Gallbladder disease, particularly gallstones and cholecystitis, is a widespread clinical problem that often requires surgical management. The evolution from open cholecystectomy to laparoscopic cholecystectomy has marked a milestone in minimally invasive surgery. Among the most critical steps in this operation is the secure closure of the cystic duct, which connects the gallbladder to the common bile duct. Traditionally, metallic clips are used to seal the duct, but ligation using suture material offers a safe, cost-effective, and versatile alternative. Laparoscopic cholecystectomy with ligation of the cystic duct combines the benefits of minimally invasive surgery with the reliability of conventional surgical principles.

Importance of Securing the Cystic Duct

The cystic duct is a vital structure in gallbladder surgery. If not sealed adequately, it can lead to severe postoperative complications:

Bile leak – causing peritonitis or biloma.

Biliary peritonitis – requiring reoperation or drainage.

Stricture formation – from improper closure or injury to adjacent ducts.

Retained stones – if the duct is incompletely divided or left open.

Therefore, ensuring safe and effective closure of the cystic duct is essential to the success of laparoscopic cholecystectomy.

Methods of Cystic Duct Closure

Several methods are available to secure the cystic duct during laparoscopic cholecystectomy:

Metallic Clips – the most widely used method, but associated with risks like clip migration, cost, and foreign body reaction.

Polymeric Clips (Hem-o-lok) – strong and radiolucent, but still foreign material.

Energy Devices – advanced tools like LigaSure or Harmonic can seal the duct but are expensive and not universally available.

Endoloop Ligatures – pre-tied absorbable sutures, effective but may increase procedure cost.

Hand-Tied Extracorporeal or Intracorporeal Knots – such as Mishra’s Knot, Roeder’s Knot, or simple ligatures, which provide secure closure without relying on clips.

Ligation of the cystic duct with sutures is considered one of the most dependable methods, rooted in open surgical tradition, and adaptable to laparoscopic techniques.

Surgical Technique
Patient Positioning and Anesthesia

The patient is placed under general anesthesia in a supine position, often with slight reverse Trendelenburg and left tilt to displace bowel loops.

Port Placement

A 10-mm umbilical port for the laparoscope.

A 10-mm epigastric port for working instruments.

Two 5-mm ports in the right subcostal and lateral positions for retraction and assistance.

Exposure of Calot’s Triangle

The gallbladder fundus is retracted cephalad and laterally. Careful dissection is performed around Calot’s triangle to identify the cystic duct and cystic artery. The Critical View of Safety (CVS) must be achieved before any ligation.

Ligation of the Cystic Duct

A suture material, typically absorbable 2-0 Vicryl or PDS, is prepared.

The extracorporeal knot (such as Mishra’s Knot or Roeder’s Knot) is tied outside the abdomen and introduced with a knot pusher.

The knot is carefully slid over the cystic duct and tightened.

A second ligature is placed for additional security.

Once secured, the cystic duct is divided between ligatures.

Securing the Cystic Artery

The cystic artery is also ligated with suture or clipped, depending on surgeon preference.

6. Gallbladder Removal

The gallbladder is dissected from the liver bed using electrocautery, then retrieved via the umbilical port.

Completion

Hemostasis is verified, irrigation may be performed, and ports are removed. The fascia of larger ports is closed, and skin incisions sutured.

Advantages of Ligation over Clips

Cost-Effective – reduces reliance on expensive clip applicators.

Secure Closure – no risk of clip slippage or migration.

No Foreign Body – eliminates complications like stone formation around clips.

Accessibility – useful in resource-limited settings where advanced equipment is unavailable.

Versatility – effective even for wide or thick-walled cystic ducts where clips may fail.

Complications and How to Avoid Them

Bile duct injury – prevented by achieving CVS before ligation.

Bile leak – avoided by applying at least two secure knots.

Stricture of common bile duct – prevented by careful identification of duct anatomy.

Intraoperative bleeding – controlled by meticulous dissection and proper ligation of cystic artery.

Regular practice in laparoscopic suturing is essential for mastering this technique and minimizing risks.

Clinical Outcomes

Numerous studies have shown that laparoscopic cholecystectomy with cystic duct ligation is:

As safe as, or safer than, clip closure.

Effective in preventing bile leaks and duct injuries.

Cost-saving for patients and healthcare systems.

Surgeons trained in laparoscopic knotting techniques report high success rates with very low complication incidence.

Conclusion

Laparoscopic cholecystectomy is the standard treatment for gallbladder disease, and safe closure of the cystic duct is a cornerstone of the procedure. While clips remain widely used, ligation of the cystic duct with sutures provides a secure, economical, and reliable method. This approach reflects the blend of traditional open surgical principles with modern minimally invasive techniques. By adopting suture ligation, especially in resource-constrained environments, surgeons can make laparoscopic cholecystectomy both safer and more accessible to patients worldwide.