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Laparoscopic cholecystectomy for acute cholecystitis
Authors
Abstract
The description of the laparoscopic cholecystectomy for acute cholecystitis covers all aspects of the surgical procedure used for the management of acute cholecystitis.
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, intraoperative cholangiography, ligation and division, extraction.
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, intraoperative cholangiography, ligation and division, extraction.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-02
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E-publication
WeBSurg.com, Feb 2001;1(02).
URL: http://www.websurg.com/doi-ot02en012.htm
URL: http://www.websurg.com/doi-ot02en012.htm
Laparoscopic cholecystectomy for acute cholecystitis
1. Introduction
Acute cholecystitis (AC) is one of the most frequent causes of an acute abdomen. The decision to operate must be made promptly. The use of laparoscopy for acute cholecystitis is less and less controversial. In fact, many publications have demonstrated that laparoscopic cholecystectomy is currently performed more and more frequently for the treatment of acute cholecystitis including a low mortality, a shorter hospital stay and a lower cost as compared to open cholecystectomy (Csikesz NG et al., 2008). Most publications support this approach even for the elderly (Uecker J et al., 2001) as well as for pregnant patients (Chiappetta Porras LT et al., 2009).
At present, in the hands of skilled laparoscopic surgeons, laparoscopic cholecystectomy for AC appears to be safe and feasible with an acceptable operative time.
Several technical key points must be emphasized.
2. Anatomy
• Location
Note: the anatomy section is identical for all chapters on gallbladder diseases.The gallbladder, situated in the right upper quadrant, is embedded in the liver at the junction of segments IV and V.
The fundus of the gallbladder is generally situated under the right costal margin.
In cases of hydrops or a low-lying liver, the fundus of the gallbladder may drop down as far as the right iliac fossa.
• Topographic anatomy
1. Liver2. Stomach
3. Lesser omentum
4. Gallbladder
5. Hepatic flexure
6. Greater omentum
• Local anatomy
1. Fundus2. Body
3. Infundibulum
4. Cystic duct
5. Common hepatic duct
6. Common bile duct
• Vascular supply
1. Gallbladder2. Cystic artery
3. Mascagni lymph node
4. Proper hepatic artery
5. Abdominal aorta
6. Portal vein
7. Gastroduodenal artery
3. Anatomopathology
In AC, there is an acute inflammation of the gallbladder wall due to prolonged obstruction of the cystic duct or neck of the gallbladder. It may also occur as an inflammatory reaction to the passing of a stone. Inflammatory adhesions can often be found around the gallbladder to neighboring organs such as the duodenum, right colon, and greater omentum.
We distinguish:
- catarrhal acute cholecystitis;
- purulent cholecystitis;
- gangrenous cholecystitis.
4. Anatomical variations I
• Variations in the cystic artery
The anatomy of the biliary tract vasculature is highly variable from one patient to another, especially with the right hepatic artery and the cystic artery. A sound working knowledge of the various anomalies that may be encountered will facilitate identification of the important structures and protect against intraoperative complications.
• Double cystic artery
• Variation 1
Double cystic artery; both from a normal right hepatic artery in the cystic triangle• Variation 2
Double cystic artery; one posterior-inferior and one anterior-superior to the cystic duct• Variation 3
Double cystic artery; both superior to the cystic duct high in the cystic triangle• Cystic artery origin
• Variation 1
Cystic artery originating from the proper hepatic artery• Variation 2
Cystic artery originating from a normal left hepatic artery, high in the cystic triangle• Variation 3
Cystic artery originating from the celiac trunk, anterior-superior to the cystic duct5. Anatomical variations II
• Intra hepatic duct
1. Common bile duct2. Gallbladder
3. Cystic duct
4. Right hepatic duct
5. Left hepatic duct
• Right hepatic duct I
• Duplication
- unique right hepatic duct (53% of cases)- right hepatic duct duplication (47% of cases)
RL: Right Lateral duct
RPM: Right ParaMedian duct
Couinaud C. Controlled hepatectomies and exposure of the intra-hepatic biliary ducts. Paris: C.Couinaud, 1981.
