Cholecystectomy 2

A

D B

E

C

FA

S

CA

Fig. 2.1   Cholecystectomy in the obese patient; arrow indicates camera port moved higher  and to the right, toward the right costal margin. A subxyphoid trocar for instrument; B midclavicular port for left hand of surgeon; D grasper for retraction of gallbladder; E additional standard port for obese. S surgeon; FA first assistant; CA camera assistant

to the superior epigastric vessels, which can lead to severe hemorrhage. If this trocar is too low, however, the angle of dissection will be incorrect and there will be conflict with the laparoscope (“knitting needle” effect).

Once the operating port has been inserted, the fundus of the gallbladder is retracted and an additional 5 mm trocar is inserted for lateral retraction of Hartmann’s pouch. The operating port, the video laparoscope, and the lateral trocar are triangulated to avoid a “knitting needle” effect between the graspers and the video laparoscope (Fig. 2.2a).

In the case of an obese patient, the surgeon should not struggle to try to retract the fat. Two tricks can be used:

Placing the patient on steep reverse Trendelenburg

Inserting an extra 5 mm trocar above and to the left of the umbilical trocar (Fig. 2.1)

This additional trocar can be very helpful. If used, it should be added at an early stage, permitting the insertion of an irrigation/suction device, which can be used as a retractor to push down the duodenum and the greater omentum. It will also serve for hydrodissection. This extra trocar should be used for all obese patients, and also when the duodenum is stuck to the gallbladder and the surgeon requires extra duodenal retraction. The

a

b

Fig. 2.2  Ideal  port  placement  for  laparoscopic  cholecystectomy.  (a)  The “American”  trocar  placement, the surgeon standing at the side, and (b) the “French” trocar placement, the surgeon standing between the legs of the patient. A operating port; B grasper for the surgeon;  C grasper/ liver retractor; D umbilical telescope; E additional trocar for an obese patient. S surgeon; FA first assistant; CA camera assistant

24 Chapter 2 Cholecystectomy

insertion of the extra 5 mm trocar will not affect the surgical result or the cosmetic appearance but will dramatically increase the safety of the procedure and reduce operative time.

Once the fundus of the gallbladder is retracted and the liver is moved up, some adhesions on the inferior surface of the liver will occasionally prevent adequate liver retraction. Such adhesions should be removed first before even attempting dissection of the triangle of Calot, as at this point of the procedure, maximal superior retraction of the gallbladder is needed.

Lateral retraction is the key to safe dissection of the triangle of Calot (Fig. 2.3a). This is performed with the left hand of the surgeon pulling laterally and inferiorly (towards the right Anterior Superior Iliac Spine) on Hartmann’s pouch while the first assistant retracts the fundus of the gallbladder towards the lateral right hemidiaphragm. This will open up the triangle of Calot and the risk of a common bile duct (CBD) injury will be minimized. Wrong retraction closing the angle between the cystic duct and the CBD is depicted in Fig. 2.3b. If the anterior peritoneum overlying the cystic duct and artery is scarred, it is very important to retract the cystic duct in a cephalad direction and incise the posterior peritoneum as closely as possible to the neck of the gallbladder. That will allow safe dissection of the cystic duct next to the neck of the gallbladder, and will create a window around the cystic duct.

a

b b

a

Fig. 2.3  Dissection of the triangle of Calot: (a) correct retraction; (b) incorrect retraction with 

the risk of injury to the common bile duct (CBD)

One way to insure that the structure that is being dissected is indeed the cystic duct is to perform what we described previously as the visual cholangiogram. This consists of dissection of the cystic duct from the neck of the gallbladder towards the hepatic duct, and with one or two movements of either a blunt dissector or the irrigation suction device some of the fat covering the hepatic duct is removed, allowing identification of the hepatic duct, and the junction between the cystic and the hepatic duct. We have performed this visual cholangiogram in almost all of our cholecystectomies except in cases of ex-treme inflammation. Until this date, we have not observed a single CBD injury (Fig. 2.4a, b).

