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Cholecystectomy using microinstruments
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摘要
The description of the cholecystectomy using microinstruments covers all aspects of the surgical procedure used for the management of common bile duct stones.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection of Calot's triangle, intraoperative cholangiography, clipping and dividing, dissection of gallbladder bed.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection of Calot's triangle, intraoperative cholangiography, clipping and dividing, dissection of gallbladder bed.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2001-02
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Feb 2001;1(02).
URL: http://www.websurg.com/doi-ot02en015.htm
URL: http://www.websurg.com/doi-ot02en015.htm
Cholecystectomy using microinstruments
1. Introduction
Needlescopic surgery aims to reduce instrument size:10 mm - 5 mm - 2 mm - 1.6 mm
Objectives:
- decrease parietal trauma,
- decrease postoperative pain,
- shorten hospital stay,
- improve patients’ well-being,
- improve cosmetic results.
2. Biliary anatomy
• Common bile duct
The right and left hepatic ducts collect bile from the liver; they merge to form the hepatic duct, which passes downward in the free edge of the lesser omentum, where it is usually joined at an acute angle by the cystic duct, to form the common bile duct (CBD). It passes behind the superior portion of the duodenum, in front of the portal vein, and to the right of the hepatic artery; it then runs in a groove near the right border of the posterior surface of the head of the pancreas. It usually unites with the pancreatic duct and opens into the duodenum by a common orifice at the ampulla of Vater (major duodenal papilla).1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Variations/extrahepatic ducts 1
• Principles
A sound, working knowledge of the anatomic variations will facilitate intraoperative identification of the various ductal structures. Complete identification of the structures of Calot’s triangle before any duct is opened or divided is mandatory to safeguard against potentially serious complications of this surgical procedure.• Variation 1
Cystic duct insertion of the right lateral (posterior) segment• Variation 2
Duct of Luschka• Variation 3
Duct of Luschka• Variation 4
Direct drainage into the gallbladder of the right lateral (posterior) segments and right paramedian (anterior) segments• Variations/extrahepatic ducts 2
• Variation 5
Gallbladder insertion of accessory right hepatic duct• Variation 6
Congenital absence of a cystic duct• Variation 7
Low union with common hepatic duct• Cystic duct
The cystic duct is around 4 cm long, runs downward and medially to join the hepatic duct to form the common bile duct. The mucous membrane lining its interior is thrown into a series of crescentic folds, from five to twelve in number (cystic valves). The cystic duct usually enters the common bile duct at an acute angle. However, the cystic duct may run parallel to the common hepatic duct for a variable distance before joining it on its right side or pass anterior or posterior to the common hepatic duct before joining it on its left side. In addition, the cystic duct may join either the right hepatic duct or a segmental branch of the right hepatic duct. An accessory hepatic duct or cholecystohepatic duct (duct of Luschka) may also enter the gallbladder through the gallbladder fossa and if encountered during a cholecystectomy should be ligated to prevent a biliary fistula.
