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Biliary lithiasis: cholecystectomy using microinstruments

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Biliary   lithiasis:   cholecystectomy   using   microinstruments

作者群
D Mutter, S Vartolomei
關鍵字
biliary,operation,Calot's triangle,cystic artery,cystic duct,gallbladder,lithiasis
媒體類型
期間
08'00''
刊物
2004-09
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en0073e.htm

Biliary   lithiasis:   cholecystectomy   using   microinstruments

1. Script 00'07''
Cholecystectomy by micro-laparoscopy is performed using a conventional approach. Four ports are used. The first 1.6mm port is inserted below the costal margin. A 2mm port is placed at the midline and a second 1.6mm port is placed in the right iliac fossa. Good vision is ensured using a 10mm optic placed through the umbilicus. The two 1.6mm ports and instruments are used in order to expose the gallbladder. The infundibulum is very well exposed in this patient and we use the 2mm instrument to perform the dissection. These are single use 2mm scissors that can be used with electrocautery. Using this instrument, we will perform a very slow and progressive dissection of all the elements with progressive coagulation in order to avoid any bleeding or oozing of blood in the operative field because such an oozing would considerably alter the view of the operative field when using the 2mm optic. The same 2mm port will be used later to introduce a 10mm clip applier in the umbilicus. Dissection of the Calot’s triangle is performed conventionally. The anterior and posterior sheet of the peritoneum is opened progressively and the cystic duct and artery will be progressively be dissected. The drawback of this 2mm instrument is that it cannot be placed in a wrong direction because they are very quickly bended if any traction is performed on this instrument. So the dissection is much slower than using a conventional technique and all the fibrous and peritoneal elements are very slowly dissected in order to be clearly controlled and coagulated. To apply the clips using the 2mm ports, the exposure must be done very slowly. The cystic duct and artery must be very well dissected to avoid any confusion between the common bile duct and the cystic duct and between the right hepatic artery and the cystic artery. Dissection is done very slowly to coagulate all the vascular elements in the operative field. The position of the 1.6mm instrument is not changed during the dissection to avoid any perforation of the gallbladder. In fact, the extremity of this instrument is very thin and frequent mobilization and traction of this grasper on the gallbladder would entail a tear in the gallbladder wall in the patient (here it’s not an acute gallbladder) and would result in perforation of the gallbladder. The dissection of the elements is completed to have a perfect recognition of the elements. Then the 10mm optic is removed from the umbilicus. A 2mm optic is placed in the 2mm port and through the umbilical port is inserted a 10mm clip applier. This will ensure a very safe control of the cystic duct and here of the cystic artery by clip application. When the clips are applied on these elements, the 2mm optic is removed. A 10mm optic is replaced in the umbilicus. The position of the clips is controlled under good vision and then the cystic duct and artery will be cut progressively using scissors introduced again through the 2mm port, which is on the midline of the patient. Division of the elements is performed slowly to control by coagulation all the thin vascular elements lying in the operative field. Then dissection of the gallbladder bed can start. Coagulation is set at a very low level because due to the thin extremity of the instrument, coagulation can induce bleeding of any small artery, which is difficult to control with the small instrument. When a small bleeding occurs as is the case here, we control it using the 1.6mm instrument. We change again the position of the port placing a 2mm optic in the 2mm port, which allows us to place a bipolar coagulator in the umbilicus through the 10mm umbilical port. Bipolar cautery allows to control easily small bleeding of the small artery, and then the coagulation and dissection of the whole gallbladder bed can be done very progressively and safely with the 2mm scissors. The difficulty of presentation of tissues and difficulty of dissection using these small instruments make it that we restrict the indication in thin patients to patients with no inflammation of the gallbladder and in patients with no abdominal adhesions. In fact, an acute cholecystitis would lead to a very long-lasting dissection that we consider inappropriate for this patient. The advantage of the 2mm and 1.6mm instruments is essentially a cosmetic benefit and this is mostly interesting in young ladies and thin patients. Dissection can be very progressively completed and the gallbladder will be removed from the abdomen through the umbilical port. To do so, we will have to introduce the 2mm optic in the 2mm port at the end of the operation, then to insert a retrieval bag through the umbilicus. At the end of the operation, the gallbladder bed will be washed with a suction-irrigation device, also available in the 2mm size. This will allow removal of any blood in the operative field in this patient who had a small hemorrhage during the dissection. We don’t usually place any suction drain after this operation. The gallbladder is removed after controlled insertion in a retrieval bag introduced through the umbilicus. The scars are very limited in this patient. The 10mm scar is completely hidden in the umbilicus and three scars less than 2mm can be seen on the abdomen.