Once the cystic duct has been dissected out, the cystic artery should be exposed as

well.

Complete dissection of the cystic artery is not always achievable, as sometimes it is impossible to reach the artery with the cystic duct intact. If the patient is thin and the peritoneum and the fatty area around the cystic duct allow dissection of the cystic artery, this should be done as closely as possible to the neck of the gallbladder to avoid injury to an anomalous right hepatic artery.

If the surgeon has a policy of routine cholangiography, this is done after clipping the neck of the gallbladder. Two clips are used rather than one, as one has a tendency to fall when the gallbladder is extracted.

Cholangiography begins with application of minimal electrocautery to control the small artery of the cystic duct, thus avoiding injury which would obscure vision upon incision of the cystic duct, and prevent proper introduction of the cystic catheter.A small oblique incision is made on the cystic duct using microscissors which are inserted with the tip angled towards the CBD. The tip of the microscissors is then used to dilate the cystic duct opening, and the presence of bile will indicate that the duct is ready to be cannulated (Fig. 2.5). This procedure is recommended each time a cystic duct is opened, as an absence of bile indicates that there is no communication between the cystic duct and the CBD, and attempts to cannulate the cystic duct will be very difficult.

It is possible to dilate the cystic duct by removing the microscissors and replacing them with atraumatic long Maryland forceps. These are introduced into the cystic duct lumen and opened to dilate the duct. This will hopefully allow visualization of bile indicating the duct is ready for cannulation.

At this point, the Maryland forceps are placed in the 10 mm operating port to retract Hartmann’s pouch laterally. The assistant now holds these forceps to free the surgeon’s two hands allowing him to focus on the introduction of the cholangiogram clamp. This description is based on the use of the Olsen cholangiogram clamp with a smooth ureteral catheter no. 4, which must be checked before insertion. This catheter should be introduced from the left lateral grasper port into the cystic duct. It is not necessary to introduce more than 1 cm of the catheter into the cystic duct, or no more than one black dot on the tip of the catheter. The clamp is secured in place and the cholangiogram is performed. If the cholangiogram is normal, the clamp is removed and the clip applier introduced. Two clips are applied as close as possible to the cystic duct opening.

a

b

Fig. 2.4   “Visual cholangiogram.” The fat overlying the common hepatic duct is gently teased  away, using a grasper (a) or a suction irrigation device (b)

Fig. 2.5   Cannulation of the cystic duct in cholangiography

It is not advisable to use an Endoloop and a clip together, as they have different squeezing actions and if a clip is in place, subsequent tightening of an Endoloop will make the clip fall off. If both are used, place and tighten the Endoloop first.

The cystic artery is now clipped and divided as close as possible to the neck of the gallbladder. It is then possible to proceed with removal of the gallbladder from the liver bed. The best instrument for this is either a hook or better a flat electrical spatula that will “slice” the gallbladder from the liver bed.

Opening of the gallbladder is an inelegant technical mishap, but studies have shown that it does not affect the outcome for the patient if all the bile is aspirated, the area is irrigated, and all the spilled stones are removed. In many instances an opening in the gallbladder occurs at the unperitonized area next to the liver bed. It is possible to grasp the gallbladder with the left grasper and apply a rotating motion on the opening exactly as one would do with a can-opener (the “spaghetti technique”), which will usually control the bile leak through a small opening. If the tear is large, the only solution is to grab it and insert an Endoloop (Fig. 2.6). Clips are not useful except for a very small tear.

If neither the spaghetti technique nor insertion of an Endoloop closes the opening, the only resource will be to suck out the contents of the gallbladder, limiting the spillage of stones, and finally introduce a bag to retrieve the gallbladder.

Spillage of stones can be managed by irrigating the area to allow the stones to float on the surface. Removal of the stones will then be easier by sucking them using a 10 mm specific suction cannula. Unfortunately the stones can easily obstruct the tubing, in which case the only option is to pick the stones up one by one and insert them in a bag.

a