• Variation 1
Anterior crossing, left insertion• Variation 2
Posterior crossing, left insertion• Variation 3
Lower insertion3. Vascular anatomy
• Hepatic artery
From the celiac trunk, the common hepatic artery passes anteriorly and to the right, to the upper margin of the first part of the duodenum, forming the lower boundary of the foramen of Winslow. It then crosses the portal vein anteriorly and ascends between the layers of the lesser omentum to the porta hepatis as the hepatic artery. Here it divides into two branches, right and left hepatic arteries, which each supply the corresponding lobe of the liver. The hepatic artery, in its course along the free edge of the lesser omentum, is in relation with the common bile duct and portal vein, with the duct lying to the lateral to the artery, and the vein behind (portal triad). The left hepatic artery may have its origin from the left gastric artery in about 15-20% of the patients. The right hepatic artery may originate from the superior mesenteric artery in up to 20% of cases.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Cystic artery
The cystic artery is usually a branch of the right hepatic but may also originate from the left hepatic, common hepatic, gastroduodenal, or superior mesenteric arteries. The cystic artery is usually located within the borders of Calot’s triangle (hepatic duct, cystic and lower border of liver). It usually enters this space by passing from behind the hepatic duct but there are a number of variations. The cystic artery divides into anterior and posterior branches before entering the gallbladder. 1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Variation 1
Double cystic artery; one posterior-inferior and one anterior-superior to the cystic duct• Variation 2
Double cystic artery; both superior to the cystic duct high in Calot’s triangle• Variation 3
Cystic artery originating from the proper hepatic artery• Variation 4
Cystic artery originating from a normal left hepatic artery, high in Calot’s triangle• Variation 5
Cystic artery originating from the celiac trunk, anterior-superior to the cystic duct• Biliary tract blood supply
The blood supply to the extrahepatic biliary tract originates distally from the gastroduodenal, retroduodenal, and posterior superior pancreaticoduodenal arteries and proximally from the right hepatic and cystic arteries. These arteries supply the common bile duct and common hepatic duct through branches that usually run parallel to the duct in the 3 and the 9 o'clock positions.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
• Portal vein
The portal vein is about 8 cm long, and is formed at the level of the second lumbar vertebra in front of the inferior vena cava and behind the neck of the pancreas by the union of the superior mesenteric and splenic veins. It ascends in the free edge of the lesser omentum behind the biliary tract and hepatic artery. It divides into a right and a left branch, which accompany the corresponding branches of the hepatic artery into the substance of the liver. It is accompanied by a rich lymphatic plexus. The right branch of the portal vein enters the right lobe of the liver, but before doing so it generally receives the cystic vein.1. Gallbladder
2. Cystic duct
3. Common bile duct
4. Proper hepatic artery
5. Cystic artery
6. Gastroduodenal artery
7. Portal vein
8. Abdominal aorta
4. Indications
IndicationsThis approach is theoretically indicated for all elective cholecystectomies.
In practice, it is indicated for:
- thin patients;
- non-inflammatory gallbladders.
Contraindications
- obesity;
- cholecystitis;
- adhesions.
5. Advantages
Advantages:- reduced pain due to the smaller incisions (not statistically proven);
- improved cosmetic results (incisions = 1.6 mm 1.6 mm 2 mm 10 mm or a total of 15.2 mm);
- quicker return to normal activities as there is no muscle damage.
Disadvantages:
- elevated cost of instrumentation;
- fragility of the instrumentation, especially the pliable 1.6 and 2 mm instruments, which must be perfectly positioned;
- difficulties in dissection due to the pliability of the instrumentation;
- relatively poor quality of the micro-laparoscope images due to image transmission by optical fibers instead of by optical lenses and reduced amount of light entering the needlescope;
- longer operative time.
6. Operating room setup
• Patient
The operating room must be large enough to accommodate all necessary anesthetic, laparoscopic and radiological equipment. The operating table must be properly adapted for intraoperative radiography.- supine position;
- left arm at a right angle;
- right arm secured alongside the body;
- legs apart.
• Team
1. The surgeon is positioned between the patient’s legs. 2. The first assistant is on the patient’s left side.
3. The second assistant’s position varies depending on the teams, but is most often to the patient’s right, facing the first assistant.
• Equipment
1. Radiological equipment (optional)2. Laparoscopic unit
3. Anesthetic unit
4. Laparoscopic unit (optional)
5. Instrument table
6. Electrocautery
7. Operating table
7. Trocar placement
• Principles
Positioned close to one another, the trocars are introduced under direct visual control facing the gallbladder.• Optical trocar A
Size: 10 mmSite: Umbilicus
Instruments:
Optical: laparoscope
Operating: clips, bipolar grasper, extraction bag
• Operating trocar B
Size: 2 mmSite: One-third of the way between the xiphoid process and the umbilicus, and one fingerbreadth from the midline.
Instruments : scissors with cauterization capabilities for dissection, suction-irrigation device, needlescope during clip application.
• Retractors
Trocars C and DSize: 1.6 mm
Site: right lateral and right subcostal positions
Instrument: retractor (assistant), retractor and operating grasper (surgeon)
8. Instrumentation
• Laparoscopes
Two laparoscopes are necessary to perform the procedure. Most of the dissection is performed using a 10 mm, 0° laparoscope. A 3-chip camera with a Xenon or halogen light source is routinely used. The 10 mm laparoscope allows for better visualization of cystic duct and artery during dissection.
