GEA knot for cystic duct and artery ligation in laparoscopic cholecystectomy

Luis Francisco Llerena Freire; Francisco Eduardo Llerena Meza; Giannella Izamar Llerena Freire; Ariana Monserrath Mayorga Vidal; Kelly Arellano Velastegui

doi:10.18203/2349-2902.isj20253833

Authors

Luis Francisco Llerena Freire School of Medicine, Pontifical Catholic University of Ecuador - Campus (PUCESA), Ambato, Ecuador
Francisco Eduardo Llerena Meza Department of Surgery, SURGCLINIC Day Hospital, Pelileo, Ecuador https://orcid.org/0000-0003-0495-0540
Giannella Izamar Llerena Freire Department of Surgery, SURGCLINIC Day Hospital, Pelileo, Ecuador https://orcid.org/0000-0001-9404-2030
Ariana Monserrath Mayorga Vidal School of Medicine, Pontifical Catholic University of Ecuador - Campus (PUCESA), Ambato, Ecuador https://orcid.org/0009-0002-9724-8696
Kelly Arellano Velastegui Medical Student, School of Medicine, Pontificia Universidad Católica del Ecuador, Ambato Campus, Ecuador https://orcid.org/0009-0005-7269-6435

DOI:

https://doi.org/10.18203/2349-2902.isj20253833

Keywords:

Cystic duct, GEA knot, Laparoscopic cholecystectomy, Minimally invasive surgery, Suture techniques

Abstract

Background: The GEA knot has emerged as a potential alternative to conventional clips or staplers for cystic duct and artery ligation during laparoscopic cholecystectomy. However, its safety and efficiency remain under-evaluated in clinical practice.

Methods: This retrospective study included 178 patients who underwent laparoscopic cholecystectomy with GEA knot ligation. Demographic data, operative time, intraoperative and postoperative complications, and hospital stay were analyzed. A subgroup analysis compared the first 50 versus last 50 procedures to evaluate learning curve. A multivariate linear regression model identified predictors of operative time.

Results: Mean age was 44.2±11.7 years; 63.5% were female. Mean operative time was 48.6±12.4 minutes and mean hospital stay was 1.2±0.6 days. No major complications occurred. Intraoperative bleeding (1.1%) and conversion to open surgery (0.6%) were rare. Only one case of superficial wound infection was recorded (0.6%). Operative time decreased significantly from the first 50 cases (54.1±10.6 min) to the last 50 cases (45.3±9.2 min; p=0.001). Regression analysis showed that male sex (β = +2.5, p=0.04) and case order (β = -0.31 per case, p<0.001) were significant predictors of operative time (adjusted R² = 0.41).

Conclusions: The GEA knot is a safe and effective method for cystic duct and artery ligation. It demonstrates a short learning curve and excellent safety profile, with potential advantages in cost and resource-limited settings.

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References

Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180(1):101-25.

Sharma S, Behari A, Shukla R, Dasari M, Kapoor VK. Bile duct injury during laparoscopic cholecystectomy: An Indian e survey. Ann Hepatobiliary Pancreat Surg. 2020;24(4):469-76. DOI: https://doi.org/10.14701/ahbps.2020.24.4.469

Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2010;97(2):141-50. DOI: https://doi.org/10.1002/bjs.6870

Gupta A, Agrawal S, Sharma N, Parth N. Extra hepatic bile duct injury after laparoscopic cholecystectomy: a retrospective study. Int Surg J. 2020;7(8):2517-22. DOI: https://doi.org/10.18203/2349-2902.isj20203084

Komatsu M, Yokoyama N, Katada T, Sato D, Otani T, Harada R, et al. Learning curve for the surgical time of laparoscopic cholecystectomy performed by surgical trainees using the three port method: how many cases are needed for stabilization? Surg Endosc. 2023;37(2):1252-61. DOI: https://doi.org/10.1007/s00464-022-09666-0

Peterli R, Herzog U, Schuppisser JP, Ackermann C, Tondelli P. The learning curve of laparoscopic cholecystectomy and changes in indications: one institution's experience with 2,650 cholecystectomies. J Laparoendosc Adv Surg Tech A. 2000;10(1):13-9. DOI: https://doi.org/10.1089/lap.2000.10.13

Deziel DJ, Millikan KW, Staren ED, Doolas A, Economou SG. The impact of laparoscopic cholecystectomy on the operative experience of surgical residents. Surg Endosc. 1993;7(1):17-21. DOI: https://doi.org/10.1007/BF00591230

van Dijk AH, van Roessel S, de Reuver PR, Boerma D, Boermeester MA, Donkervoort SC. Systematic review of cystic duct closure techniques in relation to prevention of bile duct leakage after laparoscopic cholecystectomy. World J Gastrointest Surg. 2018;10(6):57-69. DOI: https://doi.org/10.4240/wjgs.v10.i6.57

Arkle T, Lam S, Toogood G, Kumar B. How should we secure the cystic duct during laparoscopic cholecystectomy? A UK wide survey of clinical practice and systematic review of the literature with meta-analysis. Ann R Coll Surg Engl. 2022;104(9):650-4. DOI: https://doi.org/10.1308/rcsann.2021.0264

Booij KA, de Reuver PR, Yap K, van Dieren S, van Delden OM, Rauws EA, et al. Morbidity and mortality after minor bile duct injury following laparoscopic cholecystectomy. Endosc. 2015;47(1):40-6. DOI: https://doi.org/10.1055/s-0034-1390908

Richardson MC, Bell G, Fullarton GM; West of Scotland Laparoscopic Cholecystectomy Audit Group. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5,913 cases. Br J Surg. 1996;83(10):1356-60. DOI: https://doi.org/10.1002/bjs.1800831009

Törnqvist B, Waage A, Zheng Z, Ye W, Nilsson M. Severity of acute cholecystitis and risk of iatrogenic bile duct injury during cholecystectomy: A population based case control study. World J Surg. 2016;40(5):1060-7. DOI: https://doi.org/10.1007/s00268-015-3365-1

Sgaramella Sgaramella LI, Gurrado A, Pasculli A, de Angelis N, Memeo R, Prete FP, et al. SYoN Italian Collaborative Group. The critical view of safety during laparoscopic cholecystectomy: Strasberg yes or no? An Italian multicentre study. Surg Endosc. 2021;35(7):3698-3708. DOI: https://doi.org/10.1007/s00464-020-07852-6

Vithayathil M, Yong C, Dawas K. Clinical outcomes of early and delayed cholecystectomy for acute gallstone-related disease. Turk J Surg. 2025;41(1):19-23. DOI: https://doi.org/10.47717/turkjsurg.2025.6568

Ferguson CM, Rattner DW, Warshaw AL. Bile duct injury in laparoscopic cholecystectomy. Surg Laparosc Endosc. 1992;2(1):1-7.