Choledocholithiasis: laparoscopic approach by choledochotomy

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Choledocholithiasis:   laparoscopic   approach   by   choledochotomy

Authors
D Mutter
Mots-clés
biliary,operation,Calot's triangle,cystic artery,cystic duct,gallbladder,lithiasis
Type de vidéo
Durée
20'00''
Publication
2005-06
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Jun 2005;5(06).
URL: http://www.websurg.com/doi-vd01en0074e.htm

Choledocholithiasis:   laparoscopic   approach   by   choledochotomy

1. Case demonstration 00'17''
We have a very obese patient with acute cholecystitis, we have placed 4 ports to start the procedure with the first port on the umbilicus, a 5mm port on the epigastric, one port very close to the medial line; this is an obese patient so there is a longer distance between the gallbladder and the midline and also the port from the lower right quadrant that is also placed a little bit higher than is normal because of the patient’s obesity. We found an acute cholecystitis in the abdomen with an inflammatory cystic duct. Here you see the gallbladder, we have freed a lot of adhesions all along the gallbladder and at the moment, we have identified the common bile duct that seems to be dilated. Here you can see the common bile duct, and here we have identified the cystic duct, very inflamed, we have also identified an artery that may be the right hepatic artery or the cystic artery just behind our duct. You see that we have not completely dissected the cystic duct but we have to go on with our dissection, we go very slowly because it may be dangerous and it is difficult to dissect and identify all the planes. I usually work with a 0 degree optic. This case is difficult, it is an obese patient; what do you think of the positioning of the optical trocar higher than the umbilical area, between the xiphoid and the umbilicus? and so putting the trocar higher in the upper abdomen, in the epigastrium, you will have a 0 degree and a more vertical approach and maybe a better one, more similar to what you could get with open surgery. I agree: it has been demonstrated that the view you obtain with a vertical approach is closer than that of open surgery. On the other hand, we are now trying with this approach and we have identified a lot of landmarks that we try to find again when operating. When you are used to work with one view, it is easier to go on with the same view for the next operations, in fact, we mainly work with 0 degree optics and very rarely use 30 degree ones. I agree that when you are not used to the 30 degree view, it is difficult to convert, it really is a question of experience; to facilitate the approach of the hepatoduodenal ligament, especially to have a more vertical approach, I am not changing the optic, I am just changing the trocar position so I have a more vertical and a better view. It is much easier for the assistant to orientate a 0 degree optic and we know that younger surgeons have more difficulty with the orientation of a 30 degree optic, that is another reason why the 0 degree is easier to use. Here you see that I have now identified and isolated the cystic duct, I have not cut anything. I think that I will be able to place a clip on the infundibulum of the gallbladder and perform an intraoperative cholangiography. Here is the cholangiography that I have done, I have had a technical problem and you see that there is contrast product out of the cystic duct. Here is one following the technical problem, there is a very thin and very long cystic duct that will make opacification of the lower part of the common bile duct, here you see 2 biliary stones at the lower part of the common bile duct, we have no contrast medium going into the duodenum and now I am pushing the product harder in order to have an upper visualization of the common bile duct over the cystic duct. When I push hard on the syringe, you see that the bile stones are moving upwards, here you see them in a bad quality because I had this medium out, and here I have opacification of hepatic duct, it is not a very good opacification but I am sure to have the cystic duct. This image has to be compared to the intraoperative image that I show you now. Here there are clips on the infundibulum, there is a really acute cholecystitis and it’s difficult to dissect the duct. Here I have identified the common bile duct, here I am at a good distance for my operation and here I have the inflammatory cystic duct and I have had problems in the identification of the cystic duct here, this is why I had contrast medium coming out of this cystic duct. On the X-ray image that you have shown us, I could really not identify the right hepatic branch, it looked like the left one was visible but I couldn’t really see the right one. I agree that the bifurcation is behind the remnant product and I did identify exactly the bifurcation but I’ll clean my optic, when I look at the position of my clips on the gallbladder here, that are really under Hartmann’s pouch and the position of my common bile duct. First, this is a difficult case and I agree that dissection with the hook dissector is very dangerous in this case and I will use blunt dissection with the peanuts on the forceps in this case; on the other hand, there is obviously a stone in the duct and the cystic duct is too small so you have to do a choledochotomy, now I agree that this is the common bile duct; at the beginning of your dissection, I was not sure at all because you are quite far off the cystico-choledochal junction and you have to dissect the hepatoduodenal ligament to be sure that you are not confusing the hepatic artery and the common bile duct. Hopefully for you, there is not too much inflammation at the level of the hepatoduodenal ligament, there is more inflammation at the level of the cystico-hepatic junction. Here with blunt dissection, I have a very good exposure of the common bile duct, here I have the duodenum and I think I will be able to make a short choledochotomy at this place. I will introduce one more port. But you have to repeat at some stage the intraoperative cholangiography because there are 2 reasons to do one; the first is the stone problem and the other is a bilic injury problem. For the first, you are sure there are stones in the duct, for the other you didn’t have a very nice opacification of the whole biliary tract and I agree that you have to repeat the cholangiogram at some stage of the operation to be sure that everything is perfect, especially after such a difficult dissection in a difficult situation. I agree with you, my idea is now to perform the choledochotomy, get the stone out, then I will insert a T-tube drain in order to do an easy cholangiography. One more port here in order to lift the liver, it is in fact important to retract the liver and here in the internal image, you can see that the liver is retracted with the liver retractor. I have a good presentation of the common bile duct, I think that my presentation is wide enough and I will perform a choledochotomy. I perform a small opening of the duct with my 11 blade and I will continue the opening with scissors in order to avoid posterior injury. You see that there is an infection in the common bile duct. OK here I have the first stone out, I will take it out immediately with the grasper. I will try to wash the duct in order to see if some other stones are coming out; no stone is coming out from the lower part and I will invert my instrument and do the washing on the upper part. Are you recommending routinely when you have opened the common bile duct to wash the duct with irrigation pressure, I am always personally a little bit afraid that the duct will go everywhere and especially in the upper part of the intrahepatic bile duct, where they are more difficult sometimes to reach. OK, I will do what you say and not flush upwards and immediately perform my choledochoscopy. What do you think about stay sutures at the cutting edge of the common bile duct, do you think that it is necessary? I don’t routinely put these sutures because it is very difficult I believe to hold these sutures in a satisfactory way. I think it is also dangerous because they can rip out and damage the common bile duct. I will perform my choledochoscopy, here I have the papilla, normally I avoid going in the duodenum in order to avoid postoperative pancreatitis. Now I will go slowly back. The choledochoscope is a 5mm. I am here at the level of my incision and here I am out. Now I will stop the irrigation. To summarize, we have seen that there are no more stones in the lower area of the common bile duct and the papilla looked normal to me. Now I will go to the upper part of the ducts, I can see very clearly the bifurcation and I always try to see the second division that I have here. There is no residual stone on the left side. Sometimes you see we have problems with the orientation of the scope, and here we are on the right side. Here you see the papilla, the best way to explore the duct is not to go forward with your scope but to go backwards and that is what I do very slowly because backwards you have fewer chances to miss a stone. It is always possible to miss a stone, the problem is we have very high quality material, new optics, a brand-new choledochoscope and despite this, you see that it is very difficult to have an optimal exploration of the duct. I agree that I will put a T-tube, and here I am coming out of the duct.