• Trifurcation
- upper biliary trifurcation (10% of cases)- right paramedian (anterior) duct right lateral (posterior) duct left hepatic duct
• Caudal entrance of RL duct
- caudal entrance of the right lateral (posterior) duct into the main channel (6% of cases)• Caudal entrance of RPM duct
- caudal entrance of the right paramedian (anterior) duct into the main channel (20% of cases)• Right hepatic duct II
• Left entrance of RL duct
- entrance of the right lateral (posterior) duct into the left hepatic duct (2% of cases)• Left entrance of RPM duct
- entrance of the right paramedian (anterior) duct into the left hepatic duct (6% of cases)• Segmental branching of RL duct
- upper biliary quadrifurcation (1.5% of cases)- segmental branch (VI and VII) sectorial branch (paramedian) left hepatic duct
• Segmental branching of RPM duct
- quadrifurcation of the upper biliary confluence (1.5% of cases)- segmental branch (V and VIII) sectorial branch (lateral) left hepatic duct
• Left hepatic duct
• Breakdown
- common stem II and III and a separate branch for segment IV in 80% of cases- common stem III and IV and a separate branch for segment II with duplication of the left hepatic duct (20% of cases)
• Unique duct: distribution II, (III IV)
- unique duct, distribution (III IV) and II (10% of cases)• Duplication: distribution (II, III), IV
- duplication, distribution (II III) and IV ( 7% of cases)• Distribution II, (III IV)
- duplication, distribution (III IV) and II (3% of cases)6. Anatomical variations III
• Variations in extrahepatic bile ducts
A sound, working knowledge of the anatomical variations will facilitate intraoperative identification of the various ductal structures. In addition, strict accordance with the basic rules of exposure and of dissection, as well as mastery of laparoscopic skills, will provide further protection from potentially serious complications of the surgical procedure.• Bile and accessory hepatic ducts I
• 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• Bile and accessory hepatic ducts II
• Variation 1
Gallbladder insertion of accessory right hepatic duct• Variation 2
Congenital absence of a cystic duct• Variation 3
Low union with common hepatic duct• Abnormal junctions of the cystic duct
• Variation 1
Anterior crossing, left insertion• Variation 2
Posterior crossing, left insertion• Variation 3
Lower insertion7. Anatomical variations IV
• Morphological factors
Morphological characteristics of patients may require an adaptation of the basic technique.Hypertrophy of the right lobe of the liver or an excessively large gallbladder can present difficulties during the dissection. In these cases, the position of the retracting trocar can be adjusted to allow for improved access to the subhepatic region.
• Unusual localization of gallbladder
The gallbladder may be located inside the hepatic parenchyma, in rare cases.8. Indications
IndicationsClinical symptoms of inflammation at admission:
- hyperthermia over 37.5°C;
- nausea or vomiting;
- severe pain around the right hypochondrium or epigastrium.
Ultrasonic evidence of AC:
- thickened gallbladder wall (>=4 mm);
- distended gallbladder;
- US Murphy's sign when the ultrasound probe is introduced.
Relative contraindications
- patient ASA 4 (moribund) or in Intensive Care Unit with acute calculous cholecystitis (percutaneous cholecystostomy may be a good alternative in these critically ill patients);
- gangrenous cholecystitis (abscesses);
- longstanding AC (over 10 days): this point remains controversial since many recent reviews have found early laparoscopic cholecystectomy safe as it shortens hospital stay, enables a better quality of life, and is not associated with more complications than delayed laparoscopic cholecystectomy (Wilson E et al., 2009).
- surgeon's limited experience in laparoscopy.
Time point for surgery:
For many years, it has been debated that the surgical approach for the treatment of acute cholecystitis, regardless of the surgical approach (open or laparoscopic), should be carried early or should be delayed after the onset of symptoms. Currently, most studies suggest that on average, early laparoscopic cholecystectomy appears less expensive than the delayed approach. The results regarding quality of life do seem improved (Wilson E et al., Br J Surg, 2009). Concerning the surgical results, laparoscopic management of acute cholecystitis is associated with an increased rate of conversion (10-15% versus 1-2%) but is not associated with a higher rate of intraoperative or postoperative complications (Michalowski K et al., Br J Surg, 1998; Csikesz NG et al., Surgery, 2008).
