Acute cholecystitis and CBD stone: difficult laparoscopy and ERCP

Cholecystectomy for symptomatic gallstones is one of the mostly performed laparoscopic procedures. Early laparoscopic cholecystectomy during acute cholecystitis appears to be safe and shortens the total hospital stay. This video shows a cholecystectomy for acute cholecystitis associated with an intraoperative ERCP for common biliary duct stone.

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Acute cholecystitis and CBD stone: difficult laparoscopy and ERCP

Authors

F Costantino, D Mutter, Gf Donatelli, J Marescaux

Abstract

Cholecystectomy for symptomatic gallstones is one of the mostly performed laparoscopic procedures. Early laparoscopic cholecystectomy during acute cholecystitis appears to be safe and shortens the total hospital stay. This video shows a cholecystectomy for acute cholecystitis associated with an intraoperative ERCP for common biliary duct stone.

Mots-clés

Acute cholecystitis, CBD stone, laparoscopy, intraoperative ERCP, symptomatic gallstones

Type de vidéo

Vidéo chirurgicale

Durée

14'00''

Publication

2011-10

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Oct 2011;11(10).
URL: http://www.websurg.com/doi-vd01en3293.htm

Acute cholecystitis and CBD stone: difficult laparoscopy and ERCP

1. Clinical case 00'11''

We report the case of a patient referred to our department for an acute cholecystitis with biliary lithiasis. When admitted in the department, this 65-year-old patient presented with acute pain in the right hypochondrium. Serum chemistries demonstrated the presence of a moderate inflammatory syndrome (11,500 white blood cells) as well as a slight hepatic impairment. A CT-scan is performed as conventionally. It will demonstrate both an acute cholecystitis—as diagnosed on the first CT-scan images, and a common bile duct lithiasis—as diagnosed on the same images as well as on the 3D reconstruction. It is therefore decided to perform a videolaparoscopic cholecystectomy. The intervention is begun conventionally with the placement of 4 ports. The first port is introduced under visual control.

2. Intraoperative view 01'05''

An acute cholecystitis associated with a big gallbladder edema and adhesions is immediately observed. The gallbladder cannot be manipulated since it is highly distended. The distension is related to the inflammatory reaction and to lithiasis in the common bile duct, inducing biliary retention.

3. Gallbladder puncture 01'26''

As soon as the first adhesions are taken down, the exposure is completed by a puncture of the gallbladder contents. This strategy offers 2 advantages. First, it allows for a bacteriological sampling of the bile. The second advantage is to decompress the gallbladder so that it can be manipulated much more easily.

4. Calot\'s triangle exposure and dissection 01'46''

Hence, exposure and dissection of the triangle of Calot will be facilitated. A gauze pad has been introduced immediately so that any blood-induced contamination is eradicated during dissection and an improved view is achieved. The left lobe of the liver is not standing in the way and can be retracted easily. Dissection is carried out using monopolar cautery. Ideally, monopolar scissors are used for cauterizing and dividing the different adhesions. Dissection will be further continued towards Calot’s triangle. The infundibulum of the gallbladder is the first anatomical structure that is searched for. The objective is to rapidly identify the fundus of the gallbladder, and then the cystic duct. In this patient, the lithiasis measures about 1cm. An intraoperative cholangiography is decided upon in order to control the anatomy and to confirm the existence of persisting lithiasis. Dissection is performed gradually using monopolar cautery, and if necessary using bipolar cautery. The coagulation power is kept to a minimal--that is 20 Watts, in order to avoid dissemination of the electric current towards the common bile duct that could result in secondary common bile duct ischemia. If need be, bipolar coagulation is used to complete the dissection. The hook remains a useful instrument in acute cholecystitis as it will load the tissues, coagulate and divide them safely. It also helps to control that the different coagulated structures are very thin in caliber and smaller than any bile capillary. It is essential to observe as shown in these pictures that the dissection should be performed into the fibroid shell of the cholecystitis. Indeed, if the dissection is performed way too externally, it could result in an appropriate dissection in contact to the biliary pedicle of the common bile duct or of the bifurcation. The shell--being the thickening of the peritoneum surrounding the gallbladder because of acute cholecystitis will stay in place. The gallbladder is situated within this anatomical landmark. This dissection is also essential as it allows to keep away from the vascular elements of Calot’s pedicle. It will allow to very precisely identify the cystic duct and the cystic artery. Dissection is performed step by step in the inferior portion, then in the superior portion of the gallbladder. The planes are identified meticulously and progressively. The quality of the view obtained from High Definition cameras must be noted. Despite the global inflammatory nature of the tissues, the color enhancement parameters allow for a perfect anatomical identification of all dissected structures. Dissection at the superior portion of Calot’s triangle will progressively help to identify the cystic artery.

5. Cystic artery identification 04'50''

The cystic artery is first preserved. It is also used as an anatomical landmark. Dissection is also continued posteriorly in contact to the infundibulum. One should indeed avoid going too inferiorly in order to preserve the noble structures, and especially the right hepatic artery whose posterior part may be easily injured in the dissection as well as the common bile duct that could also be dissected inappropriately.

