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Laparoscopic cholecystectomy for symptomatic cholelithiasis with or without cholangiogram
The description of the laparoscopic cholecystectomy for symptomatic cholelithiasis with or without cholangiogram covers all aspects of the surgical procedure used for the management of symptomatic cholelithiasis. 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 of Calot's triangle, intraoperative cholangiography, clipping and division, common bile duct injuries, gallbladder bed dissection. Consequently, this operating technique is well standardized for the management of this condition.
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LAPAROSCOPIC CHOLECYSTECTOMY FOR SYMPTOMATIC CHOLELITHIASIS WITH OR WITHOUT CHOLANGIOGRAM
Autores
Resumo
The description of the laparoscopic cholecystectomy for symptomatic cholelithiasis with or without cholangiogram covers all aspects of the surgical procedure used for the management of symptomatic cholelithiasis.
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 of Calot's triangle, intraoperative cholangiography, clipping and division, common bile duct injuries, gallbladder bed dissection.
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 of Calot's triangle, intraoperative cholangiography, clipping and division, common bile duct injuries, gallbladder bed dissection.
Consequently, this operating technique is well standardized for the management of this condition.
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Tipo de mídia
 Data da publicação
2001-02
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Popular
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E-publicação
WeBSurg.com, Feb 2001;1(02).
URL: http://www.websurg.com/doi-ot02en011.htm
URL: http://www.websurg.com/doi-ot02en011.htm
LAPAROSCOPIC CHOLECYSTECTOMY FOR SYMPTOMATIC CHOLELITHIASIS WITH OR WITHOUT CHOLANGIOGRAM
1. Introduction
Cholecystectomy, consisting of complete removal of the gallbladder, was one of the first surgical interventions to be performed laparoscopically.Laparoscopic cholecystectomy is performed using the same operative technique and principles as open cholecystectomy. Nonetheless, the two-dimensional downward to upward view coupled with the use of long instruments for distance manipulation requires specific training. Furthermore, the laparoscopic approach is associated with a risk of specific complications during the learning curve. One should always keep in mind that there is no such thing as a simple cholecystectomy.
2. Anatomy
• Location
Note: the anatomy section is identical for all chapters on gallbladder diseases.The gallbladder is located in the right upper quadrant. It is attached to the liver at the junction between segments IV and V.
The fundus of the gallbladder is generally situated under the right costal margin.
• Topographical 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. 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 duct4. 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)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
• 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 insertion6. 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.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.9. Instrumentation
• Standard
A standard system providing optimal quality is used.If intraoperative cholangiography is indicated, a cholangiography catheter will be needed.
• Optical
AThe 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. Liver2. 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
• Variation 1
Lateral clipping of the CBD• Variation 2
Traumatic desinsertion of the cystic duct junction• Variation 3
Tenting of the CBD• Dangers II
• Variation 1
Instrument injury of the CBD during dissection of the triangle of Calot• Variation 2
Instrument injury of the CBD during cholecystectomy • Variation 3
Thermal injury of the CBD• Variation 4
Injury to an anomalous right hepatic duct• Variation 5
Injury to an anomalous right hepatic duct• Variations
• Large cystic duct
If the cystic duct is too large to allow for safe clip application, ligation of the cystic duct stump becomes necessary. This can be done either with intracorporeal suturing or by application of a prefabricated loop.• Difficult dissection
Difficult dissection of Calot's triangle:In cases of difficulties encountered during simultaneous dissection of the cystic duct and cystic artery, it is possible to dissect, clip, and divide the cystic duct first. This maneuver will create additional operating space that will then allow the dissection, control, and safe division of the cystic artery.
• Clip application
Clip application with 3 mm scope17. Gallbladder bed dissection
• Downward traction
Dissection of the gallbladder bed is performed by progressive use of electrocautery with a hook or scissors. Constant downward traction over the infundibulum of the gallbladder allows exposure for this operative time.• Accessory biliary duct
The dissection of the gallbladder bed must be performed carefully to allow for the identification of any accessory biliary ducts draining directly into the gallbladder from the liver. Any such accessory ducts identified during the dissection of the gallbladder bed must be clipped.18. End of the procedure
• Extraction
The gallbladder is placed into an extraction bag and removed via the umbilical incision.The use of an extraction bag offers 2 advantages:
- reduced risk of contamination of the umbilical incision by bile or stones in case of a gallbladder rupture during the extraction maneuvers,
- reduced risk of parietal wall seeding in cases of unrecognized gallbladder cancers.
The umbilical incision may enlarged as needed.
• Irrigation and lavage
In cases of bile leakage during the procedure, a lavage of the right upper quadrant can be realized.Any spilled stones during the procedure should be looked for and extracted. Such stones can be the cause of early as well as late complications (abscess and chronic fistulae).
• Drainage
Under normal conditions in an elective setting, postoperative drainage is not indicated for laparoscopic or open cholecystectomy (Mutter, 1999). If a drain is used, it must be a suction drain and must be removed relatively quickly. Indeed, prolonged postoperative drainage following open cholecystectomy has resulted in increased morbidity when it lasted more than 48 hours (Hoffmann, 1985; Playforth, 1985; Monson, 1986).
• Closure
At the end of the procedure, the pneumoperitoneum is evacuated after the trocar sites are carefully controlled for bleeding and the trocars are removed. Fascial closure is indicated for incisions >=10 mm in size.Skin is closed based on the surgeon's preference using:
- clips;
- interrupted sutures;
- steristrips;
- surgical glue;
- or intracuticular sutures (recommended).
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