9. Operating room set-up
• Patient
US Reviewers' note: The operating room set-up has been described by a European author. The standard US set-up has been added under the subtitle American school position.The patient is prepped and draped in the usual fashion:
- standard skin preparation;
- sterile field;
The patient is placed:
- supine position;
- left arm at 90°;
- right arm alongside the body;
- legs abducted.
• 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 is usually to the patient's right, opposite 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
• American school position
• Patient
The patient is placed:- in a supine position;
- without abduction of the legs;
- with right arm tucked along the body.
• Team
1. The surgeon stands to the left of the patient.2. The first assistant stands on the right of the patient.
3. In case a second assistant is needed, he or she stands on the right of the patient.
10. Trocar placement
• Standard technique
In most cases, 4 trocars are used. The open approach is strongly recommended, as acute cholecystitis may be associated with bowel obstruction or adhesions.• Optical
The optical port is placed in the umbilical region (or higher in obese patients). • Operating
Two operating trocars are placed in the right upper quadrant and in the left subcostal region. Graspers, scissors, hook, dissector, and clips are introduced through these trocars.• Retractor
The retractor trocar is placed in the epigastric region.The suction-irrigation device is introduced through it.
• Optional
A fifth, optional trocar may be placed halfway between the umbilical trocar and the left subcostal trocar. It is used to pull the duodenopancreatic structures caudally. When this fifth optional trocar is added, the epigastric trocar is used for the suction-irrigation device.
11. Instrumentation
• Optical devices
In addition to a direct view lens (0°), it is necessary to have a scope with a large depth of field combined with a HD camera. A high quality camera is recommended as it significantly increases the possibility of anatomical identification in a difficult status (Singhal T et al., 2009).• Operating devices
Instrumentation 5 mm in diameter is used by most surgical teams.• Retracting devices
Atraumatic graspers must be used. The suction-irrigation device is often used as a retractor.• Optional devices
The effectiveness of ultrasound dissectors on inflammatory tissue remains to be proven.12. Major principles
The aim of this surgical technique is to remove the gallbladder after freeing it from adhesions to adjacent organs.In comparison to elective cholecystectomy, certain technical points must be emphasized:
1. Decompression of the gallbladder so that it may be optimally grasped;
2. Dissection performed in contact with the gallbladder wall;
3. Cautious utilization of ultrasonic cautery;
4. Frequent suction-irrigation of the operative field;
5. Subtotal cholecystectomy in difficult cases: this option remains controversial for most authors; nevertheless, it remains an option for others in a case of major inflammation or fibrosis, which can preclude conventional dissection of Calot's triangle (Michalowski K et al., 1998; Singhal T et al., 2009)
6. Systematic use of an extraction bag;
7. Drainage of the gallbladder bed (debated).
13. Exploration
• Check for peritoneal effusion
Thorough exploration of the abdominal cavity to check for peritoneal effusion and related pathologies is required.• Evaluation of inflammatory process
Exploration of the abdomen should evaluate:- the inflammatory state of the gallbladder and possible necrosis,
- the spread of the inflammation to the hepatoduodenal ligament (porta hepatis).
It should search for:
- the presence of adhesions around the gallbladder (to the omentum, duodenum, colon, etc),
- the presence of collections of bile or pus.
14. Exposure
• Principles
Exposure of the operative field is the first step of all surgical acts. In AC, this operative step is made difficult by inflammatory adhesions to adjacent organs. First, the gallbladder must be identified in the right subhepatic region, then at the level of Calot's triangle.• Exposure of right subhepatic region
• The 3 techniques
In order to open the right subhepatic region (a maneuver made difficult by inflammatory adhesions), 3 techniques are used:- suspension of the liver;
- use of gravity, which naturally lowers the organs towards the pelvis;
- use of retractors on the adjacent organs.
