A special technique for single port laparoscopic cholecystectomy using Hartmann's pouch stitch

This video demonstrates a single port laparoscopic cholecystectomy using conventional reusable instruments. In addition, safe visualisation of Calot’s triangle is achieved via a percutaneous silk suture passed through the Hartmann’s pouch permitting anterior and posterior dissection without the need for additional ports.

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A special technique for single port laparoscopic cholecystectomy using Hartmann's pouch stitch

Authors

M Malik, I Ahmed

Abstract

This video demonstrates a single port laparoscopic cholecystectomy using conventional reusable instruments. In addition, safe visualisation of Calot’s triangle is achieved via a percutaneous silk suture passed through the Hartmann’s pouch permitting anterior and posterior dissection without the need for additional ports.

Classification

single port, contribution

Keywords

cholecystectomy, single port, laparoscopy, Hartmann’s pouch stitch, straight laparoscopic instruments

Media type

Surgical video

Duration

10'30''

Publication

2011-01

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E-publication

WeBSurg.com, Jan 2011;11(01).
URL: http://www.websurg.com/doi-vd01en3155.htm

A special technique for single port laparoscopic cholecystectomy using Hartmann's pouch stitch

1. Patient position 00'21''

The patient is positioned in modified Lloyd-Davies position. The operating surgeon stands between the patient’s legs and the camera assistant stands on the left side. The scrub nurse and the instrument trolley are placed on the patient’s right side.

2. Umbilical incision 00'36''

A vertical 1.5cm incision is made through the umbilicus. Mayo’s forceps are used to bluntly dissect the subcutaneous tissue and expose the rectus sheath. The rectus sheath is incised with a knife under direct vision. A finger is inserted to ensure safe entry into the peritoneal cavity and to check for intra-abdominal adhesions.

3. SILS port insertion 01'03''

A well-lubricated SILS port manufactured by Covidien® is inserted. The gas inlet is attached and insufflation is carried out to an intra-abdominal pressure of 12mmHg.

4. Gallbladder fundus retraction 01'50''

After a general inspection of the peritoneal cavity, the gallbladder fundus is grasped and retracted upwards. Any omental adhesions are dissected bluntly or with a hook diathermy. Hartmann’s pouch is exposed clearly.

5. Needle insertion in epigastric area 04'55''

A silk 2/0 suture on a straight needle is introduced under vision from the epigastrium, keeping to the right side of the falciform ligament. An adequate length of suture is also pulled inside at this time.

6. Hartmann\'s pouch needle passing 05'12''

The needle is then grasped and passed through the Hartmann’s pouch twice to ensure a secure grip and prevent slipping of the suture back and forth. The suture has to be pulled all the way through after each pass through the gallbladder wall to prevent the thread from locking. The needle is then passed out of the abdominal wall laterally in the right anterior axillary line.

7. Outside stitch closure 06'57''

The two ends of the suture on the outside can now be pulled in order to swing the Hartmann’s pouch to the left or right, thereby affording excellent anterior and posterior critical views of Calot’s triangle.

8. Calot\'s triangle dissection 07'28''

Dissection of Calot’s triangle proceeds as in standard laparoscopic cholecystectomy, the aim being clearly the safe identification of the cystic artery and duct and to demonstrate a window between them and the liver surface. A combination of hook diathermy and blunt dissection is used to achieve safe visualisation. Using the stitch for dynamic traction, standard straight laparoscopic instruments can be used to get access to both the anterior and posterior peritoneal leaves.

9. Cystic artery dissection 08'05''

The cystic artery is dissected, clipped and cut leaving two liga-clips on the proximal stump.

10. Cystic duct dissection 08'33''

The cystic duct is further skeletonised to clearly visualise the junction of the cystic duct and the bile duct. Three Liga-clips are applied using a 5mm clip applier. The cystic duct is divided with scissors, leaving two clips on the proximal stump.

11. Gallbladder dissection 09'34''

The gallbladder is dissected off the liver using a straight hook diathermy. The Hartmann’s pouch suture proves useful at this stage also, making it convenient to swing the gallbladder back and forth to aid dissection. While holding the gallbladder with a suitable grasper, the Hartmann’s pouch suture is cut and all other instruments removed.

12. Gallbladder and SILS port retraction 10'24''

Finally, the SILS port is also removed, withdrawing the gallbladder through the umbilical port. The wound is closed conventionally using 2 PDS sutures on a J needle and the skin is closed with a 3/0 monocryl suture.