The 2 mm needlescope (or micro-laparoscope) lets in a reduced amount of light compared to the conventional laparoscope; therefore, the visual acuity is reduced. The 2 mm needlescope is therefore only used for clip application and for the introduction of the gallbladder into an extraction bag.
The needleports are 1.7 to 3.2 mm in size to accommodate instruments 1.6 to 3 mm in size.
• Micro-instrumentation
• 1.6 mm
- atraumatic grasper;- grasper with ‘teeth’;
- suction-irrigation device;
- dissector;
- scissors;
- reusable trocar
• 2 mm
- atraumatic grasper;- grasper with ‘teeth’;
- hook;
- disposable scissors;
- reusable scissors;
- disposable trocar;
- specific laparoscope: optical fiber (as opposed to optical lens) image transmission.
• 10 mm instruments
- laparoscope with 3-chip camera and cold light source;- extraction bag;
- clip applier (5 or 10 mm).
9. Major principles
Laparoscopic cholecystectomy using micro-instruments is performed following the same principles as conventional cholecystectomy:- identification of anatomical elements;
- dissection of Calot's triangle;
- clipping and division of the cystic duct and of the cystic artery;
- cholecystectomy.
10. Exploration
Objective:- to confirm operabilility using micro-instruments (2 mm);
- to rule out acute cholecystitis and extensive adhesions.
11. Exposure
• Beginning
The operation begins with the 10 mm laparoscope in the umbilical trocar. One grasper is inserted in the most cephalad trocar (via C) to grab the fundus of the gallbladder, and retract it cephalad and laterally. Another grasper (via D) is placed on the infundibulum, retracting the gallbladder caudally and laterally to open Calot's triangle.• Danger
When exposing the gallbladder, caution must be exercised since the needlescopic instruments are fragile and easily damaged. Additionally, the instruments are sharp and can inadvertently cause damage in the abdominal cavity during insertion, withdrawal, and retraction. The same care should be taken when handling the needlescope. The operator of the scope should use two hands to hold it, one hand along the shaft and the other hand holding the camera to avoid breaking the needlescope.
12. Dissection/Calot
• Principles
This operative step is performed using two 1.6 mm graspers (via C and D), 2 mm scissors (via B) and a 10 mm laparoscope (via A).• Dissection of Calot’s triangle
Dissection is started by opening the peritoneum between the gallbladder and the cystic duct using scissors and a grasper. Occasionally, opening the peritoneum between the gallbladder and the liver bed can make the anatomy clearer.• Anatomical dissection
• Principles
Progressive dissection of Calot’s triangle, by cauterizing and dividing fibrous tissues, millimeter by millimeter, allows complete isolation of the biliary and vascular elements, which constitute Calot’s triangle.• Of the cystic duct
The cystic duct forms the lower part of Calot’s triangle. It is usually dissected first. This dissection begins at the infundibulum and is extended along approximately 1 cm, thus keeping at a distance form the common bile duct.• Of the cystic artery
The cystic artery forms the superior-lateral part of Calot’s triangle. It must be identified and dissected above the cystic duct. The dissection is performed close to the gallbladder in order to prevent mistaking the right branch of the hepatic artery for the cystic artery.13. IOC: Technique
• Principles
It is indicated when the presence of CBD stones is suspected.It is used:
- to determine the location, size and number of the calculi;
- to assess the anatomy of the intrahepatic and extrahepatic bile ducts: anatomic variations and size of the CBD.
