Laparoscopic cholecystectomy: a step by step basic procedure

Authors

D Mutter, J Marescaux

Abstract

This video shows detailed steps when performing laparoscopic cholecystectomy.

Mots-clés

Laparoscopic, cholecystectomy, step by step, basic, procedure

Type de vidéo

Durée

17'50''

Publication

2010-11

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2010;10(11).
URL: http://www.websurg.com/doi-vd01en3036.htm

Laparoscopic cholecystectomy: a step by step basic procedure

1. Introduction 00'18''

Here we have a typical case of a 60-year-old woman, who presented an acute pancreatitis three months ago. This was spontaneously healed and we performed preoperatively an MRI that confirmed the lack of stones in the common bile duct. We have the policy in our unit not to perform any intraoperative cholangiography systematically if there are no more bile stones. That is the reason why we have performed an MRI.

2. Patient and trocar position 00'51''

The standard installation that you have here is the patient in a French position; the surgeon will stay between the legs. I have just placed the first port in order to have a very clear positioning of the anatomy. I have drawn on the skin the costal margin, the xiphoid appendix, the second costal margin, the iliac crest that you see here, so we have the landmarks. The umbilicus is just above the trocar and I’ve placed the first 10mm trocar into the umbilicus by a direct approach. We don’t use a Veress needle, we do systematically a direct approach. Positioning of the trocars: we want to create a triangulation for the operator to operate, I will place one 5mm trocar on the midline with a distance of 7cm between the optic and the trocar; the second 5mm trocar here, to have a good triangulation at the level of the gallbladder and I will add one retracting trocar, which is placed very high. Usually we try to place it at the level of the xiphoid appendix, we’ll place approximately here to have it also on the midline to have an esthetic scar and to have the possibility to retract the gallbladder from a place out of the operative field. I will make immediately the three little 5mm incisions and I will place under direct control with a safety movement, you see, a protective movement. I will insert the trocar with a direct control under the view. Here you see the view. The trocar is inserted very easily thanks to its blade. It is a very effective single-use trocar. Under direct vision, I will place a second trocar on the midline, and then I will place the third trocar at the level just below the xiphoid appendix, a little bit higher thanks to the insufflation, and I will insert it directly in the abdomen. It is at the level of the round ligament. Usually we start by placing the trocar directly on the side of the gallbladder and we will see if we need or not to retract the round ligament. I will move, I will go between the legs of the patient, surgeon between the legs, one assistant on the left of the patient. We gently grasp the gallbladder approximately at the level of the liver. We retract the gallbladder and we have a very nice exposure. In the left hand, I will place another retracting forceps, which will be a dissecting forceps. It should allow to control the dissection area. I work with a 0-degree optic. Here we see the duodenum. Here we see the dissection area. There are very smooth adhesions related to the previous pancreatitis. The stomach is empty. There is no other abnormality seen in the operative field.

3. Dissection of adhesions 04'02''

Here you see the duodenum, the gallbladder neck. I will first free gently the adhesions below the gallbladder neck and you see that even with 20 Watts there is absolutely no problem to cut these smooth adhesions. Advantage of this low voltage current is that there is very few diffusion of electricity and so, almost no risk of damage at the distance of the application of the cautery. Here we see that we identify the position of the common bile duct.

4. Exposure of Calot\'s triangle 04'38''

Here is the triangle of Calot. The objective will be to open first anteriorly, and then posteriorly the peritoneal sheet. I will grasp the peritoneal sheet and I will, only using the monopolar cautery, which is very useful in this type of surgery, open anteriorly and posteriorly the peritoneal reflection at the level of the triangle of Calot. Again, the objective is to free the peritoneal reflection over the triangle of Calot. The direction of dissection is always up and towards the liver and never down towards the common bile duct. You see that the hook is always looking upwards. Second thing, I always have a view by transparency in order to avoid grasping any structure that should not be coagulated at this step. After having dissected upwards, I will do a posterior freeing of the reflection of the peritoneum, and this will have its advantages to free and to lengthen Calot’s triangle. I preserve a little distance of 2mm in order to avoid injury of the liver and dissection is done until here, you see a little vessel, and usually when you make this opening, you always identify a very short vessel going from the liver to the gallbladder.

