Impacted Stone (Hydrops, Empyema, Early Mirizzi) |
29 |
to make a small opening using electrical scissors and insert an irrigation suction device |
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into the fundus to aspirate the contents of the gallbladder. This will ease the tension of |
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the gallbladder and enable it to be grasped using graspers with tiny teeth. |
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With a very difficult acute gangrenous gallbladder, it is essential for safety reasons |
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to prevent injury to the CBD by limiting dissection to the neck of the gallbladder. The |
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dissection can then proceed as for a normal gallbladder. It is important to visualize the |
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CBD laparoscopically. If this is not possible secondary to inflammation in the porta |
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hepatis, then a cholangiogram should be attempted through the neck of the gallbladder |
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to visualize the anatomy. However, if this also is not feasible, and the cystic duct and the |
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neck of the gallbladder have been clearly identified, then one can proceed with the cho- |
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lecystectomy. It is also possible to perform a cholangiogram through the gallbladder |
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itself. As a rule of thumb the aim should be to recognize the elements of the triangle of |
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Calot within 45 min of beginning the dissection. If after that period of time the anatomy |
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is still not clear, conversion should be the rule. |
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As the gallbladder is being removed from the liver bed some bleeding may occur |
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from the liver parenchyma, owing to difficulty in finding the best plane of dissection. |
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Compression should be applied using a 2 × 2 gauze, and a collagen hemostatic pad should |
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be left in place on the liver bed. |
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In some cases of gangrenous gallbladder there may not be an obvious plane of dissection. |
“Dangerous” |
If the surgeon has limited skills, or feels that the situation is dangerous, he or she should |
Cholecys |
perform a partial removal of the gallbladder, leaving part of its neck next to the CBD. |
tectomy |
This is also true when the cystic duct is either atrophic, extremely short, or virtually |
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absent owing to the amount of inflammation. If the cystic duct is very large, one should |
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not apply clips that will not hold; instead, it is preferable to use a preformed Endoloop, |
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create a knot using extracorporeal techniques, or perform intracorporeal suturing using |
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a 3–0 PDS to close the large cystic duct (Fig. 2.7). |
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In the case of a stone impacted in the neck of the gallbladder with an empyema or hydrops of the gallbladder (Fig. 2.8), a good technique is to aspirate the gallbladder after opening the fundus with hot scissors and introducing the irrigation suction canula in the opening. An incision is then made in the neck of the gallbladder, approximately two to three centimeters above the junction of the cystic duct and the neck. This incision should be generous to allow for exteriorization of the stone, almost like an “enucleation” of a mass (Fig. 2.9). Once this is performed, the cystic duct is often shortened or absent. The junction between the neck of the gallbladder and the hepatic duct is also shortened and dangerous for dissection.We recommend in this case completing the opening of the gallbladder, and obtaining a mushroom shape of Hartmann’s pouch that will be closed using a running suture after the removal of the rest of the gallbladder (subtotal cholecystectomy), (Fig. 2.10). The placement of a JP drain is also advisable.
Impacted Stone (Hydrops, Empyema, Early Mirizzi)
30 |
Chapter 2 Cholecystectomy |
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a
b
Fig. 2.7 The “dangerous” cholecystectomy: closure of the cystic duct (a) using an Endoloop;
(b) intracorporeal suturing
Fig. 2.8 Impacted stone in the neck of the gallbladder (hydrops or empyema)
Impacted Stone (Hydrops, Empyema, Early Mirizzi)f |
31 |
Fig. 2.9 “Enucleation” of impacted stone in the neck of the gallbladder
Fig. 2.10 “Subtotal cholecystectomy.” Preserving a “safety wall” represented by Hartmann’s pouch nearly fused with CBD
32 |
Chapter 2 Cholecystectomy |
Avoiding Injury
to the Common
Bile Duct
In most instances, an injury to the CBD occurs when the cystic duct is shortened or virtually absent secondary to an anomaly in the anatomy, or in the case of acute inflammation. It is also important to remember that most CBD injuries occur in so-called “simple cholecystectomies” with a minimally inflamed gallbladder. The figures depict the common mechanisms of clipping and injuring the CBD. The fat present at the hepatic duct does not allow for perfect visualization of the cystic duct.In Fig.2.11a,the fat covers a normal length cystic duct. In Fig. 2.11b, tissue and fat cover a short or absent cystic duct. Both cases present themselves in an identical manner on the screen to the eye of the surgeon who has a two dimensional vision lacking the perception of depth. A clip is placed at what is considered to be the neck of the gallbladder, and an incision is made for a possible cholangiogram. In the first example, the clip is placed across the neck of the gallbladder, and the
a
b
Fig. 2.11 (a) Represents a classic cystic duct with normal length, covered by some tissue and fat. (b) Represents a “dangerous” short or absent duct
Avoiding Injury to the Common Bile Duct |
33 |
incision is made in the cystic duct. In the second example, the cystic duct is shortened and the incision has been made in the CBD,thus injuring the bile duct (Fig.2.12b).Figures 2.13a,b clearly illustrate through color coding the visual confusion as a consequence of the shortened or absent cystic duct, leading to a CBD injury. In our opinion, these figures indicate the need for a very thorough dissection of the neck of the gallbladder,the junction between the cystic duct and neck of the gallbladder, and the junction between the cystic duct and the hepatic duct (visual cholangiogram). This “double safety” feature (dissection of the junction neck of the gallbladder and cystic duct and dissection of the junction cystic duct, hepatic duct) in addition to the lateral traction will minimize the risk of a CBD injury.
a
b
Fig. 2.12 Mechanisms of injury to the CBD. (a) Clip placed appropriately across cystic duct. (b) Clip placed across the CBD (short or absent cystic duct)
34 |
Chapter 2 Cholecystectomy |
a
b
Fig. 2.13 (a, b) Mechanisms of injury to the CBD. Color coding illustrates the illusion created by the short cystic duct