Acute cholecystitis: technical variation

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Acute cholecystitis: technical variation

Authors

Mots-clés

operation,biliary tract,Calot's triangle,cystic artery,cystic duct,gallbladder

Type de vidéo

Vidéo chirurgicale

Durée

07'00''

Publication

2002-07

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jul 2002;2(07).
URL: http://www.websurg.com/doi-vd01en1325e.htm

Acute cholecystitis: technical variation

1. Exposure: suspension of round ligament 00'16''

Suspension of the ligamentum teres allows for a better exposure of the anterior surface of the hepatic pedicle and avoids the insertion of a 5th trocar. A straight needle is introduced percutaneously at the right side of the fossa from the ligament of the liver, transfixiates the inferior portion of the ligamentum teres and is brought out of the left falciform ligament. The thread is tied on the skin surface.

2. Dissection of inflammatory adhesion with scissors 01'03''

The dissection of the adhesions around the gallbladder can be performed with coagulating scissors and should always be done in contact with the gallbladder wall. Adhesions are freed as shown while the gallbladder is progressively retracted upwards.

3. Dissection of Calot\'s triangle 01'51''

The dissection of the triangle of Calot is performed according to the surgeon’s preferences: with scissors, dissectors or peanut. In this case, we use coagulating scissors. The instrument must be well insulated. During electrocoagulation of small veins around the cystic duct, the blade of the scissors should be kept away from the cystic artery and duct to avoid heat injuries. The dissector is also useful for the identification and isolation of the cystic artery and duct as shown here. Some authors prefer to dissect with a peanut because it allows for an atraumatic and cautery-free dissection. However, it is not as helpful in the case of fibrotic and hemorrhagic inflammatory changes. Here, the presence of interstitial edema facilitates the use of the peanut.

4. Control of cystic artery 03'23''

The cystic artery can either be ligated with clips or with bipolar electrocoagulation. In the present case, the artery is very short and kicks towards the gallbladder immediately distal to its emergence from the right hepatic artery. Bipolar coagulation is used for the control of the cystic artery.

5. Control of cystic duct 04'02''

When the cystic duct is too wide, other means than the clips should be used to ligate it. It is possible to perform intracorporeal suturing and knot-tying of the duct with slowly absorbable material or to use an endoscopic loop. If the cystic duct is very wide or in the case of a subtotal cholecystectomy where the neck of the gallbladder is left in place, it is possible to close the stump with a running suture using slowly absorbable material. This is shown here.

6. Dissection of gallbladder bed with scissors 05'42''

The use of coagulating scissors is useful for dissection of the gallbladder bed in case of acute cholecystitis. When the plane between the gallbladder is difficult to identify, it is better to perform dissection close to the gallbladder as an opening of the gallbladder is preferable to liver injury.

7. Protective bag for extraction 06'47''

The retrieval bag can easily be tailored from a surgical glove as shown here.