Laparoscopic cholecystectomy for acute cholecystitis with intraoperative cholangiography

Early laparoscopic cholecystectomy is feasible and safe. Nowadays, it is an accepted treatment for patients suffering from acute cholecystitis. This video demonstrates a laparoscopic cholecystectomy with intraoperative cholangiography for acute cholecystitis in an obese patient.

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Laparoscopic   cholecystectomy   for   acute   cholecystitis   with   intraoperative   cholangiography

Authors
D Mutter, J Marescaux
Abstract
Early laparoscopic cholecystectomy is feasible and safe. Nowadays, it is an accepted treatment for patients suffering from acute cholecystitis. This video demonstrates a laparoscopic cholecystectomy with intraoperative cholangiography for acute cholecystitis in an obese patient.
Catégorie
basic techniques
Mots-clés
Laparoscopic cholecystectomy, acute cholecystitis, intraoperative cholangiography
Type de vidéo
Durée
15'10''
Publication
2009-12
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Dec 2009;9(12).
URL: http://www.websurg.com/doi-vd01en2773.htm

Laparoscopic   cholecystectomy   for   acute   cholecystitis   with   intraoperative   cholangiography

4. Freeing of adhesions 03'42''
The first step will be to identify the Calot’s triangle, adhesion of the fat close to the Hartmann’s pouch will be freed. You see that it bleeds immediately when we touch the fat. The cautery is at a very low level, usually we use 15 or 20 Watts, here we have only 15 Watts to avoid any diffusion of electricity and to avoid any injury of any structure that could be located at distance. We always start the dissection very far away from, what we would call the dangerous structure, the hepatic pedicle, which is somewhere here. That is the duodenum that we see here and there is a lot of adhesions of the fat surrounding. We try to remove the fat before cutting any significant structure and now we will try to perform a conventional exposure by grasping the infundibulum. We have some permanent oozing but it is not a major problem at this step, the elements that are in the hook during this dissection must also be very clearly identified. Here you see that we have a thickening of the parietal wall of the gallbladder, and we go into this area here, it’s very important not to dissect externally of this adhesion but to go on the gallbladder itself. The problem here will be to identify the cystic duct and to know whether or not we can do a cholangiography, at this stage, we haven’t made the decision. We will open again the reflection line of the peritoneum and you will very quickly see the advantage of an early procedure. I do on the upper part of the gallbladder the same that same approach that I have on the lower part, opening the reflection line of the peritoneum, but I must again identify the plane of the gallbladder itself as the cystic duct is in this plane and this plane is inside this reflection line. We also have significant modification of the anatomy as the node is usually located at the neck of the gallbladder and here you see that the neck of the gallbladder is dilated and there is again a modification of the anatomy due to the inflammatory process that is especially important in this case. Here you see that we have very interestingly an identification of the anatomy, go ahead freeing the cystic duct by using the cautery a little bit.
6. Cholangiography 08'55''
The classical way to do is to have all the devices ready, so a little three-way tap. First I use pure water, clear it. That’s the catheter. At its tip, there is a metallic part that can be grasped by the grasper. This catheter can go into a specific grasper. So it can be grasped without occlusion thanks to the metallic part. I give this to the nurse here and I put water here. And then I will flush the catheter. Now I have water into the catheter; the nurse is holding one part, and I will move into the patient again. Thanks to this grasper, it’s very easy to come close. Now the most difficult part is to find again the hole. Here it’s OK. And you can see that thanks to this catheter, I can immediately put the catheter. I think that everything is, I hope, ready. So everybody is protected. I will first of all check the position. So we’ll have an intraoperative cholangiography. I will use the liquid half diluted and now I inject progressively. Cholangiography again, here we can see much better. We have a very long cystic duct located on the left side. I go a little bit up. Now you have the division isolated from the bone right and left, I will inject again upwards. There are 3 things to control. First of all, I look if the inferior aspect of the common bile duct is small, less than 5mm. here you have 3mm as compared to the grasper, that has 5. You need to see the junction with the duodenum, no stone. Here we have the cystic duct. I just wanted to control to have the cystic duct; then you need to identify first of all the main division in the hepatic-- two main branches of the hepatic pedicle, left and right. In the left, you need to see to be sure the starting of the number 4 and if you can, 2 and 3 behind. The most important is on the left, on the right side because the main confusion can occur between a division that could appear like that and the surgeon is happy if he cannot identify the posterior sector. Here we have the anterior sector with a separate little abnormality because the branches from 5 and 8 – I don’t know if this is 5 or if this is 8 or the contrary – but they don’t join together; they join separately in the right branch and the posterior sector with 7 and 6 are these two ones, 8 and 5, 7 and 6, probably this one will be the 6 anterior and this one the 7 posterior; so now I put the camera inside again. I put again a little bit the patient legs down. So after the cholangiography, you should not clip any element that could make any confusion with the cystic duct or with the hepatic artery.