• Cystic duct incision
Cholangiography is done via a hemicircumferential incision of the cystic duct along its anterior surface to approximately 1 cm from the junction of the CBD. This cysticotomy is performed in order to avoid problems in inserting the cholangiocatheter due to valvulae or plications of the cystic duct. The right margin of the CBD must be identified.• Operating table
The operating table is brought back to a flat position (i.e. taken out of reverse Trendelenburg and left tilt) and a slight right tilt is given to displace the CBD anteriorly.• Catheter introduction
• Procedure
The cholangiocatheter is brought to the cysticotomy site using a rigid introducer, either percutaneously or through the right subcostal trocar. It is inserted 1 to 3 cm inside of the cystic duct and held in place with a clip or a grasper. • Controlling leakage
A blue methylene dye is injected via the cholangiocatheter to make sure there is no leakage.• Cholangiography
• Three steps
The cholangiography should be done in three steps:1. A few milliliters of diluted contrast are injected into the bile ducts under radiographic guidance. A static cholangiogram is able to detect CBD stones.
2. The dye injection is continued until a complete cholangiogram is obtained. A second radiograph is performed to confirm it. The Trendelenburg position may facilitate the opacification of the intrahepatic bile ducts.
3. The passage of dye into the duodenum under low pressure should be confirmed by a third radiograph.
• Catheter removal
The cholangiocatheter is removed and the cystic duct is closed using a clip.14. IOC: Results
The presence of stones in the CBD is suspected when the radiograph demonstrates:- radiolucent defect(s);
- a crescent-shaped blockage of the contrast;
- dilatation of the bile ducts;
- the absence of passage of the contrast into the duodenum.
The thorough analysis of both the calculi and morphology of the bile ducts facilitates choosing between a transcystic approach or a choledochotomy.
15. Clipping and dividing
• New instrumentation
The 2 mm needlescope is introduced into the 2 mm median line trocar in place of the 2 mm scissors (via B).The 10 mm clip applier is inserted through the umbilical trocar in place of the laparoscope (via A).
• Clipping
• Principle
Application of the 5 mm or 10 mm clips is performed under guidance of the needlescope inserted in the left lateral trocar (via B).• Cystic duct
A clip is first applied around the cystic duct with a 5 or 10 mm clip applier inserted through the umbilical trocar (via A).• Cystic artery
A clip is applied around the cystic artery, either before or after dividing the cystic duct, with a 5 or 10 mm clip applier inserted through the umbilical port (via A).• Division
• Principles
The initial positions of the 10 mm laparoscope (via A) and of the 2 mm scissors (via B) are restored.The cystic duct and then the cystic artery are divided under direct visual control.
• Cystic duct
The initial positions of the 10 mm laparoscope (via A) and of the 2 mm scissors (via B) are restored.The cystic duct and artery are divided under direct visual control.
• Cystic artery
The initial positions of the 10 mm laparoscope (via A) and of the 2 mm scissors (via B) are restored.The cystic duct and artery are divided under direct visual control.
16. Dissection GB bed
• Principle
A hook or scissors with electrocautery are used to dissect the gallbladder free from its bed.• Freeing of gallbladder
The gallbladder is dissected free from its hepatic attachments. Care must be taken to perform hemostasis of the dissection zone, step by step. This dissection may be laborious, due to the lack of rigidity and weakness of the graspers.• Introduction into a bag
The needlescope is reintroduced through the 2 mm median trocar (via C). An extraction bag is introduced via the umbilical port and the gallbladder is placed into it under visual guidance of the 2 mm needlescope (via A). The gallbladder is then removed through the umbilical incision. • Danger
• Hemorrhage
Bleeding may occur during dissection of the gallbladder bed.• Clipping
Bleeding is controlled with provisional hemostasis, by means of a clip (via D).• Bipolar cauterization
The 2 mm needlescope is reinserted into trocar B.Coagulation is achieved by a bipolar cautery grasper, introduced through the umbilical trocar (via A).
Extra clips may be required to control the bleeding.
17. End of procedure
• Irrigation
The dissection zone is irrigated at the end of the procedure to clear the operative field.- abundant irrigation (via B).
• Suction
- suctioning the fluid (via B).• Closing
An absorbable suture is used to close the aponeurosis at the level of the umbilicus. The needlescopic trocar openings are simply closed with adhesive bandages.
18. Postop management
- food intake may be resumed immediately and the patient may get up on the evening of the operation;- hospital discharge on day 1 or day 2;
- no specific treatment;
- regular activities may be resumed on day 8;
- athletic activities may be resumed on day 15.