Choledocholithiasis: laparoscopic transcystic exploration

WeBSurg est une université virtuelle accessible mondialement sur Internet. Notre objectif est de fournir aux chirurgiens, aux sociétés savantes et au secteur médical un enseignement médico-chirurgical de pointe en ligne en chirurgie mini-invasive et toute information concernant les dernières avancées en chirurgie laparoscopique, dont notamment la Chirurgie Endoscopique Transluminale par les Voies Naturelles (NOTES) et la chirurgie assistée par robot.

Naviguez dans
l'Université Virtuelle
Français ▼

Choledocholithiasis:   laparoscopic   transcystic   exploration

Authors
J Leroy
Mots-clés
biliary,operation,Calot's triangle,cystic artery,cystic duct,gallbladder,lithiasis, choledochotomy
Type de vidéo
Durée
23'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en0056e.htm

Choledocholithiasis:   laparoscopic   transcystic   exploration

1. Case demonstration 00'18''
We are operating on a 44-year-old male patient that presents with small stones in the common bile duct. This patient was operated on 6 years ago for perforated ulcers by subcostal laparotomy as you can see on the screen, there is probably a risk of adhesions in this abdominal cavity. The first step of this operation will be to go into the abdominal cavity and to locate the operative field and hope that there are not too many adhesions. I think it is possible to try and enter the abdominal cavity after insufflation, or perhaps we will use open laparoscopy on the right side of the superior quadrant or on the horizontal line at the level of the umbilicus outside of the epigastric vessels. I will begin by an insufflation in this area. We are insufflating the abdominal cavity and we have low pressure. With no experience, it is probably better to do this via open laparoscopy, but the gas has spread evenly within the abdominal cavity. We now have 2.3 litres. It is better to wait until 3 or 3.5 litres of CO2 to be sure. I am not sure that there are a lot of adhesions in this case. The patient is placed on the table, both arms are alongside the body so it’s easier and better for the anesthetist and for the surgeon because we can have a lot of positions that can be useful, particularly reverse Trendelenburg position and left lateral tilt during the operation. My assistant maintains the abdominal wall. I don’t open the tap immediately. I want to be sure that I am in the abdominal cavity beforehand. I will start on the right side of the patient because I will probably use a 10 or 12mm port to introduce my scope to finish my dissection. The first step is the freeing of adhesions. Now I will change the position of my port and you will see another lateral exposure will be better. Harmonic scissor dissection is better in this case to have a good hemostasis. The idea is to open this plane because when it is open, it sometimes only sticks, not on the incision, on the scar. For example at this level, it is not the scar, just adhesion between the omentum and the peritoneum and at this level, it is possible to unstick it. At this level, there are adhesions. I think it is useful for the surgeon to work with the scope in one hand and the other instrument in the right hand. Don’t forget that when you use Harmonic dissectors and particularly scissors, never put the metallic part too deep, always seal it. It is perhaps not so good for the picture but it is safer; see it is coming down progressively. I have introduced it at mid-distance between the xiphoid appendix and the umbilicus in the left rectus muscles. Usually, the right port is a 5mm one but in this case I have introduced a 10mm port so I can introduce my scope to see the adhesions laterally. I prefer to use a 10mm because we can see the operative field widely. I will use a grasper I have introduced in the left epigastric quadrant, I put a 5mm port and I’ll give this to my assistant. You see it’s not full, it is as for coagulation. I am not sure this is the good plane and perhaps it is due to the Autosonics because it is so easy to dissect with this instrument. It is not a bad plane of dissection but it was not so useful to use this plane because what I want is to see the subhepatic area. The gravity will help me to expose and I hope to have the omentum. The duodenum will fall and this will expose the subhepatic area better. This part is fairly atraumatic to dissect and it is also useful. So we have another solution, which is to introduce another 5mm port. It is not unusual, it is not a perfect exposure. I want to have a fixed exposure of this area. I try to adapt to the patient and the pathology. The first step of each operation is always like this. I use this approach with Autosonics because there is a lot of adipose tissue as you can see, and in this case it is fairly interesting. The cystic duct is arriving, it is a big cystic duct, inflammatory one. We are on very low coagulation, around 1. Everything goes quickly now because we have good exposure; the first step seemed long. The artery is here. I prefer to put a ligature because if I put a clip, I will have trouble at the end of the operation. Like this, I will be sure that I have enough to do the cholangiography and also for the closure at the end of the operation because there is also the problem of closure. If I only have to close and not suture, I will save some time. Now I’m ready to make a hemi-incision with a ligature, with a clip it is not possible. This is the cystic duct here, there is probably a valvula. I am not sure I will manage because there is inflammatory tissue. I think it’s more than 5mm. So it is more rigid. I have described this in 1992, I presented this idea of having a long port to introduce and have more rigidity. There are some small stones here. I want to control again because it is possible to have these stones in the upper part. I am in the proximal part now. I am exploring the intra-hepatic branches. You have to play with the rotation of the scope in the abdominal cavity and use the mobility of the tip to have proper views. I have graspers that don’t grasp the sutures.