5. Dissection of cystic duct and artery 06'16''

The next step will be the freeing of all the little surrounding elements around the neck of the gallbladder. We never try to identify the common bile duct, that is not necessary as long as you stay in the area of Calot’s triangle close to the gallbladder neck. Here you see very well that there is an artery. That is the problem of pushing on Calot’s triangle: it makes that the cystic duct, certainly here, is pushed over the hepatic hilum. Here you see the common bile duct, and when I push like that over the hepatic hilum, I have certainly the right hepatic artery. It would be very dangerous to dissect here, too close, because there is a risk to grasp the right hepatic artery. The fundus that was lengthened thanks to the initial opening is here. The dissection area is close to the gallbladder and it’s very important always to dissect and to open close to the gallbladder, but there is always this risk of misunderstanding of the anatomy with a major vascular injury. From here you see that there is a very nice dissection of this area, certainly the hepatic artery, and probably a cystic artery. I don’t know if I am before or after the division of the anterior and posterior cystic branches, so I only change the orientation of my exposure. I don’t change the grasping of the gallbladder and I will do exactly the same type of dissection but anteriorly at the level of the liver. Now how is the anatomy going on? Here we see the common bile duct, we don’t dissect close to it, you see, the cystic duct has to have 1cm. At this step, I’m not sure to have eliminated the presence of any anatomical abnormality. That’s why, when I don’t do intraoperative cholangiography, I must have a perfect identification of the anatomy with at least 1cm of dissection of the cystic duct. Here we’ll take the infundibulum a little bit stronger to go ahead and to have the possibility to expose the origin of the vessels, because if I have the cystic duct here, I will go and look for the artery. Here again, there are some very small adhesions, and I guess that I am identifying the cystic artery. I can continue a little bit this dissection always in the direction of the gallbladder in order to keep a good length of the cystic duct. So what is the anatomy now? From upwards, we have a complete dissection of the Calot’s triangle, which is completely open. There is no other duct between the liver and the gallbladder. This means that there is no abnormality of the right hepatic duct that you see here. I expose for didactic reasons from behind to confirm the position of the cystic duct, at approximately 1cm from the main hepatic duct, cystic artery, and, in fact, the right hepatic artery going here. I am going into the liver here and, originating from the right hepatic artery, the cystic artery. At this level, the preparation is done. I will take out the hook, take the clip applier, and I will relax a little bit the tension up here in order to have more distance. You see the good exposure of the triangle of Calot, which is a perfect exposure requested to avoid any injury.

6. Clip application and division 10'14''

The first clip is probably the most important one. It’s the clip that controls completely the cystic duct. We see posteriorly its area of application. A second clip can be placed to ensure the first clip and one clip will be placed on the side of the gallbladder. Again, all these clips are placed and controlled to overlap completely over the duct. I place the clip on the hepatic artery. I have controlled if it is occluding the artery completely. You see that there is a complete control of the artery with the clip 1mm over the artery; one clip for the patient; one clip for the surgeon. The clip must not be one over the other, otherwise you can open the clip. One clip will be placed on the side of the gallbladder to control it completely. I always check before section. First of all, cut half of it, control if the clips are well placed, control that the structure is the one that is expected. Here it is the cystic duct. It is controlled, clipped and we do the same with the artery. If you clip half of it, if there is bleeding at this stage, you still have time to put another clip or another way of control. Here the triangle of Calot’s area is completely free.

7. Retrograde dissection 11'38''

You see again that I don’t change the position of presentation of the gallbladder and I will start the dissection. Monopolar cautery opens the peritoneal reflection as long as there is a good exposure. It can be 1cm, it can be 2 or 3cm. The objective is to diminish the tension on the gallbladder. I do the same on the opposite side, but here you see that I have 1cm between the gallbladder and the liver. The objective is really to stay in this avascular plane and to avoid any tear into the liver, which could be associated with bleeding. If there is any association with bleeding, the only way to clear it will be to use the bipolar cautery. For this step you can use the system you want but the hook is very effective as it allows very progressive cautery. We first open the peritoneal reflection. At this step, a little error would be to open the gallbladder because we know that bile in the abdomen can be associated with postoperative pain. The cautery is very low at 20 Watts, there is very few diffusion. I change and I do the same from a posterior view and I will go ahead freeing posteriorly the gallbladder. See: the trick is to stay away from the liver and close to the gallbladder because adhesions are always at the level of the gallbladder. Here there was a little incorrect dissection area. When I apply a little bit cautery on the elements that are under tension, there is a progressive freeing of the adhesions. Here I will have again to change the position of the gallbladder. The peritoneal reflection line is here. We can grasp it this way. The gallbladder is almost completely free. If you have any doubt, there is really no problem to complete the coagulation, for example as I do here. The best way to control it is to do like that. Now there is no bleeding. I have a bag that I can insert and can free completely in the abdomen. That’s very important because it’s the only way to take out the gallbladder into a bag with three 5mm ports and a 10mm one. The position of the trocar is looking in the direction of the gallbladder. I will hold the trocar to avoid its displacement. I will insert the bag, push the bag, which will be inserted directly at the correct place. With the second grasper I hold the bag like that so the bag is kept open. Thanks to this position, it’s very easy to use this grasper to push the gallbladder immediately in the bag. I close the bag and then I will hold this plastic sheet with the grasper of the epigastric port, and I will introduce the grasper into the trocar as you can see here. Now that it is in, you see that I can take out the optic. I will push on the grasper to have it completely in and then from this position, I have the bag. Now my assistant opens and takes out the bag, and immediately I take the bag at the level of the skin. Second problem: I know that I have a lot of bile in the gallbladder. I look if it can go slowly out. As in frequent cases, I will have to empty the gallbladder. The bag will play the role of a protective sheath. I hold the bag with 2 graspers and I open the gallbladder into the bag. I perform suction of the bile and by emptying the gallbladder it’s possible to take it out. In case I have resistance, it is related to the stones in the gallbladder. I hold the gallbladder. I go inside to open the gallbladder largely to grasp the stones and by grasping the stones and placing traction, I have everything out together without having any contamination of the skin incision. I like to control a second time and a last time what is going on in the abdomen. The gallbladder bed is correct. So I put an instrument in and I take the first trocar out. The trocar is out and if I have bleeding, I still have a control of the route of the trocar. Here you see there is no bleeding on this side, no opening on that side, so this is not a bleeding hole. See instrument in, trocar out so there is no pressure on the parietal wall otherwise you can very easily open and make some cautery like that. There is no need to check bleeding at the umbilical trocar site because it was an open approach. OK, no bleeding, trocars are not bleeding from outside nor from inside. The gallbladder bed is perfect.

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