• Suspension
A transcutaneous transfixing stitch is used to lift the liver towards the top of the round ligament, improving exposure of Calot's triangle and of the hepatic pedicle. It is introduced through the abdominal wall below the costal margin to the right of the suspensory ligament. After transfixing the inferior margin of the round ligament near the liver, the thread is pulled out to the left of the suspensory ligament, near its point of introduction. The thread is tightened outside of the abdominal wall on a gauze pad.
• Gravity
The patient is placed in steep anti-Trendelenburg position with a slight left tilt, causing the organs to drop towards the pelvis and the left side. • Retraction
Retraction of adjacent organs must be atraumatic due to the fragile, inflammatory state of the tissues.• Exposure of gallbladder neck
• Principle
Exposure of the gallbladder neck is possible after freeing of the adhesions. This can be achieved after decompression of the gallbladder, which allows the surgeon to properly grasp the gallbladder wall.• Decompression
Using a needle (eg, Veress needle) inserted laterally under the rib cage and through the fundus of the gallbladder, the gallbladder is emptied to obtain a bacteriological sample (routine culture) and to enable proper grasping with atraumatic forceps. • Liberation
Freeing of adhesions is easily accomplished during the first 3 to 4 days of inflammation. Most adhesions involve the omentum, but they can also involve the duodenum and the right colon. Ideally, a dissection plane should be found, with attempts to minimize unnecessary bleeding.15. Dissection
• Calot's triangle
Dissection of Calot's triangle is the most delicate step of the operation. Access to it is often difficult due to an incarcerated stone that displaces the infundibulum towards the hepatoduodenal ligament. Inflammation may induce adhesions between these structures.• Dissection progress
1. Infundibulum2. Cystic duct
Once the inflammatory adhesions surrounding the gallbladder have been removed, dissection of Calot's triangle always begins at the suspected junction between the neck of the gallbladder and the cystic duct. It should never start at the junction of the cystic duct and the common bile duct (CBD) due to the fact that the cystic duct is sometimes very short and may therefore be confused with the CBD.
Dissection of the cystic duct is carried out 1 cm distal to the neck of the gallbladder towards the CBD. Contact with the gallbladder wall must be the rule while Calot's triangle is being dissected.
• Technical insight
Depending on the preference of the surgeon, he or she may choose from a variety of instruments for dissection: monopolar hook electrode, ultrasonic scalpel or hook, monopolar scissors, dissector or peanut swabs. In AC, the presence of inflammatory tissues always makes the operative field more hemorrhagic. The following measures are therefore necessary:
- utilization of a high-performance light-enhancing HD video camera: a high quality camera is recommended as it significantly increases the possibility of anatomical identification in a difficult status (Singhal T et al., 2009);
- frequent irrigation and washing of the operative field with a suction-irrigation device.
• Danger
Electrocautery should only be used selectively and with extreme caution. In case of diffuse effusion from inflammatory tissues, the electrical conductivity is increased due to water content whereas the efficiency of the electrocautery is diminished. The danger therefore lies in increasing the electrical power in contact with the biliary tract (with a resulting risk of secondary necrosis or stenosis). • Variation
In case of a large stone impacted in the gallbladder neck making access to the triangle of Calot difficult, after suctioning out the gallbladder contents, the gallbladder neck may be opened and the stone removed and placed in a plastic bag introduced into the abdominal cavity through a trocar. Once the surgeon has identified the location of the cystic duct from within the gallbladder lumen, the dissection of the cystic duct and superior aspect of Calot's triangle may begin. This is particularly useful in case of inflammatory adhesions between the gallbladder and the hepatoduodenal ligament.
16. IOC: technique
• Indications
This 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 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.• Position of operating table
The operating table is brought back to a flat position (ie, taken out of reverse Trendelenburg and left tilt) and a slight right tilt is given to displace the CBD anteriorly.• Cholangiography
• Catheter introduction
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.• The 3 steps
The cholangiography should be done in 3 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.• 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.
