Laparoscopic cholecystectomy for symptomatic cholelithiasis with or without cholangiogram

Double cystic artery; both from a normal right hepatic artery in the cystic triangle

Double cystic artery; one posterior-inferior and one anterior-superior to the cystic duct

Double cystic artery; both superior to the cystic duct high in the cystic triangle

• Cystic artery origin

Cystic artery originating from the proper hepatic artery

Cystic artery originating from a normal left hepatic artery, high in the cystic triangle

• Caudal entrance of RL duct

Cystic artery originating from the celiac trunk, anterior-superior to the cystic duct

4. Anatomical variations II

• Intra hepatic duct

1. Common bile duct
2. 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 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)

5. 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

• Anatomy

Cystic duct insertion of the right lateral (posterior) segment

Duct of Luschka

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

• Anatomy

Gallbladder insertion of accessory right hepatic duct

Congenital absence of a cystic duct

Low union with common hepatic duct

• Abnormal junctions of the cystic duct

• Anatomy

Anterior crossing, left insertion

Posterior crossing, left insertion

• Unusual localization of gallbladder

Lower insertion

6. 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.

The gallbladder may be located inside the hepatic parenchyma, in rare cases.

7. 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:
- in a supine position;
- left arm at 90°;
- right arm alongside the body.
- legs abducted;

• Team

1. The surgeon stands between the legs of the patient.
2. The first assistant stands to the left of the patient.
3. If a second assistant is needed, he or she stands to the right of the patient.

• 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.

8. Trocar placement

• Standard technique

The position and size of the trocars used vary from one surgeon/institution to another.
The standard technique utilizes 4 trocars (12 - 10 - 5 - 5 mm).
Most authors use an optical trocar of 10 to 12 mm introduced in the periumbilical region.
One operating trocar is usually situated to the left side of the mid-epigastric region. A second operating trocar is placed in the inferior aspect of the right upper quadrant. The fourth trocar placed in the epigastric region accommodates one or several means of liver and viscera retraction.

• Optical

A - One optical trocar allows introduction of the laparoscope and the camera, usually 12 mm in diameter

• Operating trocars

B - operating trocar introduced left lateral to the umbilicus (10 mm)
C - operating trocar introduced in the right iliac fossa (5 mm)

• Retractor

D - Retracting trocar in the epigastric region (5 mm)

• Variations

• 3 trocar technique

In this technique, the liver can be retracted with the help of a percutaneous suture that suspends the round ligament toward the upper left side of the abdomen. A fourth trocar can be added as needed to help in the exposure of the infundibulum of the gallbladder.

• Using 10/12 - 5 - 5 - 5mm

There is a current tendency to reduce the size of the trocars during laparoscopic procedures. In laparoscopic cholecystectomy, this has been rendered possible by the use of 5 mm clip applicators. The use of 3 trocars plus only a single 10/12 mm trocar does not allow for placement of the gallbladder into an externally controlled extraction bag nor for grasping of the sac through the umbilical trocar under direct vision (unless the 10 mm scope is replaced by a 5 mm scope via the operating/retraction ports for visualization). In these cases, the sac is grasped and guided with the help of an intra-abdominal grasper to the umbilical opening for extraction at the end of the procedure.

• Use of 12 - 2 - 1.6 - 1.6 mm trocars

Attempts to reduce abdominal wall trauma and improve cosmetic results have led to the use of smaller and smaller instruments. The availability of microsurgical instruments (1.6 - 2 - 3 mm in diameter) as well as 2 mm optical scopes allows for a significant reduction in the size of the incisions and trocars used.

• Obese patients I

The position of the trocars needs to be adapted to the morphology of the patients. In obese patients, the distance between the usual trocar introduction site and the operative field is increased by the thickness of the abdominal wall. It is necessary in these cases to move the trocars closer to the operative region.

• Obese patients II

9. Instrumentation

• Standard

A standard system providing optimal quality is used.
If intraoperative cholangiography is indicated, a cholangiography catheter will be needed.

• Optical

A
The endoscopic view is provided by a 10 mm endoscope with a 0° angle.
A 3CCD camera with a Halogen or Xenon light source is used.

• Operating

B
- straight and curved scissors
- 5 mm hook
- grasper
- 10 mm clip applicator
- extraction bag

C
- grasper

• Retractor

D
- suction-irrigation device
- 5 mm grasper

10. Major principles

The basic surgical principles of laparoscopic cholecystectomy are:
1. achieving perfect exposure of the right subhepatic region;
2. identification of all anatomical structures;
3. dissection of Calot's triangle;
4. dissection, clipping, and division of the cystic artery and duct;
5. cholecystectomy.

11. Exploration

• Anatomical structures

1. Liver
2. Gallbladder
3. Round ligament
4. Stomach
5. Duodenum
6. Transverse colon
The first operative step consists of the creation of the pneumoperitoneum.
A quick exploration of the abdominal cavity is performed allowing for identification of all the anatomical structures of the right upper quadrant before the start of the dissection.

• Establishing the pneumoperitoneum

We recommend the use of a semi-open or open Hasson technique for creation of the pneumoperitoneum due to the increased risk of injury to vital intra-abdominal structures associated with the use of a blind entry technique of Veress needle placement (Bonjer, 1997).