6. Cystic duct identification 05'24''

The progressive dissection in contact to the infundibulum of the gallbladder is performed from right to left. It will allow to identify the origin of the cystic duct after control of the cystic artery. As can be seen here, the hook allows to simultaneously coagulate and manually dissect the small structures surrounding the different anatomical structures. Cautery is very meticulous since any blood-induced contamination would make the anatomical identification of the structures impossible. As can be seen here, coagulation is pursued. Monopolar cautery is mostly used. But if need be, it may be associated with bipolar cautery. This inflammatory mass is slightly hemorrhagic. It will be totally controlled when cholecystectomy is completed. Here, one may notice that it is uneasy to dissect the fibrotic elements. Here dissection assisted by the aspirator, potentially by regularly injecting some saline, may help perform hydrodissection. It is always completed by small bipolar coagulations in order to achieve hemostasis. The anatomical rendering is here physiological. The course of both the cystic duct and of the cystic artery is visible here. The peritoneal fold above Calot’s triangle can then be opened from left to right and cranially in order to keep away from the biliary bifurcation by all means. The cystic duct will be dissected over a length of 1 to 2cm at the most, once again by keeping away from the common bile duct. The objective is to obtain a sufficient length of cystic duct to perform an intraoperative cholangiography. It is essential to perform such a cholangiography in difficult cholecystectomies as in the present case. Indeed, one must identify the anatomy perfectly in order to avoid any injury to the common bile duct or should there be any injury to the common bile duct, to repair it immediately. The previously identified cystic artery is clipped immediately. A grasper is placed posteriorly to the cystic duct underneath the infundibulum of the gallbladder. Not only will it help to ligate the cystic duct at its superior portion but also to open the cystic duct without getting too much bile into the operative field, hence preventing its contamination. This thread will also help to mobilize and more precisely control the anatomical structures.

7. Intraoperative cholangiography 08'27''

The cystic duct is thick, fibrotic. However, it is dissected over 1 to 1.5cm in length. This length is sufficient to perform the intraoperative cholangiography. The cystic duct is slightly opened. Bile starts to ooze in the operative field. It is the area chosen to perform the intraoperative cholangiography. The thread is knotted beyond this opening. Attention is paid to make sure that it is really a bile capillary. Considering the dissection that has been carried out above this capillary, this must be the cystic duct. No other duct can be identified in the dissection area. It is prepared over a sufficient opening to allow for the introduction of a cholangiocatheter intraoperatively. The biliary duct is well identified here. An intraoperative cholangiocatheter is introduced through an additional opening. A simple and flexible drain is introduced first. Nevertheless, it cannot be positioned satisfactorily into the cystic duct. Indeed, there is most probably an inflammatory stenosis. A rigid drain is then introduced. Its distal part can be opened like the wings of a butterfly so as to ensure the patency of the drain after being introduced. The drain’s introduction is not satisfactory and one is forced to dissect the cystic duct over a slightly increased length. However, since this dissection is not doable entirely, it is decided to immediately perform an endoscopic retrograde cholangiopancreatography.

8. Endoscopic retrograde cholangiopancreatography 10'33''

The patient is left in a supine position. The endoscope is inserted through the mouth. The common bile duct is catheterized in order to be emptied. Balloon extraction of the stones is carried out by means of a Fogarty catheter. Once the common bile duct has been voided, the balloon is kept in place in order to obstruct the bile duct and to allow for contrast medium injection. The objective is to control the anatomy, and especially the entire common bile duct after this uneasy dissection of the common bile duct—hoping that it did not cause any injury. The ERCP already confirms that it is a conventional biliary bifurcation with adequate opacification of the posterior lateral bile ducts. Once the anatomy has been perfectly identified, dissection may be carried on. The imaging studies demonstrated that the cystic duct was persistent over several centimeters and that there was no injury to the common bile duct.

9. Completion of cholecystectomy 11'49''

The artery that has been previously clipped can now be cut. The advantage of this primary control prior to division is to make sure that no other biliary structure will be cut after the intraoperative cholangiography. This strategy helps to ensure that there is no secondary lesion when the dissection is carried on. The imaging studies also helped to confirm that the dissection has been performed at sufficient distance from the common bile duct, here again avoiding any injury to the common bile duct. The dissection is continued progressively in a retrograde fashion by using monopolar cautery and monopolar scissors. The main objective is to avoid any parenchymal wound that may be uneasy to control in this inflammatory cholecystitis-related area. During the onset of small superficial vascular wounds in the detachment bed, a complementary cauterization, ideally using bipolar cautery, is performed before completing the freeing of the gallbladder to maintain a clear operative field. An extraction bag has been placed inside the abdomen. It is directly positioned above the liver. It allows for the introduction of the emptied gallbladder along with the gauze pad that was still there. The cystic duct is controlled by a suture.