We use harmonic scalpel hook for dissecting gall bladder from its bed and used harmonic scalpel for long cystic duct. Obviously operating time is less.

Harmonic scalpel is the main tool in lape chole in our hospital, It much shortens operative time because of excellent haemostasis. As bloody field and trials to control bleeding points  costs excess time.

Reduces operative time

Interesting question. We don't routinely use Harmonic scalpel in all LCs, only during subtotal type when there are extensive adhesions in the area. Harmonic scalpel is also useful for LCs in cirrhotic livers. 

As Dr.Taha says, routine use of Harmonic scalpel is expensive and gives no additional benefit. 

Harmonic gives good looking and bloodless field but the surgeon is the most important factor concerning operative times.  Harmonic scalpel just cuts tissue that is between the jaws so in difficult gallbladders it is more likely to have injury in the structures of the Calots triangle. However during bed dissection using harmonic the risk of gallbladder perforation is less. In our institution LC is performed only with monopolar and we have low operative times even in transumbilical LCs.

primarily it is surgeon's preference.cost factor is secondary but now each and every unit has Hormonic facility.We all started with monopolar cautery to start with.When i analysed my own experience of using HS( not published )in over 10000 cases,using both 10mm and 5 mm probes,personnel experience is it does shortens the operating time both in routine and in difficult cases,as our practice is except for cystic duct clipping,no need to remove the hormonic probe till the proccedure is over.Unexpected bleeding can be controlled well including most of liver bed bleeds,GB perforations are less even in the hands of my trainees.with 5mm curved probe the dissection can be done well like with a Maryland dissector.We found the post operative discomfort not the port pains is comparatively(difficult to measure) less.In training units unless the the fellow is familiar in using,he cannot progress to advanced work.Question of recycling or not it depends on various local factors.undoubtedly as mentioned by Dr Yanko,surgeon is the impotant factor.Even though sils has not gained popularity Hormonic is a must .

Harmonic Scalpel does not reduce the operative time, but the proper and correct surgical technique! Additionally, for a 15 minute surgery, using it would be waste of money!

I think it' s a very waste of money in simple cases. In cholecistitis it could be useful, but in my experience not more than a bipolar scissor, less expensive. Better in that case snob anterograd approach to the gallbladder. 

Hi everybody. You've got many opposite answers. My opinion is quite different. Every tool has its learning curve. It will reduce the operative time only for surgeons that know how to use it. For somebody used to operate with monopolar it will not.

I agree that the Harmonic Scalpel saves time and blood loss. I also agree with Dr. Ciesieslski that ther is a learnig curve to master the use of the harmonic. I use both the hook and the forceps, for dfferent times during the procedure. I encourage the incorporation of this technique for all the cases of cholecystectomy. We have been using it routinely since 1998, with excellent results.

I agree that there is a learning curve for all new tools and new techniques.For an experienced surgeon it should not take more than one or two Lap Choles with harmonic.

I used one on a patient with a spinal implant who we could not use diathermy on.  It was fine with no increase in time but i don't think it is worth the significant increase in the overall cost of the operation that a harmonic device adds to a laparoscopic cholecystectomy.  This may not be relevant to your healthcare system.

I agree, cost of the instrument outweighs any potential advantage - the surgery can be done safely with the tools we currently have. Also worth mentioning that although there is no zone of current spread as with diathermy, the blades of the harmonic stay at extremely high temperature for some time - a lot more than diathermy, so one needs to be careful an iatrogenic injury does not occur to nearby bowel or bile ducts.

it doesn't give significant difference in the operative time ....but still its main problem is in the cost which increases much using harmonic shears

It is sure that Harmonic Scalpel increase the operation cost. Every new  device used  during operations will achieve a additional cost.  I think that  Harmonic Scalpel reduce operation time.  Also a safety operation. Because of the minimizing blood loss I think drain use reduce too. 

Agree with others. I suppose cost is an issue. Useful when diathermy is not safe as in patients with for example a defibrillator. No other advantage?

I am astonished with many of the answers. Hook diathermy if used appropriately is  precise, safer, bloodless, and sometimes quicker than harmonic which is excruciating expensive for most non- complex gallbladder surgery . For complex gallbladder surgery you have to be careful no matter which instrument you use and time should not be a  factor and in fact one need not remove the gallbladder in its entirety.

No! Neither quicker or safer and because it can be used to seal the cystic duct may tempt surgeons not to perform an operative cholangiogram to reconfirm the anatomy however 'obviously normal' it appears to be. Only appropriate when diathermy cannot be used, but it is reasonable to turn off a pacemaker with a magnet enabling diathermy to be used.

I agree with Dhiren Nehra regarding hook diathermy being a precise, safe, bloodless and quick way of doing gallbladder surgery.  If you dissect the gallbladder off the liver in the correct plane it should be relatively bloodless surgery - in the acute emergency setting and definitely in the elective setting.

The ultrasonic blade of the harmonic gets extremely hot during use and the potential for thermal injury is well recognised.  I would have concerns of the blade (which is not insulated) causing accidental thermal injury on adjacent structures.

Finally the cost of the harmonic cf the cost of sterilising and reusing a hook diathermy would not be justified in all health budgets.  It has a limited role in the setting where standard diathermy cannot be used.

Use of Harmonic scalpel not schoten operation time, does not increase efficiency.

I do not think harmonic scalpel will decrease operation time in laparoscopic cholecystectomy. If operation is going by the books, harmonic is useless, because there will be no bleeding.

