Efficacy and Cost-Effectiveness of Extracorporeal Knotting Compared with Conventional Clip Ligation During Laparoscopic Cholecystectomy: Experience from a Bangladeshi Tertiary Center

Open Access

Abstract

Introduction: Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstone disease, and secure cystic duct closure is essential for preventing bile leak and other postoperative complications. Conventional clip ligation is widely used, but the cost of disposable clips may increase the overall procedural expense. Extracorporeal knotting has been proposed as a low-cost alternative that may provide comparable clinical outcomes. This study aimed to compare the efficacy and cost-effectiveness of extracorporeal knotting and conventional clip ligation during laparoscopic cholecystectomy in a Bangladeshi tertiary care hospital. Methods & Materials: This observational cross-sectional analytical study was conducted in the Department of Surgery, Al Haramain Hospital, Sylhet, Bangladesh, from July 2025 to December 2025. A total of 100 patients undergoing elective laparoscopic cholecystectomy were included using a consecutive sampling technique and were categorized into two groups according to the method of cystic duct closure: the Extracorporeal Knotting (EK) group (n = 50), in which absorbable suture was used for extracorporeal knotting, and the Conventional Clip Ligation (CL) group (n = 50), in which metallic clips were applied. Statistical analysis was performed using SPSS version 26. Results: Among 100 patients undergoing laparoscopic cholecystectomy, the extracorporeal knotting group showed clinical efficacy comparable to the conventional clip ligation group, with all procedures completed laparoscopically in both groups. The rates of intraoperative and postoperative complications- including bile leak, bleeding, wound infection, and 30-day readmission- were similarly low in the two groups, indicating no significant difference in efficacy or safety between the techniques. Although operative time was slightly longer with extracorporeal knotting (54.1 ± 8.8 vs 48.2 ± 7.9 minutes), it resulted in a marked reduction in material-related cost (560 ± 68 vs 1,380 ± 145 BDT) and showed superior overall cost-effectiveness. Conclusion: Extracorporeal knotting in laparoscopic cholecystectomy showed clinical effectiveness and postoperative safety comparable to conventional clip ligation, with similarly low incidences of bile leak, bleeding, wound infection, and readmission. Although the procedure required a slightly longer operative time, it was associated with a marked reduction in material-related costs and demonstrated significantly better overall cost-effectiveness.