retrieved through the umbilical port. Haemostasis was achieved and an abdominal drain was placed if needed.

Laparoscopic surgery of all the patients was operated by the same surgeon. First, assess the mass for its resectability. Then lift up transverse colon and identify C of duodenum. Just on the inferior side of duodenum make the incision over peritoneum with Harmonic Ace (Ethicon Endosurgery, Cincinnati). Pass a gauze piece, and CO₂ itself insufflates in to dissect duodenum and kept away from operative injury. We adopt the medial-to-lateral approach, so the vessels are taken very near to the origin of the superior mesenteric artery with a clearance of lymph nodes. Ileocolic and right branch of middle colic vessels are clipped proximally and on specimen side. True right colic vessels are present only in about 10%–15% of patients.[2 (link)] Along the white line of Toldt, mobilise entire right colon with up to mid transverse level. This step is done with care to prevent injury to the right ureter and gonadal vessels. Now, the resection and anastomoses can be done extracorporeally by delivering colon through 5 cm sized incision in the right iliac fossa. The resectional margin of colon should be at least of 5 cm. For specimen removal, we use glove bag so as to prevent contamination of the wound by tumour cells.