Additionally harmonic scalpel reaches too high temperature, so if your are using this device you must have an additional caution, and because of that it is too dangerous to be used in Callot's triangle's dissection. Also it will not seal the cystic duct. So, in my opinion, there is no need to use harmonic scalpel in laparoscopic cholecystectomy because its advantages are useless in this setting.

i think the answer to this question is given in the Publications of Dr.Arthur Janus who has not only proven that is worthwile but also cost effectiv in the Swedish setting.

Cost analysis comparing ultrasonic fundus-first and conventional laparoscopic cholecystectomy using electrocautery.

Fredrik Tempé

Arthur Jänes

Yucel Cengiz

Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden.

Surgical Endoscopy (Impact Factor: 3.31). 05/2013; DOI: 10.1007/s00464-013-2841-7Source: PubMed

ABSTRACT BACKGROUND: Costs associated with laparoscopic fundus-first cholecystectomy using ultrasonic dissection versus a conventional laparoscopic cholecystectomy has not been compared. METHODS: Adult patients subjected to elective laparoscopic cholecystectomy between June 2002 and March 2004 were randomized to either an ultrasonic fundus-first dissection or dissection from the triangle of Calot with electrocautery. Differences in direct and indirect costs related to either technique were studied. RESULTS: The duration of the operation and hospitalization was longer when dissection was with the conventional technique. With the ultrasonic fundus-first technique, the direct cost was 1,190 SEK lower, and the total cost, taking also the cost for sick leave into account, was 5,370 SEK lower. CONCLUSIONS: Both direct and indirect costs are lower with a laparoscopic fundus-first cholecystectomy using ultrasonic dissection than conventional laparoscopic cholecystectomy using electrocautery.

Yes. the surgery becomes blood less, less GB bile spil, no irrigation. it is much better than cautery

The paper from Dr. Janus would have been better if both arms used the same technique but were randomised for either ultrasonic or electrocautery. Hence I am cautious with using data from that paper to justify using harmonic scalpel in laparoscopic cholecystectomy. Naturally for me, harmonic scalpel is not required at all for lap chole. For lap chole, it is not so much of haemostasis but preservation of other important structures especially ensuring preservation of CBD. I am not sure if the bulky tip of harmonic scalpel can truly ensure we don't accidentally injure other structures; in my patients-who are paediatrics, there's hardly any space for a bulky tip compared to a hook diathermy and ligatures.

Adhering to meticulous dissection techniques while using standard unipolar current in laparoscopic cholecystectomy is adequate in most of the cases. Harmonic , in my opinion can be useful in dissecting GB from the liver bed in some difficult cases.

I think it may add advantage as regard operative time in some difficult cases only, I mean some cases with much Calot triangle adhesions...but in straightforward cases it doesn't add much

I do not think that harmonic scalpel is useful in ordinary cholecistectomy. It may be useful in some selected cases, is probably right. But to use harmonic scalpel as a routine, I think is not necessary and does not produce significant benefits regarding time of the procedure and the length of hospital stay.

I do not think that using the harmonic scalpel in routine laparoscopic cholecystectomy (LC) has any added advantage over the ordinary hook diathermy. Also, I do not think it has any added advantages in cases of LC for acute cholecystitis. I do not thing it speeds up the operation and has no bearing on the length of hospital stay in an operation which is carried out as a day case.

The evidence regarding the impact of harmonic scalpel on operative time in laparoscopic cholecystectomy is quite contradictory. For instance, Zanghi et al (2014) noticed significant shorter operative times (35.36 + 10.15 min vs. 55.6+12.10,p < 0.0001)  and a reduced frequency of intraoperative gallbladder perforations (6.98% vs 20.66% p < 0.05) in the harmonic group as compared to conventional laparoscopic cholecystectomy, while Rajnish et al. (2018) did not observe this effect (67.3 vs. 64.3 mins; p = 0.30). 

Any difference is likely to be marginal and would not justify the added expense for routine use. It's niche is the very scarred thick-walled gallbladder, but even then only if there is troublesome bleeding with diathermy dissection

Harmonic scalpel makes the surgery bloodless. Time or Surgery is shorter. Possibly the conversation rate even in difficult cases are less. If the ace is reused and used properly can go even for over hundred cases. It is worth using.

As a self-trained old surgeon, I have been practicing lap surgery for over three decades with more than five decades of open surgery experience; I have not had a single occasion to change my hook electrosurgery instrument. Those surgeons or colleagues who watched me operating never failed to praise the bloodless operating field. A lap surgeon must have patience, forbearance, and respect for tissues. It is cheap and every surgeon can easily afford it. If I may respectfully, I have often found my surgeon colleagues operating but with very poor knowledge of the physics of monopolar and bipolar electrosurgical units and its physics. Today, we have myriads of electrosurgical units in markets. I am still comfortable with my old cheap model and it is giving me the best service and nothing to complain about. I even teach my juniors to learn the physics of electrosurgery units. My very humble and strong request/recommendation is to include the physics of electrosurgery in every medical curriculum starting from UG to PG. I refrain from elaborating further on the paucity of information on this topic. Once I even faced a strong dissidence from few colleagues for it.

In my humble opinion, the main goal that the surgeon should keep in mind is to make his surgery (cholecystectomy) safer.

You understand that the fear of the surgeon (my fear) during the realization of a cholecystectomy is to induce an operative bile duct injury, for that I take my time to protect my patients from my errors of identification.

The rush, ego, and ease of the procedure create an environment that fosters the illusion that lead to an involuntary injury.

The time lost in achieving hemostasis of the gallbladder bed is generally marginal compared to the time spent in identifying the different elements of the Calot's triangle and in the achievement out the critical view of safety.

I think for routine lap cholecystectomy, Harmonic scalpel has very little advantage and even time saving is also very minimal. Harmonic scalpel I do not recommend in lap cholecystectomy