• Goals of the exploration

- Confirm the absence of adhesions, this allowing for safe introduction under direct vision of the operating trocars;
- confirm the feasibility of the laparoscopic approach;
- confirm the good positioning of the trocars with regard to the patient's anatomy;
- eliminate any unsuspected abdominal pathology (particularly malignant pathologies because of the specific risks involved).

12. Exposure

• Retraction of the liver

Usually, the gallbladder is largely covered by the right lobe of the liver. Exposure of the operative field mandates upward retraction of the liver to give access to the subhepatic region. In cases of adhesions, access to this region may be difficult.
The procedure starts with a 10 mm laparoscope through the umbilical trocar (A).

• Retraction of the gallbladder

A grasping forceps is inserted via the epigastric trocar (D) to grab the fundus of the gallbladder and retract it cephalad and towards the right shoulder of the patient.
A grasping forceps is introduced via trocar C and used to grasp the infundibulum retracting the gallbladder laterally and caudally, thus opening up Calot's triangle.
Exposure can also be facilitated by placing the patient in a reverse Trendelenburg position with a slight leftward tilt.

• Lysis of adhesions

Adhesions, whether spontaneous, inflammatory or postoperative, limit access to the right upper quadrant and the mobility of the instruments.
Any adhesions between the gallbladder and the duodenum or the colon are divided.

13. Dissection/Calot

• Anatomical structures

During this step of the procedure, all the biliary and vascular elements that constitute the triangle of Calot will be dissected. This can be done with the help of two 5 mm graspers introduced via trocar C and D, 5 mm scissors or a hook connected to electrocautery introduced via trocar B, and a 10 mm laparoscope introduced via trocar A.

• Anatomical dissection

The goal of the dissection of Calot's triangle is to clearly identify the cystic duct and the cystic artery. The dissection is started close to the gallbladder at the junction of the infundibulum with the cystic duct. The anterior and posterior peritoneal leaflets are incised, allowing access to the vascular and biliary elements of the triangle of Calot. The cystic duct and the cystic artery are skeletonized.
This dissection can be difficult in cases of inflammation of the Calot triangle lymph node (Mascagni lymph node).

• Identification of the cystic duct

The cystic duct is dissected first. This dissection is started at the level of the infundibulum of the gallbladder. The peritoneal coverage of Calot's triangle is incised. Gradual dissection will lead to the identification of the cystic duct. The cystic duct must be freed over a 5 to 10 mm area starting from the infundibulum of the gallbladder and running towards the CBD in order to allow for safe clip application. The dissection of the cystic duct must not be taken too low, in order to avoid injury to the CBD.

• Identification of the cystic artery

The search for the cystic artery is begun cephalad to the cystic duct and in close proximity to the gallbladder. Taking this dissection further to the left puts the right branch of the hepatic artery at risk. The cystic artery can be either dissected along with the cystic duct or after division of the cystic duct. It should be identified and freed at the level of the gallbladder. In certain cases, a double cystic artery may be identified.

• Discrimination: cystic duct and CBD

Excessive traction exerted on the gallbladder can result in distortion of the CBD with its middle portion shifted rightwards. This may cause:
- confusion between the CBD and the cystic duct, leading to the clipping of the CBD;
- a tenting effect of the CBD, leading to placement of lateral clips over this duct.

14. IOC: Technique

• Indications

IOC 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: anatomical variations and size of the CBD.

• Cystic duct incision

Cholangiography is done via a hemicircumferential incision of the cystic duct along its anterior surface. This cysticotomy is performed approximately 1 cm from the junction of the CBD in order to avoid difficulties in inserting the cholangiocatheter due to valvulae or plications of the cystic duct. The right margin of the CBD must be identified.

• Position of the operating table

The operating table is brought back to a flat position (ie, taken out of reverse Trendelenburg and left tilt) and a slight rightward 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

Dilute methylene blue 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 defects;
- a crescent-shaped blockage of the contrast;
- bile duct dilatation;
- the absence of passage of contrast into the duodenum.
The decision to perform a transcystic CBD exploration or a choledochotomy will be based on the analysis of the location of the calculi and morphology of the bile ducts.

15. Clipping and division

• Anatomical structures

All important anatomical structures must be identified prior to clipping or division of the cystic duct in order to prevent injury to other vital structures in the region.

• Clip application

A 5 or 10 mm clip applicator is inserted through the lateral trocar on the left side (B) to allow placement of 3 clips on the cystic duct and 3 clips on the cystic artery:
- 2 clips are placed on the CBD side,
- 1 clip is placed on the gallbladder side.
Complete obliteration of the cystic artery and cystic duct by the clips is confirmed before division of these structures.

• Division of the cystic duct

The cystic duct is divided under direct vision.

• Division of the cystic artery

The cystic artery is divided under direct vision.

16. CBD injuries

• Therapeutic options

The intraoperative recognition and identification of a CBD injury (either by direct vision or by cholangiography) normally mandates a conversion to laparotomy.
In rare cases, the treatment of select injuries can be done using the laparoscopic approach. Depending on the type of injury encountered, the therapeutic options are (Gigot, 1997):
- direct suturing without drainage;
- direct suturing over a T-tube;
- Roux-en-Y hepaticojejunal anastomosis.

• Dangers I

Lateral clipping of the CBD

Traumatic desinsertion of the cystic duct junction

Tenting of the CBD

• Dangers II

Instrument injury of the CBD during dissection of the triangle of Calot

Instrument injury of the CBD during cholecystectomy