Thorough analysis of both the calculi and morphology of the bile ducts facilitates choosing between a transcystic approach or a choledochotomy.
17. Ligation and division
• Approach
This operative step is delicate and often hemorrhagic due to the inflammation of the tissues. There is sometimes no dissection plane between the liver and gallbladder. Conventionally, a retrograde approach is used to perform the cholecystectomy, but this will depend on the operative findings and difficulties, which may necessitate a change in strategy.• Division
• Cystic artery
The cystic artery may adhere tightly to the gallbladder and hepatoduodenal ligament. It must be meticulously dissected before being clipped and divided.• Cystic duct
The division of the cystic duct should be performed as close to the gallbladder as possible, checking that no stones are present in the distal portion of the cystic duct.• Retrograde dissection
Dissection of the gallbladder bed can be performed using a hook electrode or scissors. These instruments are useful when dense fibrotic tissues are present between the liver parenchyma and the gallbladder wall. In case of major inflammation, liberation of the gallbladder from the liver may be difficult and hemorrhagic since the plane of cleavage is barely, if not at all, existent. When the plane is difficult to find, part of the gallbladder wall can be left in contact with the liver.• Hemostasis of gallbladder bed
To achieve hemostasis of the gallbladder bed, in addition to electrocautery, it is sometimes necessary to use an absorbable hemostatic gauze sponge or 'figure of eight' stitches. Certain authors use other methods, such as the Argon Beam.• Danger: enlarged cystic duct
After ligation, the cystic duct is divided at a distance from the CBD. Putting clips on an inflammatory and often enlarged cystic duct is risky. Clips must therefore be used with caution.
If the outer measurement of the cystic duct is over 6 mm in diameter, it cannot be closed with clips of 8 mm maximal length. In this case we suggest using either a ligature with an intra- or extra-corporeal knot (eg, surgical loop), or placing a suture on the cystic stump.
• Variation: dissection of gallbladder bed
In case of difficulty in identifying the plane of dissection between the gallbladder and the liver (<10% of cases), part of the gallbladder wall can be left in contact with the liver. In this case, the mucosal surface of the gallbladder wall that is embedded in the liver bed is cauterized.18. Extraction
At the end of the procedure, the gallbladder is placed in a protective retrieval bag to avoid any contamination of the abdominal wall during extraction.The extraction is most often performed in the left hypochondrium area after enlarging the left subcostal trocar incision from 10/11 mm to 2 to 3 cm. It is preferred to the umbilical incision because of the 2-layered closure, which appears to be of better quality and is more dependable.
19. End of procedure
• Inspection
Before closing the abdominal wall, the surgeon must verify that there is no abnormal bleeding or bile leakage in the area of the gallbladder bed, and that the subhepatic and subdiaphragmatic spaces have been properly irrigated.• Irrigation
The gallbladder bed is irrigated with physiological solution to remove clots from the operative field and to search for bile leakage or bleeding. The subdiaphragmatic region must also be irrigated to prevent a subphrenic abcess.• Drainage
Drainage of the right subhepatic area, using a 12 to 15 French multiperforated silicone drain (its tip touching the hepatoduodenal ligament) may be performed to prevent blood clots in the gallbladder bed, and to drain any postoperative bile leak.Recommendations of the SFCD (Mutter, 1999)
Drainage of the liver bed is not mandatory after the performance of cholecystectomy for acute cholecystitis, but should be decided upon on a case-by-case basis depending on the extent of hemostasis and biliary stasis.
• Closing
After ensuring the absence of parietal bleeding, the trocars may be removed under direct vision and trocar incisions are closed.For 5 mm incisions, only the skin is closed. Incisions measuring 10 mm or more are closed both at the deep musculo-fascial level and at skin level.
20. Postop management
The abdominal drain is removed 1 or 2 days after surgery if there is no abnormal bleeding or bile leakage.Early ambulation is imperative (the same day of surgery or the day after).
Return to normal dietary habits is typically